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The Sehatmandi Project provides quality health, nutrition, and family planning services across Afghanistan. The delivery of health services is contracted out to nongovernmental organizations (NGOs) and uses a pay-for-performance approach to incentivize a focus on health outcomes, particularly for women and children. The project is helping to improve basic health and essential hospital services, strengthen the overall performance of the health sector, and boost demand for key health services.

Challenge

Afghanistans health system faces a critical shortage of key ingredients qualified healthcare workers, especially female healthcare workers to ensure that women can seek health services; safe and equipped facilities, particularly in areas that are experiencing active conflicts; and supplies of medicines, equipment and vaccines. Insecurity, gender imbalances, and lack of government revenue severely limit the availability of even the most basic healthcare for most Afghans and the situation has become particularly acute during the COVID-19 Pandemic.

Approach

The Sehatmandi program builds on the innovative approach of contracting out the provision of virtually all basic and essential health services to service provider non-governmental organizations (NGOs). The project takes a pay-for-performance (P4P) approach that directly links the payment of service providers to their performance on the delivery of 11 key health-related services such as immunization, skilled birth attendance, family planning visits, and growth monitoring of infants and children. The performance is verified by an independent third-party monitor before payment is made. The expected outcomes are clearly spelled out and quantified and customized for each province of the country through a contract between the MOH and the NGO with set terms for service standards.

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While cooking in the kitchen, I stopped breathing and my vision went dark. When I woke up, I was on a hospital bed. Every time I come here, doctors are so respectful and care about us. My neighbors and I are so pleased. It is five days that I am here in hospital and I have had a very good experience. I appreciate the hospitals management system. There are so many patients, but the doctors are always doing their best.

Gulab Zarin, Kama district, Nangarhar province

The project focuses on improving the value-for-money by enhancing accountability and transparency in the health sector and is a cutting-edge model for service delivery in fragile and conflict-affected settings.

The project has effectively served as a platform to channel the resources of key development partners in a common results framework to finance basic and priority health services across the country with minimal management cost, including in highly insecure and conflict-affected areas which are difficult to serve.

Results

The program made notable achievements despite the rising insecurity and the COVID-19 pandemic.

Since 2002, international development aid, including support from the World Bank and the Afghanistan Reconstruction Trust Fund, has been a critical part of Afghanistan's development.

Overall health outcomes in Afghanistan have improved markedly since the first decade of the 2000s:

Bank Group Contribution

The Sehatmandi Project is supported by grant of $140 million from the International Development Association (IDA), a $425 million grant from the Afghanistan Reconstruction Trust Fund (ARTF). The ARTF is a multi-donor trust fund administered by the World Bank on behalf of 34 donor partners which have contributed almost $12 billion. The ARTF is a vital mechanism to coordinate international aid. Through the ARTF, donors align and coordinate their support around key development programs, reducing aid fragmentation.

Partners

The Afghanistan Sehatmandi Project is implemented by the Ministry of Public Health of Afghanistan in close cooperation with the donors to the Afghanistan Reconstruction Trust Fund (ARTF), WHO and UN agencies. Afghan and international NGOs support the project as service providers.

The Global Financing Facility for Women, Children and Adolescents (GFF) supports the project with a $35 million grant. The GFF supports low- and lower-middle-income countries to accelerate progress on reproductive, maternal, newborn, child and adolescent health and nutrition, and strengthen financing and health systems for universal health coverage (UHC).

Moving Forward

Building on the programs success and to further enhance health service delivery, additional financing for the project is under preparation to make further investments in health facilities and the capacity of the healthcare system and healthcare providers and expand the menu of health services provided.

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Delivering Strong and Sustained Health Gains in Afghanistan: The Sehatmandi Project - Afghanistan - ReliefWeb

SHAHRISTAN, Afghanistan It was midnight on 6 August when there was a loud knocking at my front door. My husband answered. Standing in the dark was a person asking for my help a baby was being born, Shirin described to UNFPA.

It was the start of the greatest challenge she had ever faced as a midwife.

Shirin, 31, manages a family health house in Usho Golaka Village, in Daikundi Province. Family health houses are community-based facilities that provide a host of basic reproductive health services in remote communities, including family planning, antenatal care, safe delivery services, newborn care and immunizations.

She knew the man. He was a relative of Fatima, one of her patients. Tonight her situation was critical, Shirin said.

Fatima, already a mother of six children, was in labour with her seventh. Shirin was immediately alarmed an earlier examination had shown that the delivery would be dangerous.

Fatimas baby was found to be in the wrong position and the delivery was to be a breach birth, Shirin explained. I'd provided information and counselling on her condition, but advised her to refer the case to the provincial hospital in Nili, the center of Daikundi, for further management of her delivery.

But Fatimas family couldnt afford to seek care so far from home. Were a poor family and the economy and unavailability of transport was a big problem for us, Fatima said. We would have had to pay 13,000 afghanis [$170] for transport to reach the provincial hospital in Nili. This was not possible.

Afghanistan has one of the highest maternal mortality rates in the world, according to United Nations data. Some 638 women die per 100,000 live births. Poverty, lack of access to health services and gender inequality all contribute to these tragically high numbers; fewer than 60 per cent of births are overseen by skilled health professionals.

To address these concerns, UNFPA supports Afghanistans community midwifery education programme, a training programme funded by the Canadian Government, which equips midwives to provide essential basic maternal health services and other midwifery care. These midwives then operate from UNFPA-established family health houses, which provide the only medical services available in Afghanistans remotest and most difficult-to-reach areas.

Shirin graduated from the community midwifery education programme in 2015. She has since worked in the family health house in Usho Gholaka, where she has served hundreds of women.

A midwife wears full protective gear to prevent the spread of COVID-19. UNFPA Afghanistan

Her husband is supportive of her work. That night, he took her by motorbike to the village where Fatima and her family live.

The intent was to save a mother and her baby, her husband said. Ive pledged to support my wife in this work, even if its midnight.

Shirin found Fatima suffering in terrible pain, shouting for help. She tried to find a way for the family to urgently transport Fatima to the provincial hospital, but the family felt it was impossible.

Although Shirin is an experienced midwife, she is not equipped to manage serious complications like breach delivery. But in that situation, she was forced to improvise.

I called an expert gynaecologist who was working in the provincial hospital and asked for instructions. This was the only solution I could come up with that might save their lives. I was instructed to use different manoeuvres to shift the position of the baby in the womb. I followed the gynaecologists guidance carefully.

It was a tense labour but in the end, her efforts paid off.

Finally, the uterine contraction began and a baby boy was born after one hour and 45 minutes of labour. He was safe and healthy, Shirin recalled.

Fatimas family was greatly relieved.

When I heard that Fatima and her baby were alive, I cant tell you how happy I was, Fatimas mother-in-law told UNFPA. I am so grateful to Shirin for being there and helping women in need.

Fatima later brought her newborn to the family health house for postnatal services. Im grateful to Shirin, she said. She saved not only my life but also the life of my child.

And Shirin, too, is grateful. Though the experience was harrowing, she feels she has grown as a midwife.

I was very proud of what I did, she said.

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Midwives on the front lines working to reverse Afghanistan's high maternal death rate - UNFPA News

Significant questions remain: Would the Taliban accept elections? Would they accept a coalition government? An elected parliament? In recent weeks, the Taliban leaders have revealed that they envision a religious authority at the apex of a future Afghan government if not the chief executive position, then a body with power to oversee the executive.

Peace negotiations will be strained on questions such as the Talibans refusal to accept the current share of womens participation in public service. Without the Taliban agreeing to a compromise on individual rights and freedoms, an agreement wont be reached.

In fact, the Talibans positions and attitudes stem from Afghan cultural norms as much as they do Islamic doctrine, which influences them in both strongly conservative and relatively progressive directions. The socially conservative views the Taliban espouse are common among rural Afghans, as well as a substantial share of urban educated youth.

Unlike other modern jihadist groups, the Taliban are not fixated on a literalist reading of textual sources. Their movement was born out of a combination of Islamic oral tradition and pre-Islamic cultural norms, and does not have a single ideological document. In fact, that absence of a definitive intellectual foundation in the Taliban has driven some of its more educated radicalized youth to join rival groups such as the Islamic State in Afghanistan.

The absence of core, rigid ideological texts might enable the Taliban to integrate into mainstream Afghan politics. There are many in Afghanistan who are deeply skeptical about genuine change in the Taliban and the prospect of future transformation. But there are no easier ways to test and build on those possibilities than through political engagement in the context of ongoing peace negotiations.

The evolution of the Talibans political thinking, though, is likely to be slow. Rushing the negotiations would risk producing an unstable result that only papers over the two sides differences; successful negotiations will require not only patience but also a more hands-off approach from other governments than they are usually comfortable with.

The shaping of the post-Taliban Afghanistan by the Western governments, primarily the United States, eventually turned out to be its vulnerability and undermined its legitimacy in the eyes of many Afghans. A new dispensation in Afghanistan will need the support of conservative elements of Afghan society if we want the long war in the country to finally be over.

Borhan Osman is a senior consultant on Afghanistan for the International Crisis Group.

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Whose Islam? The New Battle for Afghanistan - The New York Times

When given a choice between security and freedom, people always choose security. That is why so many dictators and demagogues survive by creating a false sense of threat and then presenting themselves as the saviours.

The same logic applies when people are given a choice between safety and justice. They would choose safety over justice. In the case of Afghanistan, this has fed a continuous cycle of violence over the past few decades.

The absence of any legal consequences for violence and war crimes has only further emboldened armed groups. The release of Taliban fighters as part of an agreement between the United States and the Taliban and the continuing negotiations between the armed group and the Afghan government will not lead to peace. Only a thorough transitional justice process will.

The decision to sideline justice to supposedly maintain security and peace is not without precedent in recent Afghan history.

During the Soviet invasion of Afghanistan (1979-1987), more than 800,000 people lost their lives. The United States and several Muslim countries supported the mujahideens fight against Soviet forces.Both sides regularly committed serious human rights abuses and violations of international humanitarian law throughout the conflict. While the atrocities committed by Soviet forces were widely reported on, war crimes committed by the mujahideen during the same period were largely undocumented.

After the withdrawal of Soviet troops, infighting broke out between various mujahideen groups which led to more war crimes being committed. In February 1993, for example, the infighting between mujahideen factions resulted in the Afshar massacre, in which up to 1000 Hazara men, women and children were brutally murdered. Intra-mujahideen fighting lasted from 1992 to 1994 costing up to 50,000 civilian lives. It is this violence and upheaval that gave birth to the Taliban, which took over Kabul in 1996 and established an Islamic emirate. In August 1998, the Taliban executed between 2000 to 5000 civilians from the Hazara ethnic group in the northern city of Mazar-i-Sharif.

The 9/11 attacks on the US turned the odds in favour of the same mujahideen as the US-led coalition which invaded Afghanistan in October 2001 allied with them against the Taliban. In 2007, after a US-backed government was installed in Kabul, mujahideen leaders involved in the 1990s civil wars passed legislation in parliament granting them amnesty for their war crimes. The justification given for these laws was simple: if the international community and the government of Afghanistan tried to bring them to justice, the mujahideen would provoke more chaos and insecurity.

Hence, no transitional justice measures were carried out, thereby sacrificing accountability to maintain an illusory post-2001 peace. Suffering for more than two decades, the people of Afghanistan who were the primary victims of the mujahideens war crimes let go of justice in the hope of security.

The absence of a transitional justice process against the mujahideen emboldened the Taliban and reassured its members that there would be no consequences for their actions and they continued to commit ever more gruesome violence against the Afghan people. In other words, the impunity the mujahideen enjoyed did not really bring peace to Afghanistan.

This approach to war ethics is problematic, not only because it denies justice to the victims of the Taliban atrocities but also because it strengthens the Talibans capacity to prolong the war to achieve its goal of establishing a theocracy.

The release of thousands of Taliban fighters after the armed group concluded an agreement with the US on February 29 this year has been justified as necessary to jump-start peace negotiations. However, the odds are against any permanent peace in the country.

The Taliban will not give up violence because it knows that it is only through violent means that it can have any political power. Even with its enormous corruption scandals and its own track record of violence against civilians, the government in Kabul is still preferred by 92 percent of Afghans, according to a 2015 poll. Any impunity the Taliban enjoys will also motivate other groups to continue committing crimes against the Afghan people.

Because of this, calls are growing for the leaders of the Taliban to be tried at the International Criminal Court (ICC). Nevertheless, Taliban leaders are unlikely to face the court soon. Not only the Afghan government and its international backers would be happy to give the members of the group amnesty should they agree to make peace, the US itself is not willing to allow the ICC to investigate the crimes its troops allegedly committed in the country.

Moreover, an ICC investigation at this critical junction risks undermining the ongoing Doha peace talks, as it may discourage the Taliban from agreeing to make peace. But there are ways to achieve some transitional justice without insisting on an ICC investigation.

The war crimes committed in Afghanistan in the last four decades by all parties can and should be officially documented. This would put an end to widespread attempts to whitewash history and force the perpetrators of these crimes to face some accountability. Following the documentation of these crimes, all political parties, including the communists, the mujahideen factions and the Taliban, should officially apologise to the people of Afghanistan in general and the victims of violence in particular, to officially acknowledge and atone for their past crimes.

A public apology by leaders involved in war crimes has a precedent. During his 2013 election campaign, President Ashraf Ghanis running mate, Abdul Rashid Dostum, issued an apology for being a part of the 1990s civil wars. Dostums apology and pledge to never repeat his past mistakes was welcomed by many Afghans.

The people of Afghanistan are once again being asked to choose between justice and security. While an acknowledgement of war crimes and a promise by perpetrators to not repeat them would not heal the victims of these crimes, it can be an important step towards healing Afghanistan. If these steps are backed by a commitment by the international community to prevent further human rights violations in the country, Afghanistan can finally leave its painful past behind and turn its face towards the future.

The views expressed in this article are the authors own and do not necessarily reflect Al Jazeeras editorial stance.

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Clemency for the Taliban will not lead to peace in Afghanistan - Al Jazeera English

Sarah Hawkes, co-director of the Global Health 50/50 research group

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In May, in a small village in Herat Province in Afghanistan, Sediqas husband came down with symptoms of Covid-19 and was taken to a hospital in Herat City for treatment. When he came home, 10 days later, Sediqa looked after him.

Within a week, she fell ill, too.

I had the same symptoms and day by day, it got worse, said Sediqa, whose last name has been omitted for fear of repercussions. I was feeling so weak, I didnt feel like eating or drinking.

But when she asked to go to a hospital, her husband refused. He said no way. He told me to sunbathe and drink more tea.

Sharifa, who lives in Kabul, faced a similar situation. Her husband tested positive for the coronavirus and, in caring for him, she eventually fell sick, too. But her husband stopped her from getting a test or seeing a doctor.

My husband said that I wasnt even sick, and that I was just seeking his attention, Sharifa said. He was even laughing at me.

In Afghanistan, the number of women reported to have tested positive for the virus or to have died of Covid-19 is far below the numbers reported for men. Globally, men account for 53 percent of confirmed cases and 58 percent of deaths, according to the independent research group Global Health 50/50. But the same organizations country tracker shows that in Afghanistan, men account for 70 percent of cases and 74 percent of deaths a peculiarly wide discrepancy that experts say is most likely the result of gender inequalities that shut women like Sediqa and Sharifa out of the healthcare system and the public sphere.

Theres a really legitimate concern that this is about womens lack of access to services, said Sarah Hawkes, professor of global public health at University College London and co-director of the Global Health 50/50 research group.

There is, however, an important caveat to the data from Afghanistan it doesnt include information on the countrys testing rates, Professor Hawkes noted. Anecdotally, testing is not reported to be either frequent or widespread, despite being free, meaning the numbers arent fully capturing whether the discrepancy in infection and death rates is because women arent being tested or because they are actually not being infected.

Afghanistan also is not the only country with a notably wide gap between male and female infection and death rates. In Singapore and Qatar, for example, men make up around 90 percent of confirmed Covid-19 cases, Professor Hawkes said, partly because of bad outbreaks among male migrants who work in low-paying jobs and live in tight quarters (neither of those countries has disaggregated data for deaths).

Some experts have also pointed to biological differences between men and women as a major driver behind the sex discrepancy in global fatality rates.

But with Afghanistan, it is quite likely that women simply arent getting into the system, Professor Hawkes said.

Decades of conflict and widespread poverty have made access to Afghanistans fragile health care infrastructure difficult for both men and women, noted a recent report by Mdecins Sans Frontires, the group also known as Doctors Without Borders. But women and children are more likely to be left out of that system or receive substandard care because of patriarchal traditions that remain deep and prevalent in Afghanistan.

Afghan women face obstacles both within their own households and the healthcare facilities themselves, explained Suraya Dalil, who served as Afghanistans public health minister from 2010 to 2014 and now leads special programs in public health at the World Health Organization.

Women have to be accompanied by somebody to go to the hospital, so those decisions are often made by the men in a household, whether its the husband or the father or the son, Ms. Dalil said.

And when women do get to healthcare facilities a perilous task in itself owing to the countrys vast mountainous landscapes they are expected to engage only with female doctors, Ms. Dalil added. That becomes a near-impossible hurdle to overcome given the small number of female doctors, particularly in rural settings.

Currently, the country has just over 2,000 female healthcare professionals, according to official government figures, serving the countrys more than 18 million women. And many of these workers, according to the World Health Organization, are concentrated in Afghanistans urban centers.

Because Sediqas husband insisted that she would not be checked by male doctors, her brother was compelled to consult a doctor over the phone. She was prescribed some paracetamol and, after 27 days, started to feel a little better.

In Sharifas case, seeing a doctor was simply out of the question. Now 50 years old, Sharifa hasnt seen a male doctor since she married 35 years ago, when she was 15.

When my husband gets sick, I do anything I can, she said. I take him to the doctor, I talk to his male doctors. But when I get sick, I am not allowed to see a male doctor. I delivered my two boys at home.

If a woman does end up seeing a doctor, and the situation gets to a point where she is hospitalized, another female relative is expected to stay with her at the hospital, Ms. Dalil said, creating yet another wrinkle in a complex situation.

Add to all of this the cost of health care, which is unaffordable for many Afghans, and a volatile environment in which health care facilities are frequently bombed or attacked by insurgents, and the chances of a woman actually receiving adequate care become increasingly slim, Ms. Dalil explained.

The Afghan government claims that it has tried to remove some of these barriers over the years. The ministry does its best to provide services for female patients, said Masooma Jafari, the deputy spokesperson for the ministry of health. We have female doctors and we try to allocate separate areas and beds for female patients.

But the government did not provide specifics about how it planned to close the gender gap in coronavirus testing and treatments.

Another explanation for the gap in female infection and death rates in Afghanistan could be the fact that the countrys labor force, even before the pandemic hit, is still male-dominated.

A new study, published in May by the Centre for Economic Policy Research, tracked data from Global Health 50/50 against workforce participation rates of O.E.C.D. countries, and found a positive correlation between womens participation in the workforce and the Covid-19 death rate for women.

The percentage of female deaths due to Covid-19 is higher in countries in which women comprise a greater share of the full-time workforce, writes Rene Adams, the author of the study and a professor of finance at the University of Oxford who focuses on gender inequality. Work may be associated with a higher incidence of pre-existing conditions and greater exposure to the coronavirus.

In Portugal, for example, women made up almost 50 percent of the workforce in 2018 and accounted for 50 percent of Covid-19 deaths in April. And in Mexico, women made up about 38 percent of the workforce in 2018 and 35 percent of Covid-19 deaths in April.

In Afghanistan, women make up about 30 percent of the workforce, removing many of them from situations in which they might be exposed to the virus in the first place.

That explanation, however, doesnt account for cases like Sediqas and Sharifas, who were most likely infected because their husbands carried the virus back home.

All of this brings into sharp focus just how much hangs in the balance for Afghan women as the government holds peace negotiations with the Taliban, a process that includes just a handful of female delegates representing the government side.

So far, the Taliban have been vague about whether they would support womens right to receive an education and join the workforce, leaving many women worried that a peace deal might push them back into the shadows.

From 2002 onward, there was some meaningful investment with regard to womens empowerment, Ms. Dalil said. She recalled that during her time at the ministry of health, the government made a conscious effort to deploy more female midwives in hard-to-reach communities and rigorous vaccination campaigns.

But now, with the pandemic further stressing a delicate system and widening the schism between those who receive care and those who dont, she added, Im worried about the progress that has been made.

Asad Timory contributed reporting from Herat.

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Data Shows Fewer Afghan Women Than Men Get Covid. Thats Bad News. - The New York Times