I haven't blogged in a while. My analysis is that the lack of blogging is the simple result of multiple causes: partly because I've caught a mid-winter cold, partly because I've been working to ready myself for an upcoming study on Afghanistan, and partly because I'm in an Army school on the weekends. Today, however, I am going to write down my thoughts about:
In spite of the unfortunate confluence of events and the resulting lack of blogging, I have been thinking about the intersection between health, politics and society in Afghanistan, in particular. I will be working on a 90-day USAID sponsored assessment of the US Government's health reconstruction efforts in Afghanistan. This work promises to be informative on a number of levels. I will try to blog about it as appropriate, without giving away the results and getting myself into trouble.
But first, by way of context, it strikes me that there are several fundamental ideas that should be considered in any assessment and framework for the way ahead. Here are some of my initial thoughts, culled from reading and talking with colleagues:
1. Top-down, bottom-up is the best strategy for the way ahead (I stole this from a USIP report on Afghanistan published by Seth Jones and Chris Fair who are both at RAND). Afghanistan has never had a strong central government, and from my reading, the Karzai government's efforts (as would any central government's efforts) are often viewed suspiciously. Therefore, the goal of any health reconstruction efforts must be to promote local and regional ties to the central government and demote the advancement of regional rulers who have further regionalism on their agenda. Not an easy undertaking, but one that apparently USAID and the Special Forces are using now at the provincial level. (For some good reading on this, see Sloan Mann's article on the small wars journal: http://smallwarsjournal.com/documents/79-mann.pdf. Perhaps this approach can be rolled in to a regional strategy.
2. Health care and health attitudes are somewhere pre-civil war US, I'm guessing...tho I'm not a medical historian. Basically, there is no health care system. So, a whole system has to be built. Without a strong central government. This makes me wonder about the viability of the central government's Basic Package of Health Services. The problem here is that the US Government likes to legitimize the central state, because we view the world (and desperately want the world to be) a state-based system. So, we ask the central government what needs to be done. Then we roll up our sleeves and help deliver. Unfortunately, the central government has little control outside Kabul, so this approach is problematic.
3. NGOs provide and have provided most of the care. Therefore, the public probably does not view health care as a legitimate governmental responsibility. It's something that outsiders provide.
4. The Afghan public was recently reported by an ABC poll to have turned away from a positive view of the U.S. Frankly, I'm a bit suspicious about the utility of these polls, but taking the findings in gross, it may be that the US has allied itself too strongly with the Karzai government in the public sentiment. Not sure.
Health people like to think that providing health care makes the US look good in the eyes of the populace. This is a bit naive, I'm afraid. People's sentiments are changeable, though the more stable views are pretty much driven by cultural norms. Hence application of health activities to improve public perception would necessarily have to play along cultural norms. Very tricky. But this supports the argument for bottom-up approaches. If the goal is to be well thought of in order to win the insurgency war, then we need to use current cultural norms (clientelistic, "corrupt" --in our eyes-- patrimonial systems). That implies, by logical extension, that we use health care development in these give-and-take situations to develop some amount of loyalty among the tribal divisions.
5. Everybody is in Afghanistan. (All kinds of nations, that is). Makes things complicated. Afghanistan is not divided up by ethnicity. It's divided by geography, apparently. Local power-leaders rule in geographical areas (valleys). That makes things complex, too.
6. The world economy just tanked, hence the lack of donor contributions should get worse. That means fewer resources. But this is OK, in my mind, since there is no health system, basically. Rather than focusing on hospitals and clinics, perhaps the whole of government effort could be more cheaply focused on hand washing, nutrition and basic sanitation practices. Sometimes fewer resources means more efficient expenditure.
With these points in mind, assessing the construction activities and creating a framework for the way ahead in Afghanistan should be a snap.
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