Afghanistan Public Policy Research Organization State-Civil Society Relations in Service Delivery in Health and Education In

Afghanistan Public Policy Research Organization

State-Civil Society Relations in Service Delivery in Health and Education in Kabul, Herat, Nangarhar and Takhar

August 2017

Project Report

1 www.appro.org.af 2 Acknowledgments

This report was made possible through funding from the European Union Delegation – Afghanistan for the project “From Black Boxes to Building Blocks: Citizen-State Engagement for Transparency and Accountability in Health and Education” (CS), a partnership led by Oxfam Afghanistan and consisting of Afghanistan Public Policy Research Organization (APPRO), Afghanistan Civil Society Forum-organization (ACSFo), Afghanistan Institute for Civil Society (AICS) and Peace and Training Research Organization (PTRO). We wish to express our sincere thanks to all those who agreed to participate in this research in Herat, Kabul, Nangarhar and Takhar provinces.

About the Researchers The APPRO research team responsible for this report consists of (in alphabetical order): Zahra Ghulami, Nafas Karimi, Ehsanullah Khalili, Zarghona Saify, Lima Sakhizai, Matiullah Dorman, Marzia Rahmani, and Ismail Zahidi.

Zahra Ghulami and Lucile Martin authored this report.

About the Project The CS project was designed to strengthen citizen-state engagement through facilitating civil society involvement in the budget process, particularly by capitalizing on the opportunities provided in the Provincial Budgeting Policy and the forthcoming Sub-National Governance Policy. The CS project has a thematic focus on essential services in health and education and is a follow on project from the Citizens First program, a partnership between Oxfam, PTRO, and APPRO which laid a productive foundation for state-civil society interactions by establishing District Advocacy Committees (DACs), Provincial Advocacy Committees (PACs), and the National Advocacy Committee for Public Policy (NAC-PP) as formal structures through which civil society could constructively engage with state authorities on basic needs of the citizens. For more information on NAC-PP, see: www.nac-pp.net

About this Report In early 2017, APPRO conducted research in Kabul, Herat, Jalalabad and Takhar to assess the current status of service delivery in health and education. The research was designed to document views and perceptions of civil society organizations and state authorities basic service delivery and the opportunities provided for closer collaboration through the implementation of the Provincial Budgeting Policy.

About APPRO Afghanistan Public Policy Research Organization (APPRO) is an independent social research organization with a mandate to promote social and policy learning to benefit development and reconstruction efforts in Afghanistan and other less developed countries through conducting social scientific research and monitoring, evaluations, and training and mentoring. APPRO is registered with the Ministry of Economy in Afghanistan as a non-profit non- government organization and headquartered in Kabul, Afghanistan with offices in Mazar-e Sharif (north), Herat (west), Kandahar (south), Jalalabad (east), and Bamyan (center). APPRO is the founding member of APPRO-Europe, registered in Belgium.

For more information, see: www.appro.org.af and www.appro-europe.net Contact: [email protected]

Photo: Oriane Zerah

APPRO takes full responsibility for all omissions and errors.

© 2017. Afghanistan Public Policy Research Organization. Some rights reserved. This publication may be stored in a retrieval system or transmitted only for non-commercial purposes and with written credit to APPRO and links to APPRO’s website at www.appro.org.af. Any other use of this publication requires prior written permission, which may be obtained by writing to: [email protected].

www.appro.org.af 3 List of Abbreviations

ACSFo – Afghan Civil Society Forum- organization AICS – Afghanistan Institute for Civil Society AIDS – Acquired Immunodeficiency Syndrome AOG – Armed Opposition Group APPRO – Afghanistan Public Policy Research Organization AREU – Afghanistan Research and Evaluation Unit BC – Budget Circular BPHS- Basic Package of Health Services CSO – Civil Society Organizations DoPH – Directorate of Public Health EPHS- Essential Package of Health Services ER – Emergency room HIV – Human Immunodeficiency Virus IDLG – independent Directorate of Local governance IDP – Internally Displaced Person MAIL – Ministry of Agriculture, Irrigation and Livestock MDG – Millennium Development Goal M&E – Monitoring and Evaluation MoE – Ministry of Education MoEC – Ministry of Economy MoF – Ministry of Finance MP – Member of Parliament MoPH – Ministry of Public Health MoU- Memorandum of Understanding MRRD- Ministry of Rural Rehabilitation and Development NAP 1325 – National Action Plan for the Implementation of UNSCR 1325 and Related Resolutions NAPWA – National Action Plan for Women in Afghanistan NESP – National Education Strategic Plan NGO – Non-Governmental Organization NHP – National Health Policy NRC – Norwegian Refugee Council NUG – National Unity Government PBP – Provincial Budget Policy PDC- Provincial Development Council PPFMC – Provincial Public Financial Management Committee PTRO – Peace Training and Research Organisation SCA – Swedish Committee for Afghanistan SDG- Sustainable Development Goal TB- Tuberculosis TMAF – Tokyo Mutual Accountability Framework UNHCR – United Nations High Commissioner for Refugees UNICEF – United Nations’ Children Fund USAID – United States Agency for International Development WHO – World Health Organization

www.appro.org.af 4 Table of Contents Executive Summary ...... 6 Recommendations ...... 7 Background ...... 10 Objectives and Methodology ...... 12 Organization of This Report...... 13 Provincial Budgeting Policy (PBP) ...... 13 Legal and Policy Frameworks ...... 15 Constitutional and Legal Provisions on Education ...... 15 Ministry of Education Strategic Goals ...... 16 Constitutional and Legal Provisions on Health ...... 17 Ministry of Public Health Strategic Goals ...... 17 Current Challenges in Health and Education ...... 19 Challenges in Education ...... 19 Challenges in Health...... 21 Findings from the Provinces ...... 23 Kabul ...... 24 Perceptions of Civil Society Organizations ...... 24 Government’s Perceptions ...... 25 Herat ...... 27 Perceptions of Civil Society Organizations ...... 27 Government’s Perceptions ...... 29 Nangarhar ...... 31 Perceptions of Civil Society Organizations ...... 31 Government’s Perceptions ...... 33 Takhar ...... 35 Perceptions of Civil Society Organizations ...... 35 Government’s Perceptions ...... 36 Recommendations ...... 37 Government of Afghanistan ...... 37 Civil Society Organizations ...... 38 Appendix: Key Informant Coding Protocols ...... 39

www.appro.org.af 5 Executive Summary

Civil society has a crucial role to play to ensure more inclusion and participation of Afghan citizens in the budget process, currently limited to a civil society workshop held on the first budget circular and a limited number of planned consultations with civil society. The 2014 Provincial Budgeting Policy (PBP) is a good opportunity for civil society organizations (CSOs) to engage in influencing the different phases of the budget process, from developing the provincial development plans to budget planning, execution, monitoring and evaluation.

This baseline assessment was undertaken as part of “From Black Boxes to Building Blocks: Citizen-State Engagement for Transparency and Accountability in Health and Education” (CS project), a project which aims to strengthen citizen-state engagement by facilitating civil society involvement in the budget process, particularly by capitalizing on opportunities provided in the PBP and the forthcoming Sub- National Governance Policy.

Conducted by APPRO in early 2017, research was designed to provide an overview of the state of play of service delivery in the health and education sector in Kabul, Herat, Nangarhar and Takhar provinces. This is intended to inform activities of project partners to facilitate civil society engagement in the project process.

Key informant interviews were conducted with civil society representatives engaged in the Health and Education sectors in each province, and relevant government officials form the Independent Directorate of Local Governance (IDLG), the Ministries of Finance, Economy, Public Health, and Education and their provincial directorates in the four provinces of focus of the CS project. Findings show that:

• Though the 2014 Provincial Budgeting Policy (PBP) formally provides opportunities for civil society organizations (CSOs) to influence the budget process to some extent, engagement of CSOs has been limited, and awareness of the PBP remains low among civil society. None of the CSOs consulted in Kabul, for instance, were aware of the PBP process. In Takhar, government officials mentioned some CSOs had been involved, but those interviewed were not aware of the PBP. In Herat, engagement did not go beyond CSO members of Provincial Development Committees. Nangarhar features as an exception, with most CSOs working in the health and education sector interviewed consulted in budget allocation processes. • Most government officials in Kabul, Herat and Takhar were aware of the PBP and its provisions. In Nagarhar, the Mustofiat (Provincial Department of the Ministry of Finance) were those with the highest knowledge of the PBP, with other officials explaining having only been superficially involved. • Service delivery in both sectors is highly wanting in all four provinces. Residents in Kabul city are considered to have an overall better access to both education and health due to higher availability of professional staff and facilities, but resources are insufficient to meet growing population needs. Unlike Improvements have been noted in Nangarhar provincial center in terms of both quality and

www.appro.org.af 6 quantity of health and education services delivered, but the arrival of IDPs from insecure districts and forced returnees from Pakistan has stretched resources available and increasing efforts are needed. Similarly in Herat, improvements made over the past years do not match increasing needs. In Takhar, service delivery in health and education was described inadequate. Facilities are reported as insufficient, underequipped and understaffed in both sectors. • There is a wide discrepancy in terms of availability, access and quality of services between the provincial center, where most facilities are centralized, and outlying districts, which suffer from severe basic infrastructural needs, limited availability of skilled personnel, and insecurity hindering delivery of public services. That said, facilities in the provincial centers of Herat, Kabul and Nangarhar are under increasing pressure due to demographic growth, internal displacement towards major urban centers, and returnee migration. • Basic facilities for public education are lacking. Libraries and laboratories are rare, including in provincial centers. Though Kabul, Nangarhar and Herat provincial centers have relatively better equipped education facilities, these are only available in a few schools. In the outlying districts of Herat, Nangarhar and Takhar, there were reports of students studying under tents or in the open. Basic facilities including proper toilets, clean water, chairs, desks and sport grounds are also lacking in the districts. In Nangarhar districts, schools had to be closed down, particularly for girls, due to security threats from anti-government elements. Cases of poisoning of water supplies for girls’ schools were also reported in Herat. • Public health facilities are insufficient to meet the needs of provincial populations. In Kabul, Herat, and Nangarhar, regional hospitals, attended by patients from neighboring provinces, are unable to provide sufficient care. Lack of beds, with several patients in a single bed, is a recurrent issue. Maternal and reproductive health facilities are understaffed and lack equipment. Pediatric services are available in regional centers, but cannot meet growing demand. In Takhar, specialized medical services are lacking altogether. • Lack of skilled professional staff is a persistent challenge across all four provinces, with severe needs in Takhar. This is particularly the case concerning female staff. Increasingly, insecurity and threats from conservative and anti-government elements dissuade women from taking positions outside of provincial centers. The lack of specialized professional staff is recurrently described as a serious issue in the health sector, requiring those patients to can afford it to go abroad for treatment while others are deprived from care. When specialists are available, such as in Kabul, they are usually deterred by low salaries in the public sector, and concentrate their efforts on private facilities which offer better remuneration. In the education sector, inadequate recruitment processes account for the appointment of unskilled personnel, particularly at the primary level. In Nangarhar and Takhar, corruption and nepotism were also mentioned to adversely affect the quality of education provided because of unjustified appointments. Many skilled teachers also do not apply in the public sector. • There is concern among provincial officials that the standard 1 Million USD allocated per province under the PBP have not been determined based on the specific needs of provincial populations. They suggest allocations be revised based on contextual assessments of needs in each province.

Recommendations

Given the status of service delivery in health and education and the many constraints faced in each sector, each of the key informants were asked what concrete steps needed to be taken to overcome the existing challenges. The responses were combined with the available information from secondary sources to generate the recommendations, available below.

www.appro.org.af 7 Government of Afghanistan:

• Increase quotas for tashkeels of education and health sectors. • Develop a strategy for transparent recruitment of personnel in both sectors. • Develop clear frameworks for budget expenditures at the provincial level, including measurable and outcome-based indicators. • Consider increasing budgets for the recruitment of female staff in health and education sectors, including incentives/ compensations for appointments in remote and insecure districts, or provisions for being accompanied by a mahram. • Build the capacity of provincial staff and provide incentives to retain professional personnel, including adequate remuneration for public service employees. Teachers and municipal personnel are particularly poorly paid, with no recourse to generate additional income from their profession as is the case with many medical staff such as doctors, nurses, and midwives. Currently, public sector employees take on second and third jobs to make ends meet or work with the private sector. Adequate remuneration is also likely to reduce petty corruption in the public sector. • Budget provisions for regular training of health and education staff, including specialized and refreshment trainings. Considering exposure visits in model establishments in Afghanistan or abroad. • Adapt budget provisions to provincial needs. Current budgets are standardized and not based on a contextual analysis of needs. Conduct a comprehensive survey ted to gather information on needs for education and health infrastructures at the provincial and district levels. • Consider increasing budget provisions for building and renovation of infrastructures and purchase of equipment. • Specific emergency provisions to address the needs of returnees and displaced. In both Herat and Nangarhar, the incremental arrival of returnees and IDPs placed additional pressure on already stretched resources and facilities. • Budget provisions for awareness raising programs. Engage Shuras, religious leaders and other existing traditional forms to mobilize them on the awareness of the importance of public service provision especially at the district and provincial levels where they have the highest influence. • Simplify procurement procedures for purchasing equipment or building structures. Complex procurement processes delay the timely delivery of basic services. • Engage more women in the budget process at the district and provincial levels to make sure their needs are taken into account. • Develop clear monitoring mechanisms, and consider involving civil society and communities in M&E. For continual improvement, service provision needs to be monitored and assessed based on outcomes, rather than outputs.

Civil Society Organizations:

www.appro.org.af 8 • Mobilize and engage local governance institutions and structures to participate in prioritization of needs (Community Development Councils, District Development Assemblies, shuras, jirgas, etc.) • Monitor the implementation of the provincial budgeting policy, working closely with local communities. • Work closely with the government officials at the provincial and national levels to increase responsiveness, good governance and accountability in service delivery. • Advocate for the right of IDPs and returnees to education and health in provinces of arrival. • Advocate for the inclusion of a gender perspective in the budget process and service delivery. • Pay specific attention to corruption and nepotism in the delivery of services, denounce corrupt practices and promote good ones. • Design and conduct awareness programs, advocate and provide technical consultations for citizens on health and education needs.

www.appro.org.af 9 Background

Inclusive and participatory budget processes are crucial for ensuring good governance as they ultimately determine the effectiveness of the Government’s provision of services. Despite repeated public financial management reforms, progress in Afghanistan remains elusive in terms of inclusive, accountable and transparent budgeting. In 2015, the Open Budget Index indicated a transparency score below the global average and in sharp decrease in comparison with the Open Budget Survey of 2012.1

Civil society has a crucial role to play to ensure more inclusion and participation of Afghan citizens in the budget process, currently limited to a civil society workshop held on the first budget circular and a limited number of planned consultations with civil society. Since the fall of the Taliban regime in 2001, the people of Afghanistan have expressed high expectations about gaining access to improved social services, such as health and education. However, and despite significant development efforts and resources spent on improving service delivery in Afghanistan, the government’s capacity to deliver these services remains very limited.

Public health and education services are basic tenants of rights based approach to good governance. In Afghanistan, and though their delivery undoubtedly improved since 2001 for both sexes, both the quality and extent of coverage of health and education services remains wanting, with major geographical and gender disparities. The public health sector has limited ability to retain skilled staff, provide medicine, and develop the network of facilities. To compensate for the State’s lack of capacity and resources to deliver health services, and with support from international donors, health delivery was largely outsourced to non-government providers, which are still mainly in charge of health service delivery to date. Education services are delivered primarily by the Ministry of Education. However, schools have little access to non-salary budget allocation, with many inputs provided by international donors and NGOs, including in-kind contributions, direct payments and salary top-ups.2

Civil society’s participation is crucial in overseeing the delivery of essential services such as health and education by the government. As the on-budget funding with direct allocation of funds to the Government of Afghanistan for service delivery is expected to become a major component of aid funds in the Transformation Decade, and while civil society remains the main service provider in Afghanistan to date, a key element of this participation is through influencing of the budget process by citizens and civil society alike.

1 See Open Budget Index Country Report for Afghanistan, available at: http://www.internationalbudget.org/wp- content/uploads/OBS2015-CS-Afghanistan-English.pdf 2 See for instance, AREU (2016), “The Political Economy of Education and Health Service Delivery in Afghanistan”, Afghanistan Research and Evaluation Unit Issue Paper, Kabul, available from: http://www.baag.org.uk/sites/www.baag.org.uk/files/resources/attachments/AREU%20The%20Political%20Eco nomy%20of%20Education%20and%20Health%20Service%20Delivery%20in%20Afghanistan.pdf; and AHMAD A.M., KAKAR F.K, PERROT J.,SABRI B., AND SIDDIQI S., (N.A), “Towards Sustainable Delivery of Services in Afghanistan: Options for the Future”, Bulletin of the World Health Organization, available from: http://www.who.int/bulletin/volumes/85/9/06-036939/en/, World Bank (2013), “Delivering Services to the Afghan People”, World Bank, Kabul, available from: http://siteresources.worldbank.org/AFGHANISTANEXTN/Resources/305984- 1137783774207/afghanistan_pfm_chapter8.pdf

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The 2014 Provincial Budgeting Policy (PBP) is a good opportunity for civil society organizations (CSOs) to engage in influencing the different phases of the budget process, from developing the provincial development plans to budget planning, execution, monitoring and evaluation. Figure 1 below illustrates the different steps in the budget process and entry points for CSOs to influence the process.

Figure 1: Influencing options for civil society organizations in the budget process

Source: Oxfam

The first entry point for civil society engagement is the period before the submission of budget proposals by line ministries to the Ministry of Finance (MoF) as part of the first budget circular (BC1; steps 1-3 in the graph). During this period, line ministries coordinate with provincial departments to align their budget and proposals for development projects with provincial development plans. The “unconditional funds”, introduced by the PBP and submitted together with the BC1, are of particular importance as they allow for discretionary funds to be allocated for prioritized projects in each province. This entry point provides space for civil society to influence proposals for development projects in order to incorporate the specific needs and priorities of local communities.

The second entry point is after the MoF issues the BC2 to the line ministries (steps 4-5). During this period, line ministries will have to prioritize development projects based on the available budget

www.appro.org.af 11 provided by the MoF and in coordination with provincial departments. While the BC1 submission can be considered as a “wish list”, this phase is crucial for civil society to be engaged as the prioritization following the BC2 submission entails significant cuts in the initial budget proposal and discarding of components of projects or entire projects.

The third entry point is the review period with budget hearings and Parliament discussions (steps 6-7). Bilateral meetings between the MoF and line ministries during the budget hearings provide another opportunity to re-iterate and re-emphasize the priorities of local communities in terms of health and education.

The fourth and last entry point for civil society engagement is when the budget cycle ends and budget execution starts. This constitutes the starting point for monitoring expenditures of ministries’ budgets and holding the different levels of government accountable.

Objectives and Methodology

The broad aim of this research is to provide an overview of the state of play of service delivery in the health and education sector in the four provinces targeted by the “From Black Box to Building Blocks: Citizen-State Engagement for Transparency and Accountability in Health and Education” (C.S).3 This is intended to inform activities of project partners to facilitate civil society engagement in the project process. More specifically, the research sought to:

• Review the recent provincial budgeting policy and bring available areas of influence in provincial budgeting process for civil society organizations into the attention. • Collect and analyze data on perception between government officials and civil society organizations on status of service delivery in health and education to understand the main challenges in service delivery in these two sectors. • Generate recommendations on how to improve the service delivery in these two key sectors by engagement of civil society and state authorities on provincial budgeting and contribute to efforts for instituting good governance in Afghanistan.

The following questions guided this research:

Heath Sector Availability Accessibility • Do you think the number of hospitals/clinics is enough • How do you evaluate the accessibility of health to meet the demand of the people in this province? care services based on specific groups of the community? (old people, women or children) • Are there sufficient numbers of medical staff (doctors, • Is there any difference in health care access nurses, and trained service staff) in this province? between women and men in this province? • Are there enough female doctors and nurses at this • Is there any difference in access to health province? service in provinces and districts? • Do the hospitals and clinics in this province have • Are preferences and local traditions taken into enough equipment and facilities? (proper buildings, account in service delivery in health? good food, clean water, beds, toilets, medical equipment and medicines)

3 These four provinces are: Kabul, Herat, Nangarhar and Takhar.

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Education Sector Availability Accessibility • Do you think the number of schools at different levels • How do you evaluate the accessibility of is enough to meet the demand of the students in this education services based on specific groups of province? the community? (boys and girls) • Are there sufficient numbers of professional teachers • Is there any difference in access to education in this province? between boys and girls in this province? • Are there enough female teachers at this province? • Is there any difference in access to education services in provinces and districts? • Do the schools in this province have enough • Are preferences and local traditions taken into educational facilities and equipment (proper buildings, account in service delivery in education? textbooks, libraries, clean water, and toilets)?

This research also sought to answer the following questions across both sectors:

• Is there a role for civil society in current budget process? What are the opportunities for increased civil society influence? • How could the budget process be changed to more women focused and women-rights based? • How the district and provincial demands and priorities can be reflected in health and education budget?

Seventy one (71) interviews were held with key informants in Kabul (19), Herat (18), Jalalabad (18), and Takhar (18). Key informants were drawn from four (4) civil society organizations which work in health sector, 4 civil society organizations which work in education sector in each province and government officials from budget unit and policy and plan department of Ministry of Finance (MoF), Ministry of Economy (MoEC), Independent Directorate of Local Authorities (IDLG), Ministry of Public Health (MoPH), Ministry of Education (MoE) and their directorates at the provincial level, together with provincial councils at each province. See the Appendix the data coding protocols.

Organization of This Report

A review the Provincial Budgeting Policy of 2014 is provided in the next section. This is followed with a background on legal and policy framework for health and education service delivery in Afghanistan and an overview of current challenges in service delivery in both sectors, based on a review of relevant literature and interviews with key informants. Findings from the analysis of the data are followed with recommendations for the government and civil society.

Provincial Budgeting Policy (PBP)

With pressure from the International community and increasing recognition on the need to move away from the centralized budget system in Afghanistan, the Provincial Budgeting Policy (PBP) was developed in 2013 and approved by the cabinet of Afghanistan in 2014. Prior to the PBP, the government had made two attempts in developing provincial budgeting arrangements: one in 2007, and one in 2011. However,

www.appro.org.af 13 due to lack of budget allocation, efforts in developing provincial strategic plans achieved little results.4. The 2007 policy was implemented in the three provinces of Kandahar, Balkh and Panjshir through three line ministries: The Ministry of Education (MoE), the Ministry of Rural Rehabilitation and Development (MRRD) and the Ministry of Agriculture, Irrigation and Livestock (MAIL). The main weakness of the 2007 policy was the lack of attention paid to the role line ministries in Kabul. Following a review of the 2007 PBP, an amended version was developed in 2011. It scope was extended to incorporate MoPH and the Independent Directorate of Local Governance (IDLG), and to cover 34 provinces. The implementation of the 2011 PBP was abruptly interrupted due to a misunderstanding between senior leadership of the Ministry of Finance and the United States Agency for International Development (USAID) – the donor for the project.5

Through the Tokyo Mutual Accountability Framework (TMAF) in 2012, and the London Conference of 2014, the Government of Afghanistan committed to develop a shared budgeting process and transfer service delivery responsibilities to local/provincial entities. This resulted in the development of a new Provincial Budgeting Policy. Approved in 2014, the new PBP presents a number of comparative strengths, including comprehensiveness and policy clarity. It notably provides civil society with an oversight role. This role, however, is not defined clearly, resulting in little involvement, if at all, of civil society in the provincial budgeting process in practice.6

The implementation of the PBP started in 2015 in four line ministries: the Ministry of Education (MoE), the Ministry of Public Health (MoPH), the Ministry of Rural Rehabilitation and Development (MRRD) and the Ministry of Agriculture, Irrigation and Livestock (MAIL). It guides government entities on how to utilize budget as a tool for achieving development goals in line with Public Financial Management Principles. Cross cutting issues such as gender, anti-corruption and poverty are considered in budgeting recommendations. The main areas of focus of the policy are to use the national budget for strengthening local governance to empower citizens at sub national level, and to simplify budgetary and procurement procedures with the aim to improve service delivery.

One year after the launch of the implementation of the PBP, the Ministry of Finance, the Ministry of Economy (MoEC), the Independent Directorate of Local Governance (IDLG) and other main stakeholders organized a two-day National Symposium on Provincial Budgeting Policy in April 2017. The symposium was organized to 1) strengthen the general approach of the government in budget development for budgeting units in Kabul and their provincial directorates, and 2) report about status of the implementation of the PBP, challenges, and future plans.

Challenges identified in the first year of implementation of the PBP are as follows: 7

4 KI-M-Kab-P-IDLG 5 Integrity Watch Afghanistan Report “The role of civil society in PBP, 2015” available from: https://iwaweb.org/dr/wp- content/uploads/2014/12/role_of_civil_society_in_provincial_budgeting_in_afg_dr.pdf 6 Islamic republic of Afghanistan (2014), “Provincial Budgeting Policy”. The only instance in which CSOs are directly mentioned is to assume a consultative role following the publication of provincial budget allocation figures: “[when the] Mustofiat publishes provincial budgetary figures and statistics, the next step is to conduct consultative meetings with civil society organization on provincial budgeting coordination with the Budget Department of the Ministry of Finance.” Mustofiat refers to the provincial representative of the Ministry of Finance. 7 KI-M-Kab-B-MoF

www.appro.org.af 14 • Lack of institutionalization of the PBP through its incorporation in relevant guidelines. • Lack of cooperation at the line ministry leadership level. • Lack of technical capacity in the ministries and provincial directorates regarding budget planning and expenditure of public funds. • Weak coordination in different levels regarding provincial budgeting.8 • Lack of capacity regarding planning based on priorities and project costing at the provincial level. • Lack of reliable and accurate mechanisms for planning and budgeting at the local level. • Lack of clarity regarding the role of civil society organizations. • No local/provincial planning policy had been developed.9 • Lack of feeling of ownership of the process within line ministries. Many do not go beyond donor requirements and lose track of the objective of improved service delivery to citizens. • Contradictions between attempts to decentralize the system and increase citizens’ involvement on the one hand and continued centralized practices hampering the implementation process. • Lack of awareness of the PBP among the public/citizens.

Reports and discussions during the symposium resulted in the following outcomes:10

• 15 to 20 government departments are scheduled to start implementing the PBP by 2020. • Government commitment to ensure transparency and accountability of provincial public management systems. • The Government has allocated AFN 67 million for each province in the national budget of fiscal year 1396 to achieve provincial budgeting goals.11 This amount of money is to be distributed at the provincial level following consultation of central authorities of the four line ministries in charge of the implementation of the provincial budgeting reform. • Local government entities will be given more authority to spend the budget. • 359 small and medium projects for community development in 220 districts are to be funded through this mechanism. MAIL has proposed 98 projects, MoPH 96, MoE 85, and MRRD 80. • A provincial budgeting approach for development projects will be planned by local government officials in consultation with citizens.

Legal and Policy Frameworks

Constitutional and Legal Provisions on Education

The 2004 constitution provides the basis for rights approach to Education.12 The Education Law and its related by-laws and legislative documents provide the legal framework for the development and

8 This issue was solved to some extend at the end of the year as the Provincial Public Financial Management Committee (PPFMC) was established in each province said the head of provincial budget unit department of MoF. PPFMCs are responsible for improving the relationship and coordination between ministries under the leadership of MoF. 9 According to Provincial Budget Unit of Ministry of Finance, this policy has not been developed due to problems between Ministry of Economy and Local Directorates of Local Authorities. 10 Ministries of Finance and Economy, Symposium on the PBP, 2017. 11 Current fiscal year in the Afghan Calendar (March 21, 2017- March 20, 2018) 12 Islamic Republic of Afghanistan (2004), Constitution of Afghanistan.

www.appro.org.af 15 implementation of education programs by the government and other providers.13 The education sector policies are developed for the different focus areas in response to the arising needs i.e. policy for the community based education, teacher education, etc. The by-law for private schools has paved the way for increased private investment and operation of private schools.14

Afghanistan’s international commitments to the Millennium Development Goals (MDGs) and to Education for All (EFA), signed in 2005, have been integrated into its strategic plans for education and development.

To a large extent, the Afghan constitution and other legislative documents developed recently, provide a good framework for the development of education in the country, although the need for revision of selected legislative documents has become clearer with the statement of new policy directions from the new government. Major legislation/regulation areas under consideration for revision include:

• Financing and the share of education in the national budget; • Addressing the overlaps and coordination issues between the education sector ministries; • Fine-tuning MoE core mandates and transferring non-core functions to other institutions; • Creation of a more enabling environment for private sector investment in education; • Teacher recruitment, accreditation and performance evaluation, and • Support to apprentices and private skills providers.15

Ministry of Education Strategic Goals

The overarching goal of the National Education Strategic Plan (NESP) 2017-2021 is to prepare skilled and competent citizens through the education system to sustain Afghanistan’s socioeconomic development and social cohesion. In line with priorities of the National Unity Government (NUG) on building more schools, improving the quality and relevance of programs, and preparing graduates for the labor market, the recent NESP covers three key areas, with associated objectives (Table 2).

Table 2: Strategic objectives of the Ministry of Education Area Strategic Objective Quality and Learners at all levels acquire the knowledge, skills, attitudes, and values needed to be Relevance productive, healthy, and responsible citizens prepared to contribute to the welfare of society and equipped for viable employment in the national and international labor market

Equitable Access Increased equitable and inclusive access to relevant, safe, and quality learning opportunities for children, youth, and adults in Afghanistan, especially women and girls

Efficient and Transparent, cost-effective and efficient delivery of equitable quality education services at Transparent national and sub-national levels Management Source: Ministry of Education, NESP III 2017-2021

13 Islamic Republic of Afghanistan, Education law, available in Dari from: http://moe.gov.af/fa/page/2522, and in Pashto from: http://moe.gov.af/ps/page/2522. 14 National Education Strategic Plan III 15 National Education Strategic Plan III

www.appro.org.af 16 Constitutional and Legal Provisions on Health

The 2004 constitution provides the basis for rights approach to health. Afghanistan is further committed to Millennium Development Goals (MDGs). MDGs in health sector more specifically focus on reducing child mortality, improving maternal health and combatting HIV and AIDS, malaria, tuberculosis (TB), and other transmittable diseases. According to the MoPH, this ministry has achieved the MDG goal of reducing the maternal mortality ratio by three-quarters.16

The recent National Health Policy 2016-2020 (NHP) was developed according to National Unity Government’s priorities, particularly those related to good governance and anti-corruption. The NHP outlines five main policy areas: governance, institutional development, public health, health services and human resources. The aim is to achieve an incremental transition from contracting-out basic health and hospital services basic services to government delivered services throughout the country over the period covered by the policy.

In July 2014, Afghanistan committed to develop the Sustainable Development Goals (SDGs) which the recently developed National Health Strategy 2016-2020 of Ministry of Public Health (MoPH) incorporates. SDG 3 “Ensure Healthy lives and Promote well-being for all at all ages” directly target impact on health. SDG 5.6 on sexual and reproductive health and reproductive rights as part of SDG 5 on gender equality is also relevant to the NHS.17

There are two key policy documents for provision of health services in Afghanistan: the Basic Package of Health Services (BPHS), which delineates services to be provided by primary health care facilities across the country, and the Essential Package of Hospital Services (EPHS), which complements the BPHS and establishes services to be delivered by each type of health facility and resources required to provide them.18 These two documents define the Afghan health care’s referral system, from the village level to tertiary care facilities in major urban centers. Services delivered under these two systems are free of cost for all, with the MoPH responsible for ensuring all citizens benefit from quality health service delivery throughout their life cycle.

The Patients’ Charter reflects the rights based approach to health services and care. The forthcoming Citizens Charter is also expected to reflect an aspect of equality and access to community based health services.

Ministry of Public Health Strategic Goals

In order to focus on technical and managerial leadership in the sector, the Ministry of Public Health identified five priorities in its National Health Policy for 2015-2020 (Box 1).

16 Ministry of Public Health (2014), National Health Policy 2015-2020. 17 UN Open Working Group Proposal for Sustainable Development Goals available from: http://mfa.gov.af/Content/files/SDG.pdf 18 BPHS available from: http://apps.who.int/medicinedocs/documents/s21746en/s21746en.pdf; EPHS available from: http://apps.who.int/medicinedocs/documents/s16169e/s16169e.pdf

www.appro.org.af 17 Box 1: Top Health Policy Priorities, National Health Policy 2015-2020 Governance: enforcing anti-corruption measures and ensuring mutual accountability.

Institutional development: Ministry of Public Health functioning as an effective state institution, including through the development of institutional and management culture, style and practices.

Public health: changing attitudes, perceptions and practices, combatting malnutrition, prevention of uncommunicable diseases, eradication of polio, prevention and control of other communicable diseases and controlling the quality of imported food.

Health services: improving access to, and the sustainability of, quality primary health care and public health, particularly for mothers, the new born, children and adolescents, to make progress towards universal health coverage. Improving the quality of clinical care, the quantity and quality of specialist tertiary care in partnership with the private sector. Controlling the quality of imported pharmaceuticals.

Human resources management: ensure appointments re merit-based, clarify functions and workloads, and measures for staff motivation. Source: National Health Policy 2015-2020 Ministry of Public Health, Islamic Republic of Afghanistan, “The MoPH Vision, Values and Mission.”

The goal of the National Health Strategy for 2016‒2020 is to achieve strengthened, expanded, efficient, and sustained performance of the health system. This is intended to ensure enhanced and equitable access to quality health services in an affordable manner, resulting in the improved health and nutrition status of all populations, especially women, children, and vulnerable groups.19 The National Health Strategy builds on the National Health Policy of 2015‒2020 (NHP), with a planned results framework to guide policy implementation. It further complements the five policy areas identified in the NHP with an additional strategic goal on “M&E, health information, learning, and knowledge/evidence-based practices” as follows:

• Governance: Enhanced, strengthened, and accountable health sector governance decisively instituted, with strong and visible leadership and evidence-based advocacy at all levels. • Institutional development: Strengthened, expanded and sustainable health system with well- functioning institutions. • Public health: Reduced preventable death, illness, and disability through provision of cost-effective, high-impact, evidence-based public health interventions. • Health services: Improved and expanded quality health services provided in an equitable and sustainable manner across all geographic areas and population groups through more effective and efficient use of existing resources, thus achieving better value for money. • Human resources: Competent and motivated health workforce effectively developed, deployed, and retained in line with current and future requirements in an efficient and cost-effective manner. • M&E, health information, learning, and knowledge/evidence-based practices: Strengthened monitoring, evaluation, surveillance, health information, and an improved culture of learning and knowledge management, resulting in increased evidence-based decision making and practices at all levels of the health system.

19 Ministry of Public Heath, National Health Strategy 2016-2020.

www.appro.org.af 18 Current Challenges in Health and Education

Afghanistan has witnessed one of the longest lasting conflicts in the world, with adverse impact on good governance. This ultimately hinders service delivery in essential services such as health and education, particularly in remote and insecure areas where the Government has limited access. That said, numerous gains were made in service delivery in health and education in Afghanistan since 2001. The percentage of girls in schools, the numbers of schools and clinics and the numbers of teachers and medical personnel have steadily risen, albeit unevenly and with reservations about service quality, throughout the country.20 However, and despite undoubtable achievements, previous research by APPRO and others show both sectors still suffer from weak service delivery both qualitatively and in terms of coverage.21

Some of the challenges which hinder service delivery in health and education can be summarized as follows:

• Protracted insecurity and violence has a major impact on the ability of essential services to be delivered to the Afghan population. • Criminal activity, such as kidnapping and robbery, affect the willingness of people to send their children to school and of health and education professionals to travel within areas where they feel their safety is at risk. • Poverty remains an important underlying factor in hindering access to both healthcare and education.

Challenges in Education

Challenges mentioned in access to education include the following:

• Armed Opposition Groups (including Taliban and Da’esh) against girls’ education, including through the closing down and destruction of female schools. • Restrictions over girls’ education beyond Armed Opposition Groups (AOGs), including historical, traditional and cultural factors. • Safety and health concerns lead many parents to avoid sending their daughters to schools. • No or limited availability of female teachers. • Early marriage.

20 See, for instance, APPRO (2014), “Implementation of the National Action Plan for Women in Afghanistan”. Available from: http://appro.org.af/a-critical-assessment-of-napwa/ 21 See for instance APPRO’s Afghanistan Rights Monitor baseline and monitoring reports, available from: http://appro.org.af/?post_type=publication; AREU (2016), “The Political Economy of Education and Health Service Delivery in Afghanistan”, Afghanistan Research and Evaluation Unit Issue Paper, Kabul; PARTO S. and SIDDIQI K, (2016) “Localization of NAP 1325: A 15 Province Status Report”, APPRO, available from: http://appro.org.af/?publication=localization-of-nap-1325-a-15-province-status-report; MARTIN L., PARTO s. and SIDDIQI K. (2015) Security transition and women- a synthesis, APPRO, available from: http://appro.org.af/?publication=women-in-transition-a-synthesis; and ANIL A.S, KERLIDAG M.,PARTO S. (2014), “Implementation of the National Action Plan for Women in Afghanistan: An Assessment”, APPRO, available from: http://appro.org.af/?publication=a-critical-assessment-of-napwa.

www.appro.org.af 19 • Fears of harassment, sexual violence, and kidnapping preventing teenage girls’ access to school.22

Graph 1 below shows the breakdown of public schools in Kabul, Herat, Nangarhar and Takhar provinces in 2016-2017, highlighting the discrepancy in available establishments between provinces. Kabul province presents the highest total number of schools, with five hundred and fourthly five (545) establishments. By contrast, Takhar province has only four (4) public schools, and no high school.

Graph 1: Number of Schools per Province (2016-2017)

600 545 500 400

300 244 160 200 141 126 72 58 100 47 39 29 5 20 4 2 2 0 0 Kabul Nangarhar Herat Takhar

Total Primary Middle High School

Source: Afghanistan Statistics Yearbook 2016-2017

Graph 2 shows the number of students enrolled in government schools in Kabul, Herat, Nangarhar and Takhar provinces in 2016-2017, broken down by sex. In all provinces, the number of female students is lower than that of male students, Nangarhar presenting the widest gap between sexes, with 36 % of female students against 64% of male students. In Herat, girls represent 47% of students, 46% in Kabul, and 44% in Takhar.23

Graph 2: Number of Students Enrolled in Government Schools per Province. (2016-2017)

Total Male Female 1037065 709202 647924 557200 479865 411821 376577 344199 332625 236103 193133 151066

KABUL NANGARHAR HERAT TAKHAR Source: Afghanistan Statistics Yearbook 2016-2017

22 MARTIN L., PARTO s. and SIDDIQI K. (2015) op.cit. 23 Afghanistan Statistics Yearbook 2016-2017, available from: http://cso.gov.af/en/page/1500/4722/2016-17

www.appro.org.af 20

Graph 3 shows the breakdown of male and female government teachers for 2016-2017 in the four target provinces. Kabul and Herat present the higher number of teachers, the number female teachers overriding that of male teachers in both provinces with close to 74% of teachers female in Kabul and 53% in Herat. By contrast, less than 12% of teachers are female in Nangarhar, and 34% in Takhar. Overall this accounts for an average of 1 teacher for 42 students in Kabul, 1 to 49 in Nangarhar, one to 46 in Heart and one to 43 in Takhar. 24

Graph 3: Number of Teachers in Government Schools per Province (2016-2017)

Total Male Female 24904 18391 15274 13037 11532 8116 7932 7158 6513 5265 2667 1505

KABUL NANGARHAR HERAT TAKHAR

Source: Afghanistan Statistics Yearbook 2016-201725

Challenges in Health

Challenges in health are numerous. Afghan citizens suffer from high levels of vulnerability with high poverty levels, widespread food insecurity, limited access to drinking water and sanitation facilities. Access to health is further compounded by limited access to poor road infrastructure, and general shortage of medicine and skilled health workers, particularly female, including skilled midwives. Health building infrastructures are poor, and at danger of being levelled in case of natural disasters. This is further aggravated by the low level of funding of the health system (BPHS and EPHS) 26

Graph 4 shows the number of public health centers in each province in 2016-2017, broken down in basic, health centers (BHC) and comprehensive health centers (CHC), which provide the highest panel of health services at the local level, with only District and Regional Hospitals above them. Kabul and Herat present the highest number of health venters with 118 health centers for an official 4.5 million inhabitants in Kabul and 85 health centers for official estimates of 1.9 million inhabitants in Herat.

In Herat, however, the number of CHCs is relatively much lower, with only 20 CHCs against 52 in Kabul. Nangarhar presents a total of 63 health centers, including 26 CHCs and 36 BHCs, and Takhar 49 health centers, including 13 CHC s and 36 BHCs. In terms of ratio to official population estimates, however, Kabul presents the lowest ratio of facilities per inhabitant with one health center for 38,336 inhabitants,

24 Afghanistan Statistics Yearbook 2016-2017, available from: http://cso.gov.af/en/page/1500/4722/2016-17 25 Available from: http://cso.gov.af/en/page/1500/4722/2016-17 26 WHO website, available from: http://www.who.int/hac/donorinfo/afg/en/; MARTIN L., PARTO s. and SIDDIQI K. (2015), op.cit.

www.appro.org.af 21 and Takhar the highest, with one health center for 20,415 inhabitants (see graph 5). Herat province, however, presents the lowest ratio of CHCs per person, and Nangarhar the highest. These estimates, however, need to be taken with caution given debates surrounding official population estimates, notably in light of recent arrival of returnees and IDPs in the target provinces.

Graph 4: Number of Comprehensive and Basic Public Health Centers per Province (2016-2017) 70 66 65 60 52 50 40 37 36 30 26 20 20 13 10 0 Kabul Nangarhar Herat Takhar

Basic Comperhensive

Graph 5: Ratio of Health centers per inhabitant (official estimates) 0.00006

0.00005

0.00004

0.00003

0.00002

0.00001

0 Kabul Nangarhar Herat Takhar

Health Centers Basic Health Centers Comprehensive Health Centers

Based on data from: Afghanistan Statistics Yearbook 2016-2017

Graph 6 shows the number of medical personnel of MoPH in each target province in 2016-2017, broken down by sex. Kabul presents a much higher number of personnel than the other target provinces with a total of 3,810 personnel as opposed to . The percentage of female staff is generally very low, with 29% for Kabul, 23% in Herat,15% in Nangarhar; 23% in Herat; 15% in Nangarhar, and 13% in Takhar.

www.appro.org.af 22

Graph 6: Number of Medical Personnel of MoPH per Province (2016-2017) 4500 4000 3810 3500 3000 2695 2500 2000 1500 1115 1000 450 382 491 377 500 68 114 170 148 22 0 Kabul Nangarhar Herat Takhar

Total Male Female

Source: Afghanistan Statistics Yearbook 2016-2017

Graph 7 shows the number of health associate professionals personnel of MoPH, broken down by sex, in each target province for 2016-2017. As for medical personnel, Kabul province presents a much higher availability of health associate than other provinces, which present a total number of health associates ranging from 840 for Takhar to 964 for Nangarhar. Percentages of female health associates are 36 % in Kabul are female, 33% in Nangarhar, and close to 40% in Herat and Takhar.

Graph 7: Number of Health Associate Professionals Personnel of MoPH per Province - (2016-2017)

6000 5559

5000

4000 3540

3000 2019 2000

964 856 840 1000 645 516 589 319 340 251 0 Kabul Nangarhar Herat Takhar Total Male Female

Source: Afghanistan Statistics Yearbook 2016-2017

Findings from the Provinces

This section of the report provides findings from the analysis of data collected in Kabul, Herat, Nangarhar and Takhar. Findings are reported based on indicators grouped under availability, accessibility/quality and local/provincial priorities. An important aspect of questionnaires for both civil

www.appro.org.af 23 society organizations and government officials was about the recent Provincial Budgeting Policy (PBP). Civil society organizations were asked about their awareness of the PBP, and government entities about their roles and responsibilities in the process and progress to date on its implementation.

Kabul

Perceptions of Civil Society Organizations Both the quality and availability of health and education services and facilities are considered better in Kabul than in the rest of the country. This, however, is partly attributed to the higher availability of skilled professional, institutions of higher education, and health facilities.27

Some CSOs emphasize the quality of public services delivered was far from satisfying, essentially because of lack of skilled personnel. 28 Access to education outside of the capital city remains a challenge, with insufficient education and health facilities in the districts –in some cases, no facilities at all, and a general lack of qualified staff. There is widespread agreement that the quality of services and accountability of the government decreases as one moves away from the capital.29

Education

In Kabul city itself, the equipment and facilities in education are considered insufficient to meet the needs of a growing population. Only three public education institutions are considered to provide adequate facilities including a laboratory, clean water, and libraries: Habibia, Isteghlal and Amani high schools.30 More generally, the quality of education at the elementary and secondary levels is described poor, and in some places, very poor, mostly due to lack of familiarity of teaching methods for children often resulting in low proficiency of secondary school graduates in reading and writing. Most teachers are considered to lack training and experience, usually taking position without appropriate training following completion of 12th grade. The quality of education is described a comparatively better at the high school and university levels in Kabul city.31

That said, CSOs interviewed were unanimous in stating there were little differences in access to education between men and women in Kabul city compared to the rest of the country. This is attributed to a relatively stable security in the past years, little distance between schools and homes, and more acceptance of girls’ school attendance and mobility as compared to the provinces. Even in cases where schools are far, families are often willing to provide transportation for girls.32 The case is reportedly different in the districts, where conservative values still prevail, restricting women and girls’ mobility and girls’ access to education after puberty. This is further aggravated by the lack of female health and education staff. 33

Health

27 KI-M-Kab-E-CSO-1 28 KI-M-Kab-E-CSO-3 29 KI-M-Kab-E-CSO-3 30 KI-M-Kab-E-CSO-2 31 KI-M-Kab-E-CSO-4 32 KI-M-Kab-E-CSO-3, KI-M-Kab-E-CSO-4, KI-M-Kab-E-CSO-2 33 All CSOS interviewed which work in health sector

www.appro.org.af 24

Improvements were noted in the availability of health services, particularly in Kabul city, where there is relatively higher number of qualified and professional doctors.34 However, as for education, the quality of services provided is considered low, with a general lack of adequate equipment as well as trained and specialized medical staff in public institutions. Patients who can afford it are often required to travel to neighboring countries to received proper treatment, while others are deprived of the care they need.35

The poor quality of food provided to patients, the lack of beds, and the shortage of medicines are also regularly raised. The situation is even worse in districts where health facilities often lack proper infrastructures and face a serious shortage of equipment.36

Reliable pre- and post-maternal services are available in Kabul. But the utilization of these services is sometimes a challenge, depending on the degree of decision making and mobility of women in a given family. Another concern is the financial status of the families, with some families too poor to follow the doctors’ advices in terms of nutrition and treatment. 37

Awareness of and Engagement in the Provincial Budget Policy

None of the CSOs consulted in Kabul mentioned being aware of the PBP. That said, they consider the most appropriate channels for reporting district and provincial needs to government decision makers and to ensure they are reflected in sectoral provincial budgets are provincial and district councils.38 Provincial councils are indeed reported as playing a significant role in promoting responsiveness of government authorities in service delivery in these key sectors. CSOs also considered as key in channeling citizens’ needs from the district to the national level, advocating for adequate budget allocation and monitoring the budget process.39

Government’s Perceptions Interviews were conducted with officials from MoPH and MoE, IDLG, MoEC and MoF. Officials consulted believe Most CSOs interviewed are aware of the PBC process, had been involved in budget allocation through the Provincial Development Council (PDC) under the leadership of the provincial governor, and had participated in different sessions and meetings held for allocation of the budget for this province.

Education

Challenges in provision of education services in Kabul were reported primarily at the district level, with little issues reported in Kabul city itself. Officials confirmed the availability of skilled teachers in the capital, including enough female teachers to meet demands for girls’ education.40

According to MoE officials, 89% of public schools have adequate building infrastructure in Kabul city – a figure considered as high as compared to the rest of the country. That being said, and though there are

34 KI-M-Kab-H-CSO-1, KI-M-Kab-H-CSO-2, KI-M-Kab-H-CSO-3 35 KI-M-Kab-H-CSO-2, KI-M-Kab-H-CSO-3 36 KI-M-Kab-H-CSO-1, KI-M-Kab-H-CSO-2, KI-M-Kab-H-CSO-3 37 KI-M-Kab-H-CSO-3 38 All interviewees 39 KI-M-Kab-E-CSO-4 40 KI-M-Kab-B-MoE

www.appro.org.af 25 no reliable statistics on needs in terms of places required to meet the demand, the rising number of students’ places increasing pressure on existing facilities, with enrolments rates higher than the current capacity of schools and adverse effects on the quality of education provided. Low salaries in the public education sector further deter skilled teachers from applying to government jobs in primary and secondary education.41

Government officials’ estimates are similar to that of civil society in terms of lack of adequate equipment such as laboratories, libraries, and sanitation.42 The issue of child labor and its effects on children’s access to education is also a key concern, particularly for boys.43

That said, the MoE considers that the planned implementation of the NESP 2017-2021 will contribute to meet objectives in terms of equal access to education for all. In the districts, this will include literacy programs and awareness campaigns on the importance of girls’ education. The Directorate of “Social Movement” will be responsible for awareness programs, in direct collaboration with provincial councils, jirgas and shuras which demonstrate capacity to promote education opportunities for women and girls. The ministry also expects to build on the National Program for Women’s Economic Empowerment, launched in 1396 through the creation of 3000 vacancies for female educational staff. 44

Health

MoPH indicated the budget allocated to MoPH by the Ministry of Finance had been steadily decreasing over the past years. The current budget is considered insufficient to meet needs, particularly in terms of facilities. The situation is considered at risk of worsening in coming years with increasing demographic, pressure on already limited facilities.45 As a result, the MoPH primarily relies on donor funding for delivery of services. Conditions set by the donors for releasing funds reportedly leave the MoPH with limited autonomy in terms of programming and decision-making, notably as to where services are to be delivered and what priorities are. 46

Though improvements in equipment have been noted in some clinics in Kabul, a critical concern is the lack of doctors trained in using them. Despite a comparatively higher proportion of skilled health personnel in Kabul as compared to provinces, low wages for public health staff discourages professional doctors from entering the public service. To compensate for low income, many of those who do work in public structures work part time in private clinics, decreasing the time they allocate to public services to concentrate in higher income generating activities in private facilities. The poor quality of drugs and medicine is another major problem, in Kabul as in the rest of the country. 47

Assessments by public officials on the availability and usage of pre- and post-maternal care in Kabul city and the districts are similar to those of civil society. Female doctors, however, are lacking, especially in a context where it is not considered acceptable for women to consult male specialists. Officials also

41 KI-M-Kab-P-IDLG, KI-M-Kab-P-MoEC 42 KI-M-Kab-P-MoE, KI-M-Kab-B-MoE, KI-M-Kab-P-IDLG 43 KI-M-Kab-B-MoE,KI-M-Kab-P-MoE 44 KI-M-Kab-B-MoE, KI-M-Kab-P-MoE 45 KI-M-Kab-B-MoPH, KI-F-Kab-P-MoPH 46 KI-F-Kab-P-MoPH; KI-M-Kab-P-MoEC 47 KI-F-Kab-P-MoPH, KI-M-Kab-B-MoPH; KI-M-Kab-P-LDLG

www.appro.org.af 26 underline the need for increased awareness among women of the need to consult before and after birth. 48

Awareness of and Engagement in the Provincial Budget Policy

All government officials interviewed were aware of the provincial budgeting policy, had participated in different workshops and meetings about the PBP, and had incorporated policy requirements in their budget provisions for the current fiscal year – including to bring provincial staff in Kabul for consultations on budget allocation.49

However, no framework for budget expenditures at the provincial level has been developed, and officials within both the Ministry of Education and the Ministry of Public Health complained standardized budget allocation to provincial directorates was based on political considerations and did not take into account the contextual specificities of each province: 50

[Provincial budgets] are not in accordance with province population and needs, as the demand in some provinces is lower than [the proposed] amount, while it is higher in others …. The Ministry of Public Health tries as much as possible to consider the needs of each province. Budget proposals to the Ministry of Finance are technical and were developed taking in to account differential needs in each province. The issue is that when the budget is sent to the Ministry of Finance and later to the Parliament [for approval], it takes on a political dimension. They lose sight of priorities and instead propose new projects without coordinating with us [MoPH]. The budget process is also political.51

A “People’s Expectation” program has been developed, including an education committee in charge of consulting citizens on their need sin the education sector at the provincial and district levels. District and provincial councils are key stakeholders in this process.

The majority of those interviewed considered both district and provincial councils had an essential role to play in provincial budgeting. They welcome their coordination with directorates of ministries in order to prioritize education and health needs and send the requests to each ministry. 52 MoE’s Social Movement department is another channel mentioned to voice people’s needs from the district to the provincial and eventually national level.53 While they consider civil society can play a positive role in the budget process, MoE and MoPH officials deplore the lack of coordination among CSOs.54

Herat

Perceptions of Civil Society Organizations Service delivery in both sectors is considered insufficient to meet the needs of the population. While it has slightly improved in the center, drastic shortages are reported in service delivery in the districts.

48 KI-M-Kab-B-MoPH, KI-F-Kab-P-MoPH 49 All government interviewees 50 KI-M-Kab-B-MoE; KI-M-Kab-P-MoE 51 KI-F-Kab-P-MoPH 52 KI-M-Kab-B-MoE 53 KI-M-Kab-P-MoE 54 All government interviewees

www.appro.org.af 27 Education

There are significant discrepancies in the quality and availability of services between the provincial center and the districts. One of the significant concerns of civil society is the rising pressure on education services due to internal displacement towards Herat from provinces in the region. Rising poverty and child labor preventing children from attending school on a regular basis is a rising concern.

In the provincial center, classrooms in public schools comprise an average of 50-60 students. Allocating land for building more schools and expanding the current number of classrooms was considered a priority, as was recruiting more skilled teachers. Shortages were also reported in provision of books and material. Public schools also face the rising competition of private institutions offering better quality of education and material for smaller classrooms (an estimated 25-30 students per class).

In the districts, lack of applications from skilled teachers entail recurring to unqualified local capacities. An estimated 20% of students study in the open air or in tents due to lack of proper infrastructure. The majority of schools are deprived of basic facilities including clean drinking water, proper toilets, desks, chairs, books and laboratories. In some cases, 80-90 students attend a single class, adversely affecting the ability of students to get proper education. Unlike in Herat city, land is available for school buildings but funds are lacking for construction. In some cases, community contributions compensate for the State’s lack of capacity to fund construction of infrastructures.

Distance from schools reportedly adversely impact girls’ access to education throughout the province. In the districts especially, security conditions are considered inappropriate for girls to travel half an hour to an hour to reach schools. Conservative values, but also opposition to girls’ education by AOGs, are other serious obstacles to girls’ access to education. Poisoning of drinking water in girls’ schools over the past year have raised serious concern among both the population and CSOs.55

Among measures taken to improve girl’s access to education in Herat province is the creation of women councils in 7 districts, which encourage families to allow their daughters to attend class. This is complemented by promotion of girls’ education by provincial and district councils, government officials and civil society: 56

CSOs conduct advocacy to improve girls’ access to education. We advocate at the district, provincial and national levels so that measures to increase girls’ access education is integrated in policies and their implementation. A recent example is advocacy for simplification of the process to receive a graduation certificate.57

Health

As for education, rising demographic pressure, including due to internal displacement, have led to an increase in the demand for health services in the province.58 As the main facility in the region, the regional public hospital of Herat is visited by patients from other provinces (Farah, Ghor, Kandahar, and

55 KI-M-Her-E-CSO-2 56 KI-M-Her-E-CSO-4, KI-M-Her-E-CSO-1 57 KI-M-Her-E-CSO-3 58 KI-M-Her-E-CSO-2, KI-M-Her-E-CSO-3

www.appro.org.af 28 Badghis) placing additional pressure on the facility. This is aggravated by the physical degradation of the building, lack of skilled personnel, and of basic services, including ER, medicine and equipment for intensive care. Reproductive health services are reportedly understaffed and lack basic equipment. 59 Insecurity in neighboring provinces and districts has also affected the delivery of drugs and material. Most patients requiring advanced treatment cannot get appropriate care in Herat and have to travel to Kabul or Iran. 60

At the district level, insecurity, distance from clinics, lack of transportation facilities and skilled professional are the main challenges in access to healthcare. Insecurity deters medical personnel, particularly women, from attending to district health needs.

Pre- and post-maternal care are available in Herat provincial center. Public awareness on women’s health has also increased in recent years and more women seek these services, though more efforts are required to raise understanding of basic health needs for women. That said, the number of skilled midwives and nurses is insufficient to meet the needs of women. In the districts, access to reliable and safe healthcare for mothers remains low. 61

Awareness of and Engagement in the Provincial Budget Policy

Most of the CSOs interviewed reported not being aware of the PBP. Those who are members of Provincial Development Committees, however, had been consulted as part of the process, had access to budget and development plans, and actively participate in discussion sessions at the Departments of education and health.

CSOs interviewed in Herat believe district and provincial councils are playing a significant role in setting priorities in health and education sectors, relaying needs to the relevant government authorities:

Provincial council has an educational committee, which help us in project designing. Moreover, district and provincial councils are in contact with us in all 7 districts in which we work. They channel needs and priorities of people to Departments of health and education.62

Respondents further underlined existing structures at the district level, such as education and health councils which hold monthly meetings to discuss needs, can be used to channel information to provincial councils and sectoral committees.63

Government’s Perceptions Reports of government officials on the availability and access of health services in Herat reflect those of CSOs. There is acknowledgement that services are insufficient throughout the province, that appropriate infrastructures are lacking and most facilities in both sectors, and are understaffed. The settlement of IDPs and returnees in the provincial center and its vicinity is also placing additional pressure on health

59 KI-M-Her-H-CSO-1, KI-M-Her-H-CSO-3 60 All interviewees 61 All interviewees 62 KI-M-Her-E-CSO-4 + all interviewees 63 All interviewees

www.appro.org.af 29 and education services. Insecurity is also reported to limit government service delivery in some districts where government control is challenged.64

Quotas for personnel within tashkeels of both Directorates were also considered insufficient to attend to needs. While qualified individuals are available on the labor market, the imposition of quotas by the central government limit recruitment possibilities in both sectors.

Education

The quality of education in public schools remains weaker than in private ones. There are 1002 public schools in Herat province, 72% of which have no laboratories, 70% have space available for physical education, 426 of which do not have a yard. Unlike civil society representatives, representatives of the Directorate of education consider the number of schools in the provincial center is sufficient to address the current demand. However, they insist more schools need to be built in the districts to facilitate access for students, particularly in remote areas. 65

While girls’ access to education is widely accepted as a given in the provincial center, many girls are still denied access to secondary education in the districts. In order to increase girls’ access to education, mosques are mobilized in the start of each academic year. However, there are increasing concerns that awareness raising programs will be affected by rising insecurity.66

As above, restrictions imposed on quotas for recruitment of teachers is an additional challenge for the Directorate of Education, limiting its responsiveness to growing demands for more teachers. 67

Health

The Herat regional hospital cannot meet the needs of the growing population of the province, let alone those of neighboring ones. Built 26 years ago, the building needs to be renovated and facilities expanded. The Health Directorate requested the assistance of the private sector for 400 additional beds. More generally, there is a constant need for more skilled professional medical staff, particularly for female nurses, doctors and specialists. The issue is particularly acute in districts. Low salaries, compounded by fear due to insecurity, deter most professionals from taking on positions outside the provincial center. Health Directorate officials interviewed insisted on the need to raise salaries of those who accept to go work in the districts, particularly for women.68

Maternal mortality rates in the province have dropped in recent years, and women’s access to health services in general has improved due to targeted awareness raising programs and efforts to increase women, mothers’ access to health and gender sensitivity among medical staff. However, and while maternal care is available in the provincial center, they remain severely lacking at the district level. Insecurity, inappropriate road infrastructure, distance from health centers, and conservative views resisting women’s access to health facilities, including pre- and post- maternal care services, without a mahram, further impede women’s access to health. According to data collected by the Provincial Health

64 KI-F-Her-PC-1 65 KI-M-Her-P-ED 66 All interviewees 67 All interviewees 68 KI-M-Her-B-ECD, KI-F-Her-P-MUS

www.appro.org.af 30 Directorate, women’s utilization of maternal care services drops after giving birth, primarily due to lack of awareness.69

One of the issues raised by the Department of Public Health in Herat was the lack of monitoring staff. As for education, quotas imposed in the Health Tashkeel restrict recruitment of additional health staff in the public sector:

In previous years, we have trained 200 women and girls from all districts of Herat province, providing accommodations, trainings and an amount of allowance for them. The government public institute is active and provides two to three year trainings in nursing, midwifery and other skills annually. It is the responsibility of Ministry of Higher Education [in Kabul] to raise quotas for the girls who graduate from 12 grades so they can enter the medical university and become doctors.70

Awareness of and Engagement in the Provincial Budget Policy

The wide majority of government officials interviewed in Herat were informed on the PBP and their role in the process. However, members of the provincial council explained that due to their limited coordination and cooperation with IDLG, they were less likely to be involved in the process.

Nangarhar

Perceptions of Civil Society Organizations According to CSOs interviewed, service delivery in Health and Education in Nangarhar has qualitatively improved over the last years. However, arrival of returnees from Pakistan and the concentration of IDPs from insecure districts on Nangarhar other provinces in the Eastern region (Nangarhar, Kunar and Laghman) around the provincial center is increasing needs across all sectors in the province.

Gender differences in access to health and education are a constant concern, particularly in the districts, due to conservative norms restricting women’s mobility and rising insecurity.

Education

As a result of demographic pressure, classrooms are overpopulated, with an estimate of 70-80 students per classroom. The number of schools is insufficient, and 50% lack proper infrastructure. The majority need additional chairs, books, and improved access to clean water and sanitation. In some districts contested by AOGs, school buildings have been destroyed. 71

Public schools are available for both girls and boys, but particularly in the districts, girls face restrictions in attending school, particularly after the primary level. Efforts to increase girls’ access to education include awareness-raising on the importance of access to education for men and women, primarily through the mobilization of Islamic values. Some CSOs also signed Memorandums of Understanding (MoUs) with member of parliaments (MPs) and private universities to decrease the tuition fee for female students.

69 KI-F-Her-P-MUS 70 KI-M-Her-P-DH 71 KI-M-Nan-E-CSO-3

www.appro.org.af 31

Additional support is provided by international agencies and NGOs. The Norwegian Refugee Council (NRC) has built 60 ‘quick education’ for refugees and IDPs. NRC, UNHCR, UNICEF and SCA assisted in providing access to clean water and sanitation in schools. 72

Challenges in access to education include insufficient educational facilities and equipment, lack of qualified teachers – particularly for girls in the districts, but also rampant corruption within the sector. Increasing child labor because of poverty was also reported as hindering children’s access to school.

The quality of education in elementary schools in Nangarhar province is considered weak. This is mainly no minimum level of education has been set as a pre-requirement for recruitment of elementary school teachers. At the secondary level, the quality is considered good overall, though bribery of teachers for awarding grades and certificates is reportedly common. At the University level, Nangarhar benefits from a high reputation, with qualified teachers and decent salaries.73

Corruption and nepotism in the recruitment process of education staff is a recurrent concern, with the appointment of unskilled personnel based on relations rather than merit and qualifications. 74

Health

All CSOs interviewed explained that despite efforts, the provision of health services was in a critical state. There are not enough health centers and the regional hospital in Jalalabad cannot accommodate patients from neighboring districts, let alone those from other provinces. The arrival of returnees expulsed from Pakistan, and increasing conflict induced displacement in the region over the past year have led to a situation of crisis in the sector. Additional efforts are urgently required to address basic health needs.75

The regional hospital attends to patients coming from Behsud, Kama, Khewa, and Goshta districts. Existing facilities are insufficient to meet those needs. In remote districts, there is basically no delivery of health services since no doctor is willing to go there. Patients from remote areas face transportation issues to come to the center and are not treated well because of the huge number of patients at the hospitals in the center. Low availability of medicine and facilities is another concern.”76

Though the quality of services provided in the regional hospital is considered relatively good as compared to others in the country, it lacks medicine, qualified staff, and advanced equipment for diagnosis. The reproductive health service, in particular, is overstretched:

The delivery section of Nangarhar regional hospital is crowded and doesn’t have the capacity for current visitors. Therefore, mothers who come there for delivering after an hour or so need to leave the hospital. There are some health services available for mothers in the districts as well but mostly people don’t rely on them and they prefer the zone hospital that is why it is always crowded.77

72 KI-M-Nan-E-CSO-3, KI-M-Nan-E-CSO-1 73 KI-M-Kan-HE-CSO 74 KI-M-Kan-HE-CSO 75 All interviewees 76 KI-M-Nan-EH-CSO 77 KI-M-Nan-H-CSO-4 + all interviewees

www.appro.org.af 32 Women’s access to health is further limited by the lack of female health staff and doctors in some districts. As some are generally not allowed to consult male doctors, this de facto restricts their access to health to services in the provincial center, with implications in terms of organization and costs of transportation. More generally and insecurity and AOG activity rises, doctors of both sexes are reluctant to practice in the districts. The number of qualified doctors is 132 and nurses 108 which include both male and female.78

Attending to the needs of children in both sectors is considered as a priority requiring specific focus and separate budget allocation. 79

CSOs interviewed also expressed concern about inappropriate budget allocation to provide functioning service for all, but also political interference and corruption in appointments of doctors in public hospitals:

The total number of doctors as presented in the tashkeel is proportionate [in theory] in the center and districts. But because of corruption and insecurity this has not been institutionalized and therefore we need a transparent system to monitor appointments.80

Awareness of and Engagement in the Provincial Budget Policy

Most CSOs interviewed are aware of the PBC process, had been involved in budget allocation through the Provincial Development Council (PDC) under the leadership of the provincial governor, and had participated in different sessions and meetings held for allocation of the budget for this province. While they all welcomed the promotion of a bottom-up approach through the PBP, most didn’t think this opportunity would result in reflecting real priorities of education and health in provincial budgets due to inefficient bureaucracy and persistent centralization. Attending to needs in remote and insecure districts, in particular, is considered a challenge. 81

As in Herat and Kabul, District and Provincial Councils are considered as having a vital role to play in budget allocation at the provincial level. However, insecurity has impeded the activity of councils outside of the provincial center and relatively secure districts of Behsud, Kama, Surkhrod and Khewa. 82

Government’s Perceptions Education

Insecurity is a serious source of concern for the delivery of education in remote areas and contested districts, resulting in serious discrepancies between the center and outlying districts. There are 902 public schools Nangarhar, providing services to an estimated 800 000 students of which 38% are female. However, only approxiamtey 20 to 25 000 of these students are in the districts (2.5%).83 Secure districts also received more attention than others, with additional schools built in Surkhrod, Behsud and Kama, while in other districts, such as Spinghar, students study on the open or under tents. According to DoPH

78 KI-M-Kan-H-CSO-1 + all interviewees 79 KI-M-Nan-HE-CSO-5 + other interviewees 80 KI-M-Kan-HE-CSO-5 81 KI-M-Nan-HE-CSO-5 82 All interviewees 83 KI-M-Nan-P-ED

www.appro.org.af 33 data, 50% of schools do not have adequate infrastructure and additional funds are needed to improve and expand existing education facilities and infrastructures 84

The politicization of education, with interference of powerholders and political parties in the allocation of projects and recruitments, is another recurrent challenge, with adverse effects on identification of priorities and service delivery.

Assessments of the Directorate of Education in terms of gendered differences in access to school are similar to those of civil society, with girls’ access to education more restricted as one moves away from the provincial center, particularly after puberty. Insecurity primarily affects girls’ attendance and female teachers decline appointments in districts where they may be at risk.

Health

Representatives of the Provincial Directorate of Public Health (DoPH) consider the delivery of health services has improved in Nangarhar in recent years. However, there are still 20-30% of “white zones” where health facilities and structures are unavailable. Clinics and hospitals are available in “green zones” [ie. cleared from mines], with at least one female staff reportedly present in 70% of health centers. However, trained female personnel are increasingly reluctant to work in remote districts where security is a growing concern. The Directorate further reports that quotas set for the tashkeel are insufficient to meet needs.

In the absent of adequate support from the central government, demographic growth and the recent settlement of returnees and IDPs places additional pressure on already stretched resources and facilities. The health budget is considered to be based on inadequate assessments of the provincial demography, with estimates of the population at 1.5 million considered well below the reality. 85 There is a drastic lack of beds in hospitals, with up to 3 patients sleeping in a single bed in the pediatric service, an up to two women per bed in the maternity.

Growing insecurity has limited government, but also NGO, access to some districts, with adverse impact on the delivery of services. Facilities in the districts also often lack basic sanitation, equipment and access to quality medicine. In the center, powerholders place pressure on staff to receive preferential treatment, denying access to ordinary citizens.

Efforts have been made to improve the delivery of health services to women, including through training of staff and awareness raising. Maternal health care is considered as having improved, particularly in Jalalabad. However, maternity services offered need to expanded and staffed to meet the demand.86

Because services lack and women are constrained in remote and insecure districts such as Momand Dara, Shinwar, Khogyani, Lalpur, and Darinur, most give birth at home, and morbidity and mortality rates of children and mothers have reportedly increased in these districts.

Awareness of and Engagement in the Provincial Budget Policy

84 KI-M-Nan-B-EcD 85 KI-M-Nan-PC-2 86 KI-M-Nan-PC-1

www.appro.org.af 34 The only government entity fully aware of the PBP, its process and the amount of budget considered for health and education sectors in Nangarhar was the Mustofiat. Other officials mentioned limited involvement and expressed doubts about its effective implementation.

The provincial council mentioned not having been involved in provincial budgeting processes beyond providing suggestions to the governor. They doubt that their views will be considered at the central level and call for additional caution to avoid preferential allocation of funds for projects based on networks and relations. 87

The Directorate of Education and Provincial Council both considered the involvement of civil society was key to adequately reflect sectoral priorities in budget processes. The Directorate of Economy has reportedly been proactive in engaging CSOs, Ulamas, and development assemblies organizing a three- day workshop to define priorities and develop project proposals for 1397.88

Takhar

Perceptions of Civil Society Organizations CSOs interviewed were unanimous in considering service delivery in both health and education was inadequate. Facilities are reported as insufficient, underequipped and understaffed in both sectors. Insecurity further hinders service delivery in the districts.

Education

Schools lack adequate infrastructure, school material and basic sanitation. The scarce number of schools primarily impacts girls who are often prevented from travelling long distances to school by their families, particularly in the districts.

As in other provinces, low qualification of teachers, particularly at the primary and secondary level, is a concern. The interference of powerholder in the recruitment of teachers also affect the appointment process with adverse effects on the quality of education provided. Classes are overcrowded and students often graduate from primary school without mastering the basics off reading and writing. The quality of education at the high school and university level is reportedly higher, due to higher transparency and attention paid to the recruitment of qualified teachers.89

Health

Lack of skilled health staff and basic equipment are the main challenges reported by CSOs for the health sector in Takhar. While infrastructures are available and accessible, they are understaffed and can often not provide adequate care to patients. Maternal care also lacks at the district level, with little female health personnel available outside of the provincial center.

87 KI-M-Nan-PC-2. 88 KI-M-Nan-B-EcD. 1397 refers to the fiscal year starting March 2018. 89 KI-M-Tak-CSO-1+ all interviewees

www.appro.org.af 35 Awareness of and Engagement in the Provincial Budget Policy

None of the CSOs interviewed in Takhar were aware of the PBC. District and Provincial councils had not been involved in setting priorities for health and education. All, however, consider the process will be beneficial.

Unlike in other provinces and given the influence of power holders, provincial councils are not considered as an adequate vector to channel the needs of citizens to responsible government entities. CSOs suggested to carry out research instead to identify specific needs of the population and provide recommendations for budget allocation.

Government’s Perceptions Government officials’ views are similar to those provided by civil society. They recognize service delivery in health and education is inadequate in the province. Particularly in the districts, more infrastructures and staff are required.

Education

Despite an increase in the number of schools in the past years, these are not enough to meet the growing demand. Particularly in the district, there is a lack of basic infrastructure and additional efforts are required to ensure students have access to buildings, sanitation, clean water and school material.

Despite joint efforts by the Directorate of Education, CSOs and religious leaders, there female teachers lack in the districts, particularly at the secondary level. In many cases girls’ schools are unavailable or closed down.

Health

Priorities identified by the Directorate of Health are improved provision of basic equipment and drugs, and the recruitment of additional personnel, including specialists. Specialized surgery services, notably, are not available, including for children. There is also a severe lack of skilled female personnel.90

Significant efforts have been made to increase access to maternal care, though these are still insufficient in the districts. Whenever possible, local women are trained and recruited to provide basic health services in their own communities.

Insecurity in Ashkeshmesh and Darghad limit the access of government staff or CSO staff identified as supporting the government.

Awareness of and Engagement in the Provincial Budget Policy

Most of the officials in Takhar province were aware of the PBP. A number of civil society organizations participated in budget meetings and provided inputs during the process. However, more efforts are required to increase trust and cooperation between civil society and the provincial government.

90 KI-M-Tak-P-HD

www.appro.org.af 36 Recommendations

Government of Afghanistan

www.appro.org.af 37 Civil Society Organizations

• Conduct research on key needs of citizens at the provincial level. • Prioritize key demands and needs of citizens in education and health. • Identify points of entry for engagement in the budget process at the provincial level and national levels and plan for constructive engagement with provincial and national government authorities. • Build the capacity of district and provincial councils to prioritize needs, engage in the budget process and advocate for citizens’ rights to services. • Build capacity in understanding of the budget process and to conduct constructive advocacy at the provincial and national levels. • Mobilize and engage local governance institutions and structures to participate in prioritization of needs (Community Development Councils, District Development Assemblies, shuras, jirgas, etc.) • Monitor the implementation of the provincial budgeting policy, working closely with local communities. • Work closely with the government officials at the provincial and national levels to increase responsiveness, good governance and accountability in service delivery. • Advocate for the right of IDPs and returnees to education and health in provinces of arrival. • Advocate for the inclusion of a gender perspective in the budget process and service delivery. • Pay specific attention to corruption and nepotism in the delivery of services, denounce corrupt practices and promote good ones. • Design and conduct awareness programs, advocate and provide technical consultations for citizens on health and education needs.

www.appro.org.af 38 Appendix: Key Informant Coding Protocols

Kabul

Ministry of Public Health KI-M-Kab-B-MoPH: KI=Key Informative, M=Male, Kab=Kabul, B=Budget Unit, MoPH=Ministry of Public Health KI-M-Kab-P-MoPH KI=Key Informative, F=Female, Kab=Kabul, P=Policy and plan department, MoPH=Ministry of Public Helath

Ministry of Education KI-M-Kab-B-MoE KI=Key Informative, M=Male, Kab=Kabul, B=Budget Unit, MoE=Ministry of Education KI-M-Kab-P-MoE KI=Key Informative, M=Male, Kab=Kabul, P=Policy and Plan department, MoE=Ministry of Education

Ministry of Finance: KI-M-Kab-B-MoF KI=Key Informative, M=Male, Kab=Kabul, B=Budget Unit, MoF=Ministry of Finance

Ministry of Economy KI-M-Kab-P-MoEc KI=Key Informative, M=Male, Kab=Kabul, P=Policy and Plan department, MoEc=Ministry of Economy

Independent Directorate of Local Governance KI-M-Kab-P-IDLG KI=Key Informative, M=Male, Kab=Kabul, P=Policy and Plan department, IDLG= Independent Directorate of Local Governance

CSOs working in Education Sector KI-M-Kab-E-CSO-1 KI=Key Informative, M=Male, Kab=Kabul, E=Education, CSO=Civil Society Organization, 1=Sequence KI-M-Kab-E-CSO-2 KI=Key Informative, M=Male, Kab=Kabul, E=Education, CSO=Civil Society Organization, 2=Sequence KI-M-Kab-E-CSO-3 KI=Key Informative, M=Male, Kab=Kabul, E=Education, CSO=Civil Society Organization, 3=Sequence KI-M-Kab-E-CSO-4 KI=Key Informative, M=Male, Kab=Kabul, E=Education, CSO=Civil Society Organization, 4=Sequence

CSOs working in Health Sector KI-M-Kab-H-CSO-1 KI=Key Informative, M=Male, Kab=Kabul, H=Health, CSO=Civil Society Organization, 1=Sequence KI-M-Kab-H-CSO-2 KI=Key Informative, M=Male, Kab=Kabul, H=Health, CSO=Civil Society Organization, 2=Sequence

www.appro.org.af 39 KI-M-Kab-H-CSO-3 KI=Key Informative, M=Male, Kab=Kabul, H=Health, CSO=Civil Society Organization, 3=Sequence

Herat

Health Directorate KI-M-Her-B-HD KI=Key informative, M=Male, Her=Herat, B=Budget Unit, HD=Health Directorate KI-M-Her-P-HD KI=Key informative, M=Male, Her=Herat, P=Policy and Plan, HD=Health Directorate

Education Directorate KI-M-Her-B-ED KI=Key informative, M=Male, Her=Herat, B=Budget Unit, ED=Education Directorate KI-M-Her-P-ED KI=Key informative, M=Male, Her=Herat, P=Policy and Plan, ED=Education Directorate

Mustofiat (Finance Directorate) KI-M-Her-B-Mus KI=Key informative, M=Male, Her=Herat, B=Budget Unit, Mus=Mustofiat KI-F-Her-P-Mus KI=Key informative, F=Female, Her=Herat, P=Policy and Plan, Mus=Mustofiat

Economy Directorate KI-M-Her-B-EcD KI=Key informative, M=Male, Her=Herat, B=Budget Unit, EcD=Economy Directorate KI-M-Her-P-EcD KI=Key informative, M=Male, Her=Herat, P=Policy and Plan, EcD=Economy Directorate

Provincial Council KI-F-Her-PC-1 KI=Key informative, F=Female, Her=Herat, PC=Provincial Council, 1=Sequence KI-M-Her-PC-2 KI=Key informative, M=Male, Her=Herat, PC=Provincial Council, 2=Sequence

CSOs Working in the Education Sector KI-M-Her-E-CSO-1 KI=Key Informative, M=Male, Her=Herat, E=Education, CSO=Civil Society Organization, 1=Sequence KI-M-Her-E-CSO-2 KI=Key Informative, M=Male, Her=Herat, E=Education, CSO=Civil Society Organization, 2=Sequence KI-M-Her-E-CSO-3 KI=Key Informative, M=Male, Her=Herat, E=Education, CSO=Civil Society Organization, 3=Sequence KI-M-Her-E-CSO-4 KI=Key Informative, M=Male, Her=Herat, E=Education, CSO=Civil Society Organization, 4=Sequence

CSOs Working in the Health Sector KI-M-Her-H-CSO-1 KI=Key Informative, M=Male, Her=Herat, H=Health, CSO=Civil Society Organization, 1=Sequence

www.appro.org.af 40 KI-F-Her-H-CSO-2 KI=Key Informative, F=Female, Her=Herat, H=Health, CSO=Civil Society Organization, 2=Sequence KI-M-Her-H-CSO-3 KI=Key Informative, M=Male, Her=Herat, H=Health, CSO=Civil Society Organization, 3=Sequence KI-M-Her-H-CSO-4 KI=Key Informative, M=Male, Her=Herat, H=Health, CSO=Civil Society Organization, 4=Sequence

Nangarhar

Health Directorate KI-M-Nan-B-HD KI=Key informative, M=Male, Nan=Nangarhar, B=Budget Unit, HD=Health Directorate KI-F-Nan-P-HD KI=Key informative, F=Female, Nan=Nangarhar, P=Policy and Plan, HD=Health Directorate

Education Directorate KI-M-Nan-B-ED KI=Key informative, M=Male, Nan=Nangarhar, B=Budget Unit, ED=Education Directorate KI-M-Nan-P-ED KI=Key informative, M=Male, Nan=Nangarhar, P=Policy and Plan, HD=Health Directorate

Mustofiat KI-M-Nan-B-Mus KI=Key informative, M=Male, Nan=Nangarhar, B=Budget Unit, Mus=Mustofiat

Economy Directorate KI-M-Nan-B-EcD KI=Key informative, M=Male, Nan=Nangarhar, B=Budget Unit, EcD= Economy Directorate

Provincial Council KI-M-Nan-PC-1 KI=Key informative, M=Male, Nan=Nangarhar, PC=Provincial Council, 1= Sequence KI-M-Nan-PC-2 KI=Key informative, M=Male, Nan=Nangarhar, PC=Provincial Council, 2= Sequence

CSOs working in Health and Education Sectors KI-M-Nan-HE-CSO-1 KI=Key Informative, M=Male, Nan=Nangarhar, HE=Health and Education Sectors, CSO=Civil Society Organization, 1=Sequence KI-M-Nan-HE-CSO-2 KI=Key Informative, M=Male, Nan=Nangarhar, HE=Health and Education Sectors, CSO=Civil Society Organization, 2=Sequence KI-M-Nan-HE-CSO-3 KI=Key Informative, M=Male, Nan=Nangarhar, HE=Health and Education Sectors, CSO=Civil Society Organization, 3=Sequence KI-M-Nan-HE-CSO-3 KI=Key Informative, M=Male, Nan=Nangarhar, HE=Health and Education Sectors, CSO=Civil Society Organization, 4=Sequence

www.appro.org.af 41 KI-M-Nan-HE-CSO-5 KI=Key Informative, M=Male, Nan=Nangarhar, HE=Health and Education Sectors, CSO=Civil Society Organization, 4=Sequence KI-M-Nan-E-CSO-1 KI=Key Informative, M=Male, Nan=Nangarhar, E=Education, CSO=Civil Society Organization, 1=Sequence KI-M-Nan-E-CSO-2 KI=Key Informative, M=Male, Nan=Nangarhar, E=Education, CSO=Civil Society Organization, 2=Sequence KI-M-Nan-E-CSO-3 KI=Key Informative, M=Male, Nan=Nangarhar, E=Education, CSO=Civil Society Organization, 3=Sequence KI-M-Nan-H-CSO-1 KI=Key Informative, M=Male, Nan=Nangarhar, H=Health, CSO=Civil Society Organization, 1=Sequence KI-M-Nan-H-CSO-2 KI=Key Informative, M=Male, Nan=Nangarhar, H=Health, CSO=Civil Society Organization, 2=Sequence

Takhar

Health Directorate KI-M-Tak-B-HD KI=Key informative, M=Male, Tak=Takhar, B=Budget Unit, HD=Health Directorate KI-M-Tak-P-HD KI=Key informative, M=Male, Tak=Takhar, P=Policy and Plan, HD=Health Directorate

Education Directorate KI-M-Tak-B-ED KI=Key informative, M=Male, Tak=Takhar, B=Budget Unit, ED=Education Directorate KI-M-Tak-P-ED KI=Key informative, M=Male, Tak=Takhar, P=Policy and Plan, ED=Education Directorate

Mustofiat (Finance Directorate) KI-M-Tak-B-Mus KI=Key informative, M=Male, Tak=Takhar, B=Budget Unit, Mus=Mustofiat KI-M-Tak-P-Mus KI=Key informative, M=Male, Tak=Takhar, P=Policy and Plan, Mus=Mustofiat

Economy Directorate KI-M-Tak-B-EcD KI=Key informative, M=Male, Tak=Takhar, B=Budget Unit, EcD=Economy Directorate KI-M-Tak-P-EcD KI=Key informative, M=Male, Tak=Takhar, P=Policy and Plan, EcD=Economy Directorate

Provincial Council KI-F-Her-PC-1 KI=Key informative, F=Female, Tak=Takhar, PC=Provincial Council, 1=Sequence KI-M-Her-PC-2 KI=Key informative, M=Male, Tak=Takhar, PC=Provincial Council, 2=Sequence

CSOs working in the Health Sector KI-M-Tak-H-CSO-1

www.appro.org.af 42 KI=Key informative, M=Male, Tak=Takhar, H=Health Sector, CSO=Civil Society Organization, 1=Sequence KI-M-Tak-H-CSO-2 KI=Key informative, M=Male, Tak=Takhar, H=Health Sector, CSO=Civil Society Organization,2=Sequence KI-F-Tak-H-CSO-3 KI=Key informative, F=Female, Tak=Takhar, H=Health Sector, CSO=Civil Society Organization,3=Sequence KI-M-Tak-H-CSO-4 KI=Key informative, M=Male, Tak=Takhar, H=Health Sector, CSO=Civil Society Organization, 4=Sequence

CSOs working in the Education Sector KI-M-Tak-E-CSO-1 KI=Key informative, M=Male, Tak=Takhar, E=Education Sector, CSO=Civil Society Organization, 1=Sequence KI-M-Tak-E-CSO-2 KI=Key informative, M=Male, Tak=Takhar, E=Education Sector, CSO= Civil Society Organization, 2=Sequence KI-M-Tak-E-CSO-3 KI=Key informative, M=Male, Tak=Takhar, E=Education Sector, CSO= Civil Society Organization, 3=Sequence KI-M-Tak-E-CSO-4 KI=Key informative, M=Male, Tak=Takhar, E=Education Sector, CSO= Civil Society Organization, 4=Sequence