Cablegate: Enabling the Government of Afghanistan to Give Its Citizens

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E.O. 12958 N/A
TAGS: ESTH SOCI AF
SUBJECT: ENABLING THE GOVERNMENT OF AFGHANISTAN TO GIVE ITS CITIZENS
WHAT THEY WANT: HEALTH AND EDUCATION

1. (U) Summary: With one of the lowest literacy rates and some of
the worst health statistics in the world, the lack of an educated
and healthy population is a severe impediment to social and economic
progress and stability in Afghanistan. Enabling the Government of
the Islamic Republic of Afghanistan (GIRoA) to deliver critical,
high demand services in health and education is one of the most
simple and effective methods for increasing citizen's active and
continued support of their government. Citizen support increases
with further expansion of GIRoA service delivery as reflected in
President Obama's recent messages on Afghanistan and our COIN
strategy. Health and Education are two of Afghan citizens' most
demanded and appreciated services from the GIRoA. USG commitment to
strengthening the GIRoA's ability to expand and deliver health and
education services into more districts needs greater support -
especially since other donors are either unwilling or unable to
help. The gains we have made in education and health and the
increased support of the citizens for the GIRoA because of these
gains are not reflected in current USG funding levels. We have
requested separately additional funding for these two important
sectors. End Summary.

Progress in Health but a Long Road to a Healthy Afghanistan
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2. (U) The Ministry of Public Health (MoPH) has vastly improved its
health service provision in the last six years with USG assistance.
Afghanistan's under-five mortality rate has dropped 25%, infant
mortality 22%, and access to health care rose by 76%. The number of
midwives has quadrupled and health facilities with a female health
worker have more than doubled. A model for good governance, the
MoPH is also the first ministry in Afghanistan eligible to receive
large amounts of direct funding from the USG due to its high level
of transparency and accountability. The funds travel through a Host
Country Contracting (HCC) mechanism that allows USG assistance to
flow directly to the GIRoA for the provision of basic health
services. Currently, USAID has agreed to channel $236 million
through the MoPH in the next five years. Already managing $40
million a year in USG funding the MoPH could easily manage three
times the resources due to their proven management and capability.

3. (U) Despite these gains, Afghanistan continues to struggle with
one of the poorest public health situations in the world. According
to the United Nations Children's Fund (UNICEF), Afghanistan is the
worst place in the world for children to be born as it has the
highest infant mortality in the world, and the World Health
Organization (WHO) lists Afghanistan as the second highest maternal
mortality rate in the world. To put this into perspective, in 2008,
four times as many women died in pregnancy and childbirth than
anyone did from insurgent/battle related causes in Afghanistan.
Women and girls suffer more by these statistics, and Afghanistan is
one of few countries in which women have a lower life expectancy
than men. Fifty-seven percent of Afghan women marry before the
legal age of 16, and the average Afghan woman has 6.75 children in
her lifetime before dying at age 44. Afghanistan continues to have
extremely poor access to clean water and adequate sanitation and a
high burden of infectious diseases such as tuberculosis (TB),
malaria, and polio. Equally alarming, the population will likely
double in the next 15 years, posing a real threat to the
Afghanistan's stability.

Education - Major Success Could Lead to Major Problems
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4. (U) The USG and the GIRoA are continuing their successful
partnership extending access to and quality of education. The
Ministry of Education (MoE) and the Ministry of Higher Education
(MoHE) vastly improved education service delivery and management
capacity with USG assistance. Key achievements include a seven-fold
increased student enrollment in primary and secondary education,
especially for females; increased quality of the teaching force at
primary, secondary and university levels; increased quality of key
university-level degree programs; increased numbers of adults
enrolling in literacy programs; improved MoE management of the
education system; increased availability of teaching and learning
materials, especially textbooks and teacher guides; a new primary
school curriculum; and improved school infrastructure.

5. (U) These successes will create an estimated 100,000 high school
graduates by 2010 and 600,000 by 2014. These impressive gains
create a high demand for university education, where places are
extremely limited. With 56,000 students enrolled in higher
education institutions in 2008, the rapidly increasing demand easily
outstrips the available places - adding to the instability caused by

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large numbers of out-of-school children and youth and the lack of
workforce skills training opportunities. Women are severely
disadvantaged due to their limited access to secondary schools with
female teachers. In fact, the MoE states that 214 of 400 districts
in the country do not have any female teachers. The MoE estimates
that Afghanistan needs 160,000 new teachers by 2014 to keep pace
with current demand for education as Afghanistan's school-age
population grew by more than 3 percent or 250,000 children last
year. Even if the insurgents stopped destroying schools and
obstructing attendance, the government would face a momentous
challenge in furnishing enough classrooms and teachers for this
burgeoning generation.

Can Other Donors Step Up?
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6. (U) Thanks to excellent donor coordination by the MoPH, the
overall amount needed by the USG is rather small compared to the
amount of funding needed for measurable success in other USG funded
sectors such as rule of law, democracy, and agriculture. The MoPH
has coordinated donor financing by assigning provinces to the three
main donors: USAID has thirteen; the World Bank has eleven; and the
European Commission has ten. Unfortunately, despite the division of
labor, the World Bank (the second largest funder after the USG) is
decreasing their funding from $20 million to $12 million a year for
the next four years to the health sector, while there are no new
donors stepping up to fill the gap. USAID/Afghanistan has engaged
other donors working in health - the German Embassy, the French, the
Lithuanians, the Asian Development Bank, the British, the Canadians
and Norwegians with discouraging results. Due to smaller budgets
and a focus on provinces in which their troops are stationed, other
donors are unwilling or unable to contribute anything meaningful
enough to make a difference in USG strategy.

7. (U) Due to most donors' desire to only work in primary education,
USAID remains one a few that will fund secondary and higher
education - the two most underfunded parts of the education system.
Additive funding would enable USAID to expand much needed
programming in secondary education to allow girls the opportunity to
continue with their education. Moreover, assistance to improve the
quality and accessibility of secondary education is critical to
counterinsurgency objectives as it engages youth in productive
activities at an age when they are most susceptible to recruitment
by the insurgency. USAID could also build on its successes in
higher education by supporting expanded access to females and by
improving quality in fields of study relevant to economic growth.

So Now What?
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8. (U) In a country with the some of the lowest literacy rates and
some of the worst health status statistics in the world, the USG has
had phenomenal success in only a six-year time frame with a
relatively small budget. But, as fruitful as USG investments have
been, much more is needed to build an Afghanistan that can manage
its own future. USAID's health and education budgets have decreased
since FY 08. The USG should be expanding on its success by
increasing support with an increased budget in health and education
to support the GIRoA in these critical areas. Previous budgets have
only been a fraction of the $650 million necessary to support fully
the MoPH and the MoE as they extend their services to the furthest
districts in the USG supported provinces as well as other targeted
districts in other donor supported provinces. Such an amount of
funding could also create a workforce development program and
respond to GIRoA's need to create basic skills training and advanced
university degrees.

9. (U) The health budget could quickly be expanded and expended in
one of the most high-impact, visible and Afghanized means possible,
if we had additional resources into the direct-funding to HCC with
the MoPH. The structure is in place, and it is now a matter of
expanding its reach to further provinces and districts in the South
and East. Filled with both Afghans and expatriates, USAID believes
the MoPH Grants and Contracts Management Unit (GCMU) can triple the
amount it manages while continuing its strong oversight and
accountability. With increased funding, the USG can scale up
successful health programs to meet Afghan citizens' needs and
achieve USG COIN objectives. More specifically, the USG can enable
the GIRoA to offer critical health services to more than 13 million
Afghans through the HCC mechanism with the Public Health Ministry.
Health and education services are often the only face of GIRoA in
remote or non-permissive regions recognized by communities as an
essential service - something the Taliban definitely cannot provide.
It remains critical that the number of local NGOs contracted by

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GIRoA to deliver health services will continue to increase.

10. (U) Much like the HCC with the MoPH, an increase in funding
would enable the USG to support the Education Ministry's goal of
achieving universal primary education by 2020. As Afghanistan's
largest donor to basic education since 2002, USAID is
well-positioned to solidify its gains in the education sector.
These include a quadrupling (from 70,000 children to nearly 300,000)
of the reach of community-based primary and secondary education.
Further funding could also provide assistance to the long-overlooked
madrassas which provide education in areas with high insurgent
activity. As the only formal education accepted by conservative
communities, USG support would promote less radical agendas and
reduce the numbers of youth susceptible to insurgent recruitment.
Madrassa engagement includes support for the implementation of the
GIRoA's secular curriculum with a focus on providing practical
skills to help students transition from school to work.

Requested Levels
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11. (U) With a $212 million FY 10 initial request ($95 for education
and $112 for health) both portfolios will remain severely
underfunded. Post hopes the USG will be able to triple both
portfolios in order to meet the needs of the GIRoA as it further
expands its services into additional districts. An overall USG
commitment to an increased budget is critical for expanding these
services - especially in light of the new US Military commitment.
Expanding access and coverage of high-impact quality health and
education services to currently underserved populations, especially
in insecure areas, through ways that are highly visible and provide
immediate benefit to target communities, will increase legitimacy
and support for the government. Not only do these activities help
improve health and education status in Afghanistan, they support job
creation and employment. Support for building functional and
efficient health and education systems in Afghanistan is a
high-impact, necessary investment for Afghanistan's vulnerable rural
population that will reap benefits for generations to come.

12. (U) COMMENT: Post has requested separately a large plus up in
developmental assistance portfolios to support the emergence of a
legitimate Afghan state that meets the needs and has the support of
its citizens. Despite their importance to COIN, high Afghan citizen
demand, and success in combating some of the worst conditions in
health and education in the world, the portfolios have received low
funding. Therefore, commensurate with the requested increases
slated for the USG economic growth, agriculture, and democracy
portfolios, post believes the health and education portfolios
require an increase and sustained additional support. END COMMENT.

RICCIARDONE

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