Monday, March 19, 2012

Making Family Planning Work in Afghanistan

Afghanistan is a country ravaged by decades of war, internal conflict and strife. It is only in the last few years that a democratically elected government has been able to bring some semblance of stability in the different part of the country, though the situation still remains highly volatile.  The country is getting a lot of support from international community for the rebuilding of the infrastructure and systems which have been almost wiped out by continuous war like situation.
Though Afghanistan is going through a phase of rebuilding and restructuring, yet she still faces huge challenges in providing essential services to its citizens. These difficulties are caused by factors such as geographical remoteness, civil instability, the over-centralization of government, a lack of infrastructure such as transportation systems, and a lack of government resources, among others[1].
All the above mentioned problems have severely hampered the development process which almost stood still form many years in the past and started afresh only recently. The effects are manifest in the population statistics which are a real cause of concern for the development planners in Afghanistan. Using estimates derived from a number of recent surveys, the UN estimates the current Total Fertility Rate (TFR) at 6.6 children per woman and the U.S. Census Bureau estimates 5.7. Not only do these TFRs, as high as they are, represent quite a decline from the past, but the onset of decline has been quite recent. The real question now is: what about the country's demographic future? The UN has quantified the effect of such high TFRs in its constant-fertility projection. If the TFR remains at 6.6, by 2050 the country's population would reach 111 million and be growing at 3.6 percent per year, a rate that would double a population in 19 years[2].
Keeping in view the scarce resources and not so good economic condition, the Afghan government needs to strengthen the family planning and population planning programs in the country in order to check the alarming trends in population increase. However this a challenge as there are many obstacles in way of population planning programs because of typical socio-cultural and traditional tribal set up in Afghanistan. These challenges can only be overcome by bringing together all stakeholders on single platform.
Afghanistan can learn a lot from the other Muslims countries of Asia like Iran, Indonesia and Malaysia who have highly successful FP programs and have succeeded in overcoming the challenges caused by traditional and conservative interpretation of religion. In all these countries governments  initiated dialogues with religious scholars and convince them to look for reinterpretation of religion in the light of the changing requirements of modern times. Regular interaction of Afghan religious scholars with religious scholars of the above mentioned countries can be a right step in this direction. This interaction can be very helpful Afghan religious scholars and would help in overcoming the resistance which is mostly caused by narrow and traditional interpretation.
NGOs are also an important stakeholder and can play a very important role increasing effectiveness and efficiency of the family planning programs in the country due to their unique advantages. In all South Asian countries and similarly in neighboring countries of Pakistan, Bangladesh, Nepal and India, NGOs have emerged as alternate providers of public services, particularly within poor and rural communities.
Many lessons can be learnt from the neighboring country of Pakistan, which has successfully involved NGOs in the family programs to enhance the reach, quality and effectiveness of the service delivery. Pakistan is also similar to Afghanistan in many respects as both countries share similar socio-cultural background, traditions and the recent history of conflict. Though Pakistan has an area slightly bigger that Afghanistan and contains a population nearly six times the size Afghan population yet the challenges faced by both the countries are very similar. Many Pakistanis do not have access to government services, due different factors including geographical remoteness, lack of resources, lack of capacity in public sector and an ongoing conflict situation in northern areas of Pakistan. So the role of NGOs has increased manifold which have stepped up to fill the gap. NGOs have emerged as alternate providers of public services, particularly within poor, rural and hard to reach communities. The role of NGOs in provision of family planning services is even more prominent as NGOs have been involved in the family planning program since the beginning.
In Pakistan the early programs on family planning were started in late 1950s and early 60s. Provision of family planning services was started through setting up of FPAP which today in one of the largest organizations working in the sector of family planning[3]. NGOs have played a pioneering role in establishing family planning in all countries of South Asia and in setting the reproductive health agenda. NGOs have provided important clinical services, including contraceptive surgery. Apart from service delivery, there has been a considerable role for NGOs and CBOs in advocacy, BCC and community mobilization, where they have advantages. They have also been used as agents of information and advocacy to support the national program.  Some other roles of NGOs also include: ensuring quality of services being delivered, community mobilization, social Marketing and facilitators of Family planning education, training and linkages development.  
NGOs and civil society organizations have many advantages over the public and private sector which can contribute in enhancing effectiveness, efficiency and reach of the FP program. The foremost advantage which the NGOs and CSOs enjoy is their capacity to work at the grassroots level at very low costs. Since most of the NGOs have strong community linkages and presence, therefore they find it much easier to work at the community level and to overcome barriers and resistance which is often faced by public or private sector. Moreover, they often operate without a lot of overheads which keeps their cost very low which is a very important factor in resource constraint situations.
The slightly informal structure of NGOs gives them a flexibility which the public sector often lacks and which is of utmost importance in socially and culturally sensitive programs. They can adopt and review their program according to the changing ground realities. They do not have to go through the bureaucratic channels to review and redesign their program to meet the needs of community. This reduces the time required for taking necessary decisions and for taking prompt actions when required. Since most of the NGOs have to report back to donors and government and go through the rigorous audits conducted by donors and governments, they have to maintain high levels of transparency and accountability which is another argument for employing NGOs in FP programs. Of course, there have been studies and researches which prove that NGOs have proved more effective in implementing FP program because of higher quality of services, high rates of success, better outcomes, presence of more female workers and their capacity to scale up when pilots have proved successful[4].
However this does not mean that there are no disadvantages or challenges while working with NGO. There are several challenges which should be considered before going ahead with the decision. It is a common issue that most CSOs and NGOs have limited resources and sustainability problems, and do not have the capacity to locally raise funds for themselves. There exists a certain amount of distrust for NGOs among stakeholders due to the religious and cultural norms and they are often seen as working on foreign agenda which leads to unfavorable working environment for NGOs. NGO have also been criticized for their heavy reliance upon donors and sustainability issues of the projects. NGOs have also suffered in recent times because of the shifting trends of donor funding and lack of focus on FP. In the last decade or so the funding for FP program has declined considerably which has adversely affected the effectiveness or FP program and has resulted in stagnant indicators like unmet need and CPR.
Despite the above mentioned disadvantages and drawbacks, NGO remain the most important stakeholders in FP and population planning programs. No FP program can succeed without active and meaningful participation and support of NGOs in Afghanistan or for that matter anywhere else. This fact has been proven time and again through many studies. Learning from the experience of Paksitan with similar challenges and factors can be very helpful for the success of FP program in Afghanistan. This can be done through exchange visits, brining technical expertise from region or through involving NGOs from other countries of the region for capacity building of NGOs and civil society organizations in Afghanistan. 

[1] (Evaluating NGO Service Delivery in South Asia: Lessons for Afghanistan: Laura Antuono, Chris Meeks Melissa Kay Miller, Jean Rene Watchou, Robert M. La Follette School of Public Affairs University of Wisconsin-Madison, 2006)
[4] Evaluating NGO Service Delivery in South Asia: Lessons for Afghanistan; Laura Antuono, Chris Meeks, Melissa Kay Miller, Jean Rene Watchou, Prepared for Workshop in Public Affairs, International Issues Public Affairs, 2006