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Print version ISSN 0042-9686
Bull World Health Organ vol.84 n.8 Genebra Aug. 2006
LESSONS FROM THE FIELD
Connaissances et expérience en matière de développement : du Bangladesh à l'Afghanistan et au-delà
Conocimientos y experiencia en materia de desarrollo: de Bangladesh al Afganistán y otros lugares
A Mushtaque R ChowdhuryI,II,1; M Aminul AlamII; Jalaluddin AhmedIII
IDepartmant of Population & Family Health, Mailman School of Public Health, Columbia University, New York, USA
IIBRAC Bangladesh, BRAC Centre, 75 Mohakhali, Dhaka 1212, Bangladesh
PROBLEM: In Afghanistan the challenges of development are daunting, mainly as a result of many years of conflict. The formation of a new government in 2001 paved the way for new initiatives from within and outside the country. BRAC (formerly Bangladesh Rural Advancement Committee), a Bangladeshi nongovernmental organization with a long history of successful work, extended its development model to Afghanistan in 2002.
LOCAL SETTING: Provincial Afghanistan.
APPROACH: BRAC has implemented programmes in Afghanistan in the areas of health, education, microfinance, women's empowerment, agriculture, capacity development and local government strengthening, and has taken many of these programmes to scale.
RELEVANT CHANGES: With a total staff of over 3000 (94% Afghan and the rest Bangladeshis), BRAC now works in 21 of the country's 34 provinces. BRAC runs 629 non-formal primary schools with 18 155 students, mostly girls. In health, BRAC has trained 3589 community workers who work at the village level in preventive and curative care. BRAC runs the largest microfinance programme in the country with 97 130 borrowers who cumulatively borrowed over US$ 28 million with a repayment rate of 98%.
LESSONS LEARNED: Initial research indicates significant improvement in access to health care. Over three years, much has been achieved and learned. This paper summarizes these experiences and concludes that collaboration between developing countries can work, with fine-tuning to suit local contexts and traditions.
PROBLÉMATIQUE: En Afghanistan, les difficultés opposées au développement sont décourageantes et résultent principalement des nombreuses années de conflit. La formation du nouveau gouvernement en 2001 a ouvert la voie à de nouvelles initiatives provenant de l'intérieur comme de l'extérieur du pays. Le BRAC (anciennement Bangladesh Rural Advancement Committee), une organisation non gouvernementale du Bangladesh accumulant depuis longtemps les succès, a étendu son modèle de développement à l'Afghanistan en 2002.
CONTEXTE LOCAL: Provinces l'Afghanistan.
APPROCHE: En Afghanistan, le BRAC a mis en uvre des programmes dans les domaines de la santé, de l'éducation, de l'autonomisation des femmes, de l'agriculture, du développement des capacités et du renforcement des gouvernements locaux et a étendu à plus grande échelle nombre de ces programmes.
CHANGEMENTS PERTINENTS: Avec un effectif total de plus de 3000 personnes (94 % d'Afghans et le reste de Bangladais), le BRAC intervient maintenant dans 21 des 35 provinces du pays. Il gère 629 écoles primaires non institutionnalisées, accueillant 18 155 écoliers, principalement des filles. Dans le domaine de la santé, le BRAC a formé 3589 travailleurs communautaires, qui dispensent au niveau du village des soins préventifs et curatifs. Le BRAC gère le plus vaste programme de microfinancement du pays à l'intention de 97 130 emprunteurs, qui ont emprunté au total plus de US $ 28 millions, avec un taux de remboursement de 98 %.
ENSEIGNEMENTS TIRÉS: Les premiers résultats de recherche indiquent une amélioration notable de l'accès aux soins de santé. Sur trois ans, les résultats et les enseignements obtenus sont conséquents. Le présent article récapitule ces expériences et parvient à la conclusion que la collaboration entre pays en développement peut fonctionner, moyennant un ajustement pour s'adapter aux traditions et aux contextes locaux.
PROBLEMA: En el Afganistán los retos del desarrollo son de enormes proporciones, fundamentalmente como resultado de los muchos años de conflicto sufridos por el país. La formación de un nuevo gobierno en 2001 sentó las bases para emprender nuevas iniciativas dentro y fuera del territorio. BRAC (antes Comité para el Progreso Rural de Bangladesh), una organización no gubernamental bangladeshí que ha desarrollado una eficaz labor durante largos años, amplió su modelo de desarrollo al Afganistán en 2002.
CONTEXTO LOCAL: Provincias del Afganistán.
MÉTODOS: BRAC ha implementado en el Afganistán programas relacionados con la salud, la educación, la microfinanciación, el empoderamiento de las mujeres, la agricultura, el desarrollo de capacidad y el fortalecimiento de las administraciones locales, y ha extendido masivamente esos programas.
CAMBIOS DESTACABLES: Con más de 3000 personas en total (el 94% afganos, y el resto de Bangladesh), BRAC opera hoy en 21 de las 34 provincias del país. BRAC dirige 629 escuelas primarias informales a las que acuden 18 155 estudiantes, en su mayoría muchachas. En materia de salud, BRAC ha formado a 3589 agentes comunitarios que trabajan a nivel de aldea aplicando medidas preventivas y curativas. BRAC dirige el mayor programa de microfinanciación del país, con 97 130 prestatarios a los que se han concedido más de US$ 28 millones a una tasa de reembolso del 98%.
ENSEÑANZAS RESULTANTES: Las investigaciones iniciales realizadas muestran mejoras importantes del acceso a la atención sanitaria. A lo largo de tres años se han acumulado muchos logros y enseñanzas. En este artículo se resumen dichas experiencias y se concluye que la colaboración entre los países en desarrollo puede funcionar, siempre que se adapte a los contextos y tradiciones locales.
BRAC (formerly Bangladesh Rural Advancement Committee) is a nongovernmental organization (NGO) established in 1972 in Bangladesh, which today runs development programmes with a staff of 100 000. It has provided microfinance support to over five million women, primary education to over a million children (mostly girls) and health services to over 80 million people. BRAC has developed a sustainable model of development, working to alleviate poverty by taking a holistic approach and tackling the root causes of poverty.1 It implements programmes in the areas of education, health, microfinance, agriculture, women's empowerment, local government strengthening and capacity building. Recognizing that Afghanistan also needed to alleviate poverty and empower the poor, BRAC decided to transfer its development knowledge from Bangladesh to Afghanistan. It has worked closely with the Afghan Government and has become one of the largest NGOs in that country.
The formation of a new government in Afghanistan in late 2001 ended a long civil war and paved the way for new development initiatives from within and outside the country. This situation resembled that of Bangladesh at the time BRAC was formed, both countries having experienced devastating conflicts. Bangladesh also has historic trade and religious ties with Afghanistan. As early as January 2002 a BRAC delegation visited Afghanistan to explore opportunities to extend its development programmes to that country. Based on the findings of this delegation, and the warm reception they received from the government, people and donor community, BRAC decided to begin a new chapter in its history. With some initial funds transferred from Bangladesh, BRAC was in Afghanistan by May 2002. This paper presents some early reflections on the experience of translating and transferring a development paradigm from one country to another.
BRAC in Afghanistan
The challenges in Afghanistan a country with a population of 24 million, divided into a few but traditionally competing ethnic groups were daunting. The per capita gross national income is US$ 250. Net enrolment in primary schools is 15% for girls and 42% for boys. The under-five mortality rate is 257 per 1000 live births, while the maternal mortality rate is one of the highest in the world with 1600 mothers dying per 100 000 births. The total fertility rate is 6.8 and only 10% of couples use contraception.2
As in Bangladesh, social mobilization and community participation became the cornerstones of our approach. In Bangladesh we establish village organizations whose members attend weekly meetings. Poor women are at the center of the village organization and are enabled to overcome poverty, mainly through participation in savings and microcredit interventions. Recognizing the perennial shortage of human resources for development interventions, BRAC also trains paraprofessionals in each village organization in poultry and livestock production, health and agriculture. A community health worker (CHW), for example, is trained to look after the health of people living in her village and treats common illnesses as well as more serious diseases such as tuberculosis.3 BRAC has implemented the same programmes in Afghanistan as it implements in Bangladesh, adapted to local conditions (Table 1).
Three main challenges were identified. The first is access (due to the country's mountainous topography and poor infrastructure); second, inadequate knowledge of basic preventive measures; and third, the societal barriers preventing women from seeking care. BRAC addressed these by strengthening government services and providing complimentary care, devising a model of governmentNGO collaboration. The community-based care provided by CHWs is part of the Afghan government-recommended Basic Package of Health Services that includes maternal and newborn health, child health and immunization, nutrition, communicable diseases, mental health, disability and supply of essential drugs.4 In a typical village, BRAC starts with a survey of health problems and holds discussions with members of the community, including community leaders. One CHW covers 150200 households, which is about half the number that such a worker would cover in Bangladesh.3 In selected provinces and districts BRAC runs primary health care centres and hospitals. All maternal and child health and immunization services are provided free in line with government policy. However, in selected areas BRAC charges a token consultation fee of five Afghani (approximately 10 US cents). BRAC is also participating in a few cost-recovery experiments in health care delivery.
As a result of years of conflict, many people in Afghanistan have been forced to flee their homes and many children have been deprived of an education. Over a third of Afghan children do not attend school today. Many children were also forced to take up arms and some were disabled in the fighting. Girls suffered most as some previous governments banned girls above nine years of age from attending school. Drawing on its experiences in Bangladesh, BRAC has developed a non-formal primary education programme for Afghanistan. There was some initial resistance to providing an education for girls but it soon largely disappeared (Box 1, Table 1).
Afghanistan is one of the least economically developed countries in the world and depends on foreign aid for much of its budgetary support. There is a great demand for cash by poor Afghans. Previously, women were completely excluded from economic activity, and the banking sector was almost non-existent. Today, village organization members are given loans averaging US$ 130, with a 17.5% "service charge". BRAC has also established savings schemes and provides insurance against the death of members (Table 1). Box 2 tells the story of one successful borrower. Recently BRAC received a three-year commitment of US$ 70 million from the World Bank-supported Microfinance Investment Support Facility for Afghanistan (MISFA) to scale up these activities.
National Solidarity Programme
Village-level community development councils are being formed by the government in order to lay the foundations for local governance and accountability. BRAC helps the community development councils by registering voters, conducting elections and providing training on conducting participatory rural appraisal, project preparation, account keeping and monitoring and supervision.
BRAC is training paraveterinarians and establishing nurseries in different parts of the country in order to be able to introduce modern technologies such as high yielding variety seeds and artificial insemination of cattle.
It is well known that the knowledge required to solve many of the world's health problems exists, but that the benefits of this knowledge are often not made available to those who need it most.6 BRAC wants to make its interventions available to as many poor Afghan families as possible in the shortest possible time. As indicated in Table 1 several BRAC programmes, such as training of CHWs, setting up of health posts and schools, training of teachers, and recruitment of microfinance borrowers, have already been taken to scale in Afghanistan. They will soon be further scaled up: the DOTS tuberculosis control strategy is to be implemented in all BRAC areas; 5000 new schools are to be established; and over half a million families are to be reached through microfinance over the next five years.
Capacity building and sustainability
Capacity building is a necessary condition for sustainable development. BRAC has invested in the development of its own staff as well as village organization members. In Afghanistan BRAC has established two training and resource centres, with residential facilities for 150 trainees. There are 37 trainers, two-thirds of whom are Afghans and seven of whom are female. A total of 4348 people were trained during 2005 alone, half of whom were female. This was made possible by the availability of experienced trainers and tested modules. A number of Afghans have been trained in Bangladesh, including three doctors who are enrolled in master of public health degrees at BRAC School of Public Health.
Although donor support will be needed in the foreseeable future, a process of local fund generation through service charges has been started. BRAC is setting up a commercial bank in Afghanistan that will not only contribute to the development of the banking sector but whose profits will be channelled into supporting development programmes.
One of the factors hindering any planned initiative in Afghanistan is the absence of credible information. As in Bangladesh, BRAC has established a research unit, which is initially expected to provide research support to BRAC and later to others. A study carried out by the research unit in a BRAC district near Kabul, in collaboration with Management Sciences for Health (which is funded by the United States Agency for International Development (USAID)), found marked improvement in health service delivery between 2004 and 2006: antenatal care coverage rising from 37% to 91%, tetanus toxoid vaccination from 78% to 88%, institutional delivery from 31% to 55%, and three doses of diphtheriapertussistetanus vaccination from 16% to 51% (Hadi A et al., unpublished document, 2006).
This is a story of how the experience gained in a successful social mobilization effort in one developing country was used to improve the condition of the poor in another. It is clear that some of the principles of BRAC's development model, particularly the holistic approach, have been successfully replicated in Afghanistan. Among the lessons learned are the following:
1. Collaboration between developing countries works. BRAC was able very quickly to initiate a programme in Afghanistan similar to that carried out in Bangladesh, reaching much of the country and becoming one of the largest NGOs operating there. In this process, the name of Bangladesh, a Muslim country with some historic ties and with no strategic interest in Afghanistan, may have played a positive role. Moreover, BRAC had international credentials, which helped garner strong support from the government and donors. It provided a good example of close and effective collaboration between an NGO and a national government. The work of experienced and motivated Bangladeshi staff along with on-the-job training of local staff, and replication of previously tested models of interventions and training modules, facilitated rapid scaling up.
2. Although the basic principles of BRAC's development paradigm worked well and could be replicated, fine-tuning was required based on the situation on the ground: for example, it was necessary to set up separate schools for girls; similarly, for microcredit the term "service charge" was more acceptable to Afghan society than "interest"; the service charge itself had to be increased (from 15% in Bangladesh to 17.5% in Afghanistan) due to the increased cost of delivering credit; CHWs need to cover a lower number of households than in Bangladesh because of the thin population density in Afghanistan and are also given more incentives than in Bangladesh.
3. Throughout its years of work, BRAC has inculcated in its staff certain values, which are then put into practice. Scaling up is one such value, as part of the philosophy of aiming to serve as many people as possible. There is a saying in BRAC that "small is beautiful but large is necessary".
4. Resource constraints are not necessarily a major impediment. BRAC started its Afghan operations by transferring some of its own savings from Bangladesh. As the Afghan Government and donors saw how effectively BRAC was working they quickly became interested in supporting it. In the period 200205, BRAC Afghanistan received about US$ 27.5 million (US$ 12 million in 2005 alone) in donations from overseas donors, including the World Bank, the United Kingdom Department for International Development, the Canadian International Development Agency, the Swedish International Development Cooperation Agency, Oxfam Novib, the Food and Agriculture Organization of the United Nations, the United Nations Children's Fund, the United Nations World Food Programme, USAID and others. This does not include the US$ 10 million loan revolving fund that BRAC received for running the microfinance programme.
Some challenges remain, including security. Although there is no organized resistance to BRAC, two staff members have lost their lives. Expatriate staff are required to have special protection, although they do not feel this to be necessary. We believe that the people with whom we work are our main guarantors of security. Developing local capacity is another challenge. BRAC is training Afghan staff to take up leadership positions in the programme so that the need for expatriates is minimized. This is happening slowly but steadily.
For BRAC the Afghan experience has been very rewarding. It has confirmed that its development model can be applied elsewhere, to great effect. Based on this positive experience, BRAC is now setting up programmes in east Africa and Pakistan.
The idea of BRAC going to Afghanistan and other countries came from its founder and chairperson Fazle Hasan Abed. The authors wish to thank him for his leadership. They would also like to express their sincere gratitude to Jahangir Sardar, Abdullahel Hadi, Masood Ahmed and Manzoor Hasan of BRAC and Abbas Bhuiya of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) for help in preparing the paper.
Competing interests: none declared.
1. Chowdhury AMR, Bhuiya A. Do poverty alleviation programmes reduce inequities in health? In: Leon D, Walt G, editors. Poverty inequality and health. Oxford: Oxford University Press; 2001. p. 31231. [ Links ]
2. United Nations Children's Fund. The state of the world's children. New York (NY): Oxford; 2005. [ Links ]
3. Chowdhury AMR, Chowdhury S, Islam MN, Islam MA, Vaughan JP. Control of tuberculosis by community health workers in Bangladesh. Lancet 1997;350:16972. [ Links ]
4. Ministry of Public Health. A basic package of health services for Afghanistan 2005/1384. Kabul: Ministry of Public Health; 2005. [ Links ]
6. Freedman LP, Waldman RJ, de Pinho H, Wirth ME, Chowdhury AMR, Rosenfield A. Who's got the power? Transforming health systems for women and children. New York (NY): The Millennium Project; 2005. [ Links ]
(Submitted: 20 April 2006 Final revised version received: 4 June 2006 Accepted: 8 June 2006)