[Compa ny name] Assessment Report- Health and Integrated Protection Needs in Ghazni Province

Abdul Qadir Baqakhil Dr. Waseel Rahimi Akbar Ahmadi Vijay Raghavan

Final Report

Acknowledgements The study team thank representatives of the following institutions who have met us in both Kabul and Ghazni during the assessment. WHO – Kabul, UNICEF – Ghazni, Emergency – Ghazni, DACAAR – Kabul, Provincial Health Directorate, Ghazni; Provincial Hospital, Ghazni; Afghanistan Red Crescent Society (ARCS), Ghazni; DoRR, Ghazni; ICRC – Kabul and Ghazni, Swedish Committee for Afghanistan, Ghazni; AADA BPHS and EPHS team in Ghazni Thanks of INSO for conducting the assessment of the field locations and also for field movements Special thanks to the communities and their representatives who have travelled all the way from their villages in distant districts and participated in the consultation workshop we had in Ghazni. Our sincere thanks to the District wise focal points, health facility staff and all support staff of AADA, Ghazni who tirelessly supported in the field assessment and arrangement of necessary logistics for the assessment team. Our special thanks to Dr. Samim Nifkhar, Provincial Manager, BPHS and EPHS, AADA in Ghazni for his kind support and providing all the needed information and coordinating the field mission and stakeholders’ consultations in the province. Without his support the mission wouldn’t be possible. We thank the founder/Director of AADA, Dr Jamaluddin Jawid who proposed for this joint programme planning between Johanniter and AADA beyond our existing programme of Community Midwifery Education in Takhar province and expand the partnership to Ghazni, the neediest province for health and that too for trauma care. Thanks to Health and Protection Clusters for their constant inputs and support. Thanks to OCHA-HFU team for their feedback on our previous programme and that helped in refining our assessment focus and added the components of additional issues like operations, logistics and quality of supplies which were discussed elaborately with the field team of AADA. Thanks to Access and Security team in OCHA for their feedback on access and security sections. Special thanks to ECHO team in Kabul for their feedback to our previous assessment report of Ghazni which is valuable while we did the needs assessment in Ghazni.

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Abbreviations IEA Islamic Emirates of Afghanistan

MoPH Ministry of Public Health

ANSF Afghanistan National Security Forces

AADA Agency for Assistance and Development of Afghanistan

AHF Afghanistan Humanitarian Fund (OCHA funded, formerly CHF – Common Humanitarian Fund)

ORCD Organization for Research & Community Development

UNOCHA United Nations Office for the Coordination of Humanitarian Affairs

WHO World Health Organization

UNICEF United Nations Children’s Fund

UNHCR United Nations High Commissioner for Refugees

WSTA

SCA Swedish Committee for Afghanistan

ALP Afghan Local Police

AOG Armed Opposition Groups

AGE Anti Government Element

ACG Armed Criminal Group

INSO International NGO Safety Organization

HAG Humanitarian Access Group

ACBAR Agency coordinating Body for Afghan Relief and Development

DAC District Administrative Centre

HFU Humanitarian Funding Unit

IMF International Military Forces

BBC British Broadcasting Centre

UNAMA United Nations Assistance Mission in Afghanistan

MSF Medicine Sans Frontiers

HI Humanitarian & Inclusion/ Handicap International

SIGAR Special Inspector General for Afghanistan Reconstruction

BPHS Basic Package of Health Service

EPHS Essential Package of Hospital Service

CHC Comprehensive Health Center

BHC Basic Health Center

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DH District Hospital

PHC Primary Health Centre

PH Provincial Hospital

RH Regional Hospital

PPHD Provincial Public Health Directorate

TP Trauma Post

FATP First Aid Trauma Post (Is also mentioned as FAP- First Aid Post)

CSO Community Social Organizer

CBPF Country-Based Pooled Funds

RAF Rapid Assessment Format

HMIS Health Management Information System

IED Improvised Explosive Device

GOA Government of Afghanistan

PHCC Provincial Health Coordination Centre

EPI Expansion Program on immunization

ARCS Afghanistan Red Crescent Society

DACAAR Danish Committee for Aid to Afghan Refugees

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Glossary Shura Community Development Council Malik Head of Community Development Council IEA/Taliban Islamic Emirate of Afghanistan/Taliban Zakat payment made annually under Islamic law on certain kinds of property and used for charitable and religious purposes, one of the Five Pillars of Islam. Oashar Kind of Tax under Islamic Law in different kinds of cultivation product Lahya Rules or Statement that establishes a principle or standard, and serves as a norm for guiding or mandating action or conduct. Masuliyat Responsibility Arbaki Afghan Local Police Breshna Electricity provider company in Afghanistan

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Contents Acknowledgements ...... 2 Abbreviations ...... 3 Glossary ...... 5 Section 1 : Background ...... 8 Background of Ghazni Province ...... 8 Background for the Assessment ...... 10 Assessment Methodology ...... 11 Section 2 : Summary of the findings ...... 14 Section 3: Introduction ...... 17 Security ...... 17 Conflict situation ...... 20 Section 4 : Health Assessment ...... 22 Health Facilities in Ghazni ...... 26 Damages to Health Facilities ...... 27 Trauma Cases details in Ghazni Province ...... 33 Supporting Referral Sites with capacity to respond mass casualty ...... 42 Coordination with relevant health actors at Ghazni and Kabul ...... 43 Recommendations from the stakeholders on the recruitment of qualified staff ...... 45 Training of Health Facility Staff on Triage, First Aid and First Responder’s training and Mass Casualty Management ...... 45 Advocacy related to health and trauma care ...... 46 Section 5: Access Assessment ...... 48 Impact on Health Services in Ghazni ...... 63 Violations of Health Facilities noticed in the assessment by the actors involved in conflict...... 66 High Violations by Taliban/AOGs ...... 67 Recommendations ...... 72 Key Activities considered for the proposed project ...... 74 Section 6 : Protection Assessment ...... 75 Barrier Analysis ...... 78 Protection Risk Analysis ...... 82 Recommendations and suggestions ...... 87 Prostatic and Orthotics Care ...... 87 Mental Health in counselling Post Trauma Disorder Syndromes (PTDS) and referrals ...... 88 Coordinate with UNFPA in their implementation phases with establishing FPC in Ghazni district’s and provincial hospital ...... 89

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Coordination ...... 89 Section : 7 Key Results from the Needs Assessment for consideration for programmatic intervention ...... 90 Establishment of First Aid Trauma Posts in remote and hard to reach districts ...... 90 Improving access to Mental health care for PTDS and referral systems ...... 92 Coordination and Advocacy ...... 93 Annexure 1 : Meetings with Stakeholders ...... 95 Annexure 2 : Checklist and Questionnaires used for the survey ...... 96 Annexure : Check List for Focused Group Discussions with Community/Health Shuras ...... 102 Annexure : Principle Violated by Conflict Actors ...... 103

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Section 1 : Background 1.1 Background of Ghazni Province

Ghazni is one of the 34 provinces of Afghanistan, located in central Afghanistan. The province is home to approximately 4.7% of Afghanistan’s population, making it the 6th most populous province in the country. It has been known throughout Afghanistan’s history as a significant political, cultural and religious centre particularly since the Ghaznavid period (10th -12th Century AD), and Ghazni city has been referred to as the ‘city of shrines’ due to the numerous historic sites and monuments it contains. Ghazni city is located 145 km south from Kabul city on Kabul-Kandahar highway. It’s located in the eastern part of the country and borders Paktya and Logar in the north-east, Paktika in the south-east, Zabul in the south-west, Daykundi and Bamyan in the northwest, and Wardak in the north. The province covers an area of 23,378 km2. The terrain of the area is covered by mountainous or semi-mountainous terrain and flat land representing 59.8% and 35.7% respectively. The province has 19 districts with over a thousand villages. It has an estimated number of 1,270,192 populations (SCO 2017-18) comprising of the multi-ethnic and diverse population. Agriculture represents the major source of income for more than half the households in the province. In Ghazni, the summers are hot and dry and the winters are very cold and snowy.

Ghazni Province with its districts The province has been distributed to eighteen districts which are: Ghazni capital, Andar, Muqur, Qara Bagh, Gilan, Waghiz, Giro, Deh Yak, Nawar, Jaghori,

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Malistan, Rashidan, Ab Band, Khugiani, Nawa, Jaghato, Zankhan, Ajeristan and Khwaja Omari The population of Ghazni is culturally diverse, with the largest population being Pashtuns (49%) followed closely by Hazara (46%), and smaller groups of Tajiks (5%), Hindu/Sikhs (less than 1%) and other minorities. Kuchi nomads also inhabit Ghazni, and their presence in the province varies throughout the year. In winter their population is relatively small at around 31,000 but in summer the number of Kuchi in Ghazni increases to approximately 121,000. Most Kuchi arriving during the summer migrate from Kandahar, Nangarhar, Zabul, Uruzgan, Helmand and Khost

Table 1: District wise Population details

District HQs CDCs Population Demographics

Province Ghazni 32 171,025 Pashtun 40% , Hazara 40 % , Tajik 20 % Centre(Ghazni) Wali M. Shahid Khogyani 4 21,953 Pashtun 80% , Hazara 20 % , Tajik 0 % (khugyani) Khwaja Omari Tormai 4 20,733 Pashtun 40% , Hazara 40 % , Tajik 20 % Waghaz Waghaz 5 41,102 Pashtun 80% , Hazara 20 % , Tajik 0 % Deh Yak Dehayak/Ramak 5 51,836 Pashtun 40% , Hazara 40 % , Tajik 20 % Jaghatu Gulbawri 6 34,028 Pashtun 40% , Hazara 40 % , Tajik 20 % Andar Andar 8 130,508 Pashtun 40% , Hazara 40 % , Tajik 20 % Zanakhan Zanakhan 4 14,147 Pashtun 40% , Hazara 40 % , Tajik 20 % Rashidan Rashidan 4 19,758 Pashtun 80% , Hazara 20 % , Tajik 0 % Nawur Nawur 12 99,283 Pashtun 0% , Hazara 100 % , Tajik 0 % Qara Bagh Qarabagh 7 149,291 Pashtun 50% , Hazara 50 % , Tajik 0 % Giro Giro 3 39,029 Pashtun 100% , Hazara 0 % , Tajik 0 % Ab Band Ab Band 3 29,638 Pashtun 100% , Hazara 0 % , Tajik 0 % Jaghuri Sang Masha 14 184,297 Pashtun 0% , Hazara 100 % , Tajik 0 % Muqur Muqur' 8 53,300 Pashtun 80% , Hazara 5 % , Tajik 10 % Malistan Mirdina 11 86,232 Pashtun 0% , Hazara 100 % , Tajik 0 % Gelan Janda 7 61,106 Pashtun 100% , Hazara 0 % , Tajik 0 % Ajristan Sangar 4 30,979 Pashtun 100% , Hazara 0 % , Tajik 0 % Nawa Nawa 3 31,955 Pashtun 100% , Hazara 0 % , Tajik 0 % Total 144 1,270,192 Source: CSO 2017-18

Ghazni province is characterized by widespread conflict and insecurity motivated by the presence of armed groups, in particular, the Islamic Emirate of Afghanistan (IEA). Insecurity dynamics are made more complex by the presence of various armed groups (AOGs). At present the overall security situation in the majority of the districts including the province centre is unstable. Ghazni province has also captured once by AOGs in August 2018 leading to people migration to Kabul and neighbouring provinces. Andar, Qarabagh, Nawa, Zanakhan, Ajristan, Waghaz, Khogyani, and Rashidan districts are the most insecure districts of Ghazi having frequent conflicts in the record.

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The rugged mountainous terrain, harsh weather conditions particularly during winter; scattered population; susceptibility to natural disasters poses serious challenges in ensuring access to the basic health services particularly for the women in their reproductive age in some of Ghazni districts. Nawur, Jaghuri, Malistan, and Ajirestan amongst the districts suffer from harsh winters and are isolated for up to four months annually from the provincial capital as access roads are closed by winter snow and in spring, mud.

The casualties due to conflict has increased phenomenally and the existing health facilities are poorly equipped to meet these increased mass casualties effectively and that too after the province was fallen to Taliban briefly in August 2018. Despite of establishment of FATPs and Mobile health teams funded by CHF (now AHF) in 2016/17 and Emergency having trauma units in two locations, still there is need for additional trauma care centres and health teams to cover unreached areas.

1.2 Background for the Assessment

Johanniter and its partner, AADA had various assessments in Ghazni related to the needs in health, protection and vulnerability of IDPs in hard to reach districts. AADA has conducted needs assessments in the past.

All the assessments were conducted for application for CHF/AHF grant or other donor grants. The previous grant of AHF funded project “Provision of life saving trauma care and referral services with protection measures in conflict affected areas in Ghazni province” CBPF Code: A brief note of this project should be provided by ORCD, AFG-17/3481/SA2/H-N- APC/NGO/6764. The project was completed in 2018 and were implemented in Khogiani and Waghaz CHCs.

There was greater need for trauma care both due to increased armed conflict in 2019 where Taliban have established strong control over the province and increased military operations by Afghanistan National Security Forces (ANSF) along with International Military Forces (IMF). AADA and Johanniter have consulted Health Cluster since May 2019 to explore funding opportunity for supporting trauma care in Ghazni province. At the backdrop of expecting First Standard Allocation of Afghanistan Humanitarian Fund (AHF) for 2019 and ECHO’s Humanitarian Investment Plan (HIP) 2020, AADA and Johanniter discussed with health cluster, ECHO and Humanitarian Funding Unit (HFU) and scheduled to conduct detailed needs assessment in Ghazni province.

The feedback of previous project in Ghazni and experiences of working with BPHS implementing agency, AADA; the assessment focused on trauma health care services in the province and related protection issues. Abdul Qadir Baqakhil, Program Manager; Dr. Farhat Sahak- Technical Manager (both from AADA), Dr. Sediqullah Akbarzai, Programme Advisor; Dr. Mirza Jan Hafiz, Programme Coordinator; Dr. Waseel Rahimi, Programme Manager - Health and Vijay Raghavan, Head of the Mission, (all from Johanniter) have met at AADA Office on 19 November 2019 to discuss on joint field visit and conducting assessment in Ghazni. A follow up meeting was held at Johanniter Office where, in addition to the above mentioned staff, Nasreen Afzali, Gender & Protection Officer; Akbar Ahmadi, Monitoring & Evaluation Officer; Tawheedullah Amiri, Access and Safety Advisor (all from Johanniter) have joined together in developing the modalities of the assessment and scheduled for a joint assessment.

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It was decided that AADA will initially collect all relevant primary and secondary information from the BPHS, EPHS and other stakeholders working in trauma care in Ghazni in November 2019. Johanniter team will join the AADA team in Ghazni to conduct the assessment which includes meeting different stakeholders, BPHS health staff and communities from the conflict locations. Accordingly, AADA and Johanniter teams have met Health and Protection Cluster leads and discussed their proposed plan to conduct assessment of health and protection risks in accessing health services in Ghazni in November 2019 and accordingly, the field assessments were held in Ghazni during 1 to 4 December 2019 and Kabul level consultations were held during 8 – 15 December with stakeholders and Cluster leads.

The Johanniter International Assistance supported the needs assessment in Ghazni from its core funds and AADA taken care of all the field level processes and coordination arrangements in Ghazni. Data validation was carried out by AADA team in the field during 16 -30 December 2019. During January, the field level data and field notes of the assessment were consolidated and response plans were evolved based on our consultations at Kabul and verified in the Ghazni of feasibility of the activities. PPHDs were consulted and so also the district hospitals on these response plans and presented in this report.

1.3 Assessment Methodology From 1 to 4 Dec 2019, the Johanniter and AADA team collectively carried out a joint assessment in Ghazni to understand the health needs in conflict zones, the protections risks facing general people, women, girls, boys and other vulnerable groups in accessing health and other development services. The assessment primarily aimed at assessing the effect that conflict has had on health status of the affected population in order to identify areas of concern.

Three members from the Johanniter and AADA carried out a joint assessment mission to understand the health needs in conflict zones, the protections risks facing general people, women, girls, boys and other vulnerable groups in accessing health and other development services. These organisations chose to collaborate based on their experience of working in primary health, emergency health and research experience. The team composition includes public health expertise, social anthropology, monitoring and evaluation experience and PCM and research expertise. Assessment Objectives:  To assess the conflict sensitivity impacting health services especially trauma care  To assess the needs of the conflict affected population for effective trauma care and prostatic and orthotics care services  To assess protection risks, which includes threat analysis, vulnerability and capacity analysis; and identify areas to integrate protection in health services  To find out health and protection challenges, and gaps and to recommend related for solutions.  To reassess high risk conflict-affected districts and locations for establishment of First Aid Trauma Points (FATP)

The mission adopted both quantitative and qualitative research methodologies focused on making direct contact with representatives of the affected communities include, health Shura members, community level health workers, Psycho-social counsellors, Nursing and midwife trainees, health staff working in primary health care units and visiting health facilities. The mission has used various formats include the cluster approved Rapid Assessment Format (RAF) for health and customized sample survey related to trauma care, protection elements

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and adherence to neutrality principles. The formats are enclosed to this report Annexure 2, 3 and 4.

The mission met key stakeholders involved in the trauma care, protection and humanitarian responses include, WHO, UNECIF, ARCS and Emergency; and government agencies like DoRR, PPHD and Director of Provincial Hospital, the schedule of the stakeholder’s meetings were enclosed in Annexure 1. The questionnaires addressed health needs in conflict areas, protection risks specific to women and girls in the place of origin and at the current /displaced locations in case of IDPs.

The assessment team have carried out field based assessments based on the customized and RAF-Health assessment forms in 10 health clinics using Annexure 2. The team also interacted with Health Shura representatives of the clinics in hard to reach districts in Ghazni province. In addition to the interviews and focused group discussions, the team also did desk review of literature available about Ghazni, this includes various research publications mentioned in the following text box.

 Vijay Raghavan, Humours Frozan, Dr. Aziz Mohammad; Health, Nutrition and Protection Assessment, Ghazni Province, The Johanniter International Assistance, 2017  Vijay Raghavan, Dr. Mirza Jan Hafz and Dr. Noor Ahmad Noor; Health and Protection Assessment, Kunduz Province, The Johanniter International Assistance, 2019  Kate Clark, The Lahya – Calling the Taliban to Account, Afghanistan Analyst Network  Anthony H Cordesman, The state of the fighting in the Afghan War Mid-2019 – a working draft, Centre for Strategic & International Studies, Aug 2019  Dr. Antonio Giustozzi, Afghanistan: Taliban’s organization and structure, Landinfo, 2017  Charity Watson, INSO Special Report – Overview of IEA Taxation in Afghanistan, February 2019  Ashley Jackson, Life under the Taliban Shadow Government, ODI report, June 2018  REACH and OCHA, Assessment of Hard to Reach Districts – Factsheet Booklet Round 1, August 2019  UNOCA, Humanitarian Needs Overview 2020  UNOCHA, Humanitarian Response Plan 2020  The Asia Foundation, The Survey of Afghan People – Afghanistan in 2019

Reviewed and analysed HMIS data provided by AADA from 2014-till date, reviewed reports of PPHD, BPHS and EPHS provided to the team. These HMIS review includes analysis of Facility wise details, Staff details, Trauma cases by facility in the hard to reach districts and the capacity of health facilities in providing health care services to conflict induced injuries in conflict proven districts

1.4 Disclaimer

This report was written according to Johanniter International Assistance and AADA’s joint understanding and based on the consultations held with health and protection cluster. The report is based on carefully selected sources of information. All sources used are referenced, as much as possible, and unless otherwise stated. All information presented, except for undisputed or obvious facts, has been cross-checked. The information contained in this report has been researched, evaluated and analysed with utmost care. However, this document doesn’t claim to be exhaustive. The report doesn’t refer to a particular event, person or organisation unless referred. Furthermore, this report is not conclusive as to the determination or merit of any particular person or agency’s claim. This report is based on the assessments

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carried out before 30 December 2019 drafted. Any event taking place after this date is not included in this report. The information provided under the assessment are based on the interviews held with various stakeholders and is entirely based on the understanding of the assessment team members and doesn’t reflect on the institutions they represent. As these interviews are based on the personal requests and thus may or may not prove to hundred percent correct. There is optimal ignorance of the assessment team members while presenting the report. Some of the information collected are sensitive and thus protected the identity of the individuals. The assessment has limitation as they have used mostly the qualitative methodologies and referred the secondary /primary data of HMIS documents from the health service providers to draw inferences. Such collected information was triangulated with the stakeholders to draw inferences and assumptions. The field visit by Johanniter team was limited to Ghazni and Qarabagh only. However, AADA’s assessment team have visited 7 districts and 13 health facilities for assessment using Annexure 2 and Humanitarian Principles Violations Annexure 4. The assessment team have made efforts to discuss with representatives from all the districts, health facility staff, nutrition counsellors, Health Shura members, Psycho-social counsellors and civil society members working in these districts to get information during interviews. The document is in public domain can be referred and just need to provide acknowledgement to the source. Johanniter International Assistance and AADA specifically disclaim any liability or responsibility for any errors or omissions in any of the information contained in this document.

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Section 2 : Summary of the findings

UNOCHA’s Humanitarian Needs Overview (2020) states that, “Afghanistan is now the scene of the deadliest conflict on earth. Fighting continues to rage, exposing civilians, particularly women and children, to daily deadly risks, prompting mass displacement and choking the country’s unstable economy. Years of shocks have left an acutely vulnerable population with few economic resources, an eroded capacity to cope with the unfolding crisis and little hope of recovery if the current conditions persist.”

The cumulative impact of conflict and disaster, almost a quarter of the country’s population (9.4 million people out of a population of almost 38 million) is now estimated to be in need of humanitarian assistance in 2020. The majority of those in need are children (56 per cent). Upward adjustments in needs have been made across every sector with Protection needs showing the largest change (2.4 million in 2019, 7 million in 2020).

People’s living conditions have been eroded by years of war and disaster. Inability to access services is a key consequence of the crisis and is a product of a range of factors including conflict, insecurity and fear, poverty and under-investment

About one third of the population (mostly those living in hard-to-reach areas) does not have access to a functional health centre within two hours of their home. The country is facing a protection crisis where people’s rights to safety, security and well-being under international law are regularly threatened. Conflict and displacement have resulted in internally displaced persons (IDPs) and vulnerable people resorting to severe negative coping mechanisms such as early/forced marriages, child labour and begging. Women and girls are deprived of basic rights, particularly education, and gender based violence is pervasive. Afghanistan is littered with landmines and other explosive hazards (new and old), exposing civilians to daily risks.

2.1 Access to basic services

1. Active conflict, large-scale population movements, and limited livelihood options continue to disrupt and deprive people of access to essential services, particularly health, water and education. 2. A recent exercise by the Humanitarian Access Group ranked those districts where physical barriers severely undermine access to people in need and affected people’s ability to access services. Inability to access services is a key consequence of the crisis affecting Afghanistan. 3. According to the most recent edition of the country’s longest running perceptions survey,50 the number of people reporting that they fear for their safety or that of their family remains very high and has slightly increased (from 71 per cent in 2018 to almost 75 per cent in 2019). 4. This presents an almost 100 per cent increase from the first time the question was asked in 2006 (40 per cent). Anxieties are so pronounced that people have restricted their movements in response – 79 per cent of people reported some or a lot of fear when traveling. Conflict denies people access to vital medical treatment by interrupting services where they do exist and preventing a scale-up of services in new areas. In the first eleven months of 2019, around 24,000 hours of healthcare delivery were lost, and 41,000

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consultations missed, due to the forced closure and destruction of health facilities, as attacks against health workers and medical assets mount in both frequency and deadliness.

Access to Trauma Care Health 5. Due to unaddressed gaps in the international donor-funded public health system, trauma provision is almost exclusively delivered by humanitarian partners in Afghanistan. Indeed, despite the high prevalence of mass casualty incidents, basic and essential surgical care remains outside the seven major elements of the BPHS. 6. Nationwide there remain extreme shortage of emergency surgical capacities, ranging from oxygen supplies, blood banks, and electrical power through to dedicated and qualified personnel – including surgeons and anaesthetists, weakening the trauma care that is available for patients in need. 7. Despite significant improvements in assisting people closer to the geographic location of their injury, especially through first aid trauma posts, high rates of referral continue to be seen from conflict-affected districts, suggesting that need is outstripping response capacity in many parts of the country. 8. Of those who recovered from major trauma surgery, some 47 per cent reported a permanent disability including loss of limbs, loss of vision and neurological deficits. Disability services (prosthetics and rehabilitation) are not readily available in public health facilities.

Mental health issues 9. Constant exposure to high-stress, conflict situations is taking its toll on an ever-present part of life with survivors left to cope with their grief and, when breadwinners are killed, the added financial struggle that follows. 10. While the number of people now suffering from psychological trauma is difficult to quantify due to low reporting and diagnosis, the likelihood of significant portions of the population suffering mental health issues as a result of conflict is thought to be very high. 11. With extremely low availability of psychosocial support services and repeated exposure to traumatic shocks, recovery opportunities are likely to be minimal, with people instead resorting to negative coping mechanisms. The mental health of people living in Afghanistan. 12. According to this survey, one in every two people (50 per cent) is suffering from psychological distress and one out of five (20 per cent) face functional limitations to his or her role because of mental health problems. Post-Traumatic Stress Disorder (PTSD) risks are especially pronounced for those living in conflict areas,

Recommendations

13. Volatile security and increased injuries and trauma incidents in interior locations due to aerial attacks and intensive fighting, the need for trauma care posts in these remote and hard to reach districts. There will be need immediate trauma care at the place of conflict primarily at first aid trauma posts. These centres will ensure lifesaving and refer the trauma cases need surgical treatment to higher grade trauma care centres with in the province. In addition, it is expected that the need for prosthetics, rehabilitation, mental health and psychosocial support will increase due to the cumulative and continuing impact of the conflict. Thus, 7 in Ghazni Province are considered for presenting to any donor funding.

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14. In addition to physical trauma include assessment, triage, first aid and referral services, triage, first aid and referral services for mental health and psychosocial support (MHPSS); referral for Orthopaedic and prosthetics care for physical rehabilitation services and the provision of assistive devices by providing transportation costs and follow up services in the centre thus facilitating the greater access of health services. 15. Volatile security, as well as harmful cultural and traditional practices which see the rightful place of women as being in the home; the imposition of strict gender segregation rules; and prohibitions on men providing medical treatment to women, all compromise their access to sustained and quality healthcare. This project will have at least two female staff who are expertise in physical trauma care (Trained Nurse) and Physcho-social service counsellor (trained) available in the proposed Trauma posts. 16. Provision of essential supplies, equipment, diagnostic tools and life-saving training to doctors, nurses and health professionals working in hospitals and primary healthcare Clinics on basic lifesaving skills (BLS) and mass casualty management at the referral site identified. 17. Development of health facilities’ and personnel’s capacities for emergency response; and 18. Enhanced coordination and advocacy for improved access of beneficiaries to emergency services and life-saving treatment; and advocacy through Humanitarian Access Group and other NGO stakeholders both at the provincial and national level on protection of health staff and patients in the health facility and Joint Operating Principles developed by humanitarian actors in the country.

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Section 3: Introduction

3.1 Security According to SIGAR’s April 30, 2019, quarterly report, the U.S. military is “no longer producing its district-level stability assessments of Afghan government and insurgent control and influence. However, BBC report in December 2017 states that Taliban threaten 70% of the Afghanistan. The poor turnout in the recently concluded Presidential Elections has one way or other is the result of the threat of Taliban against the election process. . Civilians continue to be gravely impacted by the highly unpredictable and politicized situation in Afghanistan. Violence along with a number of political processes coming to a head risks impacting not only people in need, but also affects the access of aid workers and their ability to provide essential services to people in need. Months preceding to the US Talks with the Taliban where high expectations were raised of a possible peace deal, which was fallen apart due to high precedence of violence during July-September 2019. From 1 July to 30 September 2019, UNAMA documented the highest number of civilian casualties that it has recorded in a single quarter since it began systematic documentation in 2009.

From 1 January to 30 September, UNAMA documented 8,239 civilian casualties (2,563 deaths and 5,676 injured), similar to the same period in 2018. Anti-Government Elements continued to cause the majority of civilian casualties in Afghanistan and also caused slightly more civilian deaths than Pro-Government Forces in the first nine months of 2019, contrary to the first half year of 2019 when Pro-Government Forces caused more civilian deaths. Forty-one per cent of all civilian casualties were women and children.

Pro-Government Forces from 1 January to 30 September 2019, Pro-Government Forces caused 2,348 civilian casualties (1,149 deaths and 1,199 injured)28, a 26 per cent increase from the corresponding period in 2018. Pro-Government Forces were responsible for 28 per cent of civilian casualties overall. The majority of civilian casualties caused by Pro- Government Forces resulted from ground engagements, followed by airstrikes and then search operations, similar to trends reported in 2018 at the third quarter.

Children continued to be severely impacted by the armed conflict in Afghanistan. Between 1 January and 30 September 2019, UNAMA recorded 2,461 child casualties (631 deaths and 1,830 injured), an overall increase of 11 per cent compared to the same period in 2018. The increase in child casualties resulted primarily from a significant increase in suicide and non- suicide IED attacks as well as ground engagements, including the use of indirect fire weapons systems that had indiscriminate effects on polling day for the 2019 presidential election. Ground engagements remained the leading cause of child casualties, followed by suicide and non-suicide IED attacks, and explosive remnants of war. The mission reiterates concern that children comprised the majority - 77 per cent - of civilian casualties from explosive remnants of war.

Children are also disproportionately impacted by attacks on schools and hospitals, which impede their access to education and health services. In relation to incidents impacting healthcare, on 11 April, the Taliban had banned activities of the World Health Organization (WHO), which effectively brought all polio vaccination campaigns to a halt. On 25 September, the Taliban announced that it would lift its ban on WHO activities in areas under its control, which was imposed in April of 2019. However, the resumption of WHO activities was permitted only with conditions. In particular, the Taliban indicated that vaccination campaigns would only

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be allowed to be carried out from health facilities and the ban on house to house vaccination campaigns remained.

There is deterioration of security situation in general in Ghazni province. In some districts like Ab Band, where heavy motor bomb attacked the temporary building of the district governor’s office which was shifted by force from its own building to the highway from Kabul to Kandahar. In Andar, governor office is moved out from its own building by force of AOG to the a rea near to the city in Chardihwal area. In Dih Yak district, the centre of this district is recently came under the control of the government and based on that The security is getting worst nowadays in all over the district and there is active fighting every day around the centre of the district. In Gillan district, since this district is partially controlled by government /ANSF so the community is witnesses for ongoing armed clash and the security is worst day by day in all over the district. Jighatoo: A part of this district is recently occupied by ANSF during a heavy military operation and now active fighting is going on in Bazar Sedaqat and Qeyaq area. The centre of this district is still under the control of AOG and this district is located on the high way from Ghazni to four other districts as Nawur, Ajristan, Malistan and Jaghuri. Khwaja Omari: The centre of this district is recently came under the control of the government and based on that The security is getting worst nowadays in all over the district and there is active fighting every day around the centre of the district. Muqur: Since this district is partially controlled by Government/ANSF, so the community is witnesses for ongoing armed conflict. Since this district is partially controlled by government /ANSF so the community is witnesses for ongoing armed clash and the security is worst day by day in all over the district.

Internal Displacement due to conflict in Ghazni (1 January -30 December 2019)

Source: https://www.humanitarianresponse.info/en/operations/afghanistan/idps.)

The displacement is entirely depending on the ongoing fighting. People displace during fighting and return back when the fighting subsides. Some who could afford moved to Kabul. The Arbaki (Afghanistan Local Police, Pro-government Militia) and warlords have moved out from the interior villages to the district centre. People fear more fighting and thus displaced

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The health shura representatives have mentioned of deteriorating of security in the province. It is summarized as following  There is deterioration of security situation in general in Ghazni province  There are quite a huge number of checkpoints across the province held by both the Taliban and ANSF. The government and AOGs both have check points in different location, fight frequently and the government also undertake search operations and harassing people.  The district centres are mostly controlled by the government and outside of the district centres are entirely under the control of Taliban. In some district centres like Qarabagh, Nawa, Andar which are entirely under control of Afghanistan security forces, but Taliban fighters are present in and around of a kilometre distance away.  The Taliban presence and control ensures strong measures of respect to law and order and treat people with respect. There is no harassment of the common people in Taliban controlled areas.  There is always risk of ground fighting, there are reports of night raids, ambushes and airstrikes engaged by ANSF.  There is active fighting between the armed opposition groups including all ground level engagement, air strikes, mines and Ab Band, Andar, Dih Yak, Gillan district is mostly under the control of Taliban. The fighting has caused most part of Dehyak CHC got damaged.  In Gillan, it is mentioning that except one CHC, all other four HFs are under the control of AOG. Recently one of the HF building in Rasana destroyed by airstrikes that interrupted the services. In Jighatoo district, the fighting has caused part of Sabzposhan CHC got partially damaged. In Muqur, most area of the mentioned district is under the control of AOG. It is mentioning that except one DH, all other three HFs are under the control of AOG  There are quite a huge number of checkpoints across the province held by both the Taliban and ANSF. The government and AOGs both have check points in different location, fight frequently and the government also undertake search operations and harassing people.  The Taliban presence and control ensures strong measures of respect to law and order and treat people with respect. There is no harassment of the common people in Taliban controlled areas.  There is always risk of ground fighting, there are reports of night raids, ambushes and airstrikes engaged by ANSF.  During this period, people who need emergency health care and trauma cases can’t reach appropriate health and trauma care centre in time.

Reasons of displacement The reason for displacement is mostly armed conflict, military operation, IHL violation, Tribal conflict/disputes, forcibly eviction, illegal taxation, torturing, and AGEs threats in places of origin and other generalized violence. Table 2: Reasons for displacement in Hard to Reach Districts of Ghazni S.No. District Total Active % % IDPs Returnees Displacement conflict or Drought Flood arraived arrived% % Violence % event event % 1 Ab Band 39% 72% 11% 6% 24% 18% 2 Andar 43% 91% 77% 7% 30% 34% 3 Dehyak 40% 93% 87% 0% 0% 0% 4 Gillan 14% 43% 29% 10% 5% 5%

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5 Jaighatoo 50% 94% 6% 33% 33% 17% 6 Muqor 45% 48% 34% 0% 28% 24% 7 Qarabagh 39% 62% 19% 3% 33% 27% Source: Assessment of hard to Reach District Fact sheet, REACH Aug 2019 Based on the above table, there is significant population have displaced in the districts of Jaighatoo, Qarabagh, Muqur, Deh Yak, Andar and Ab Band districts in Ghazni province (hard to reach districts). The major reason for displacement is active conflict in these districts and the next most responded reason was drought in the district. In some district like Andar and Dehyak both drought and conflict were the reasons for displacement. Most of the displacement in 2019 were internal and within the district or to Ghazni city. Needs of the IDPs  Emergency Needs: Multipurpose Cash Grants to meet food and non-food needs, emergency shelter, PSS/rehabilitation services, emergency health services, WASH, winterisation, education, CFSs, trauma counselling and education in emergenices  Protracted Phase needs: Food, transitional shelter, regular health services, PSS/Rehabilitation, WASH including hygiene and sanitation, education including CBEs and supply of stationaries, livelihoods including income generation activities, information counselling and legal assistance, winterisation, identity documentations, etc. NGOs like DACAAR, DRC and CARE are providing some of the emergency needs of the communities. NGOs supported by UNHCR are providing support for protection related activities.

Conflict situation  In Ab Band district, the conflict is ongoing in some areas near to the Ab Band Shamali where the first line of the fighting is located and ground engagement has increased in last one month. The AOGs give prior warning to the people so that they can move to safer locations if any attacks are carried out from their side. Air strikes from ANSF and IMF have increased in recent times and night ambushes were also increased. There are increased search operations by the government forces. AOGs don’t undertake any search operations i.e. house to house searches.  Andar: The conflict is going on in some area near to the Andar district centre (New building) where the first line of the fighting is there and Ground engagements has increased in these days. The AOGs gives prior warning. The air strikes also has increased. Recently the night ambushes are also increased. There are search operations by ANA and it is increased by government forces. When asked about the attitude of government forces they said they do not know. The AOGs do not undertake search operations  Dih Yak : The conflict is going on in some area near to the Deh Yak Shamali where the first line of the fighting is located and Ground engagements has increased in these days. The AOGs gives prior warning. The air strikes also has increased Recently the night ambushes are also increased. There are increased search operations by government forces. When asked about the attitude of government forces they said they do not know. The AOGs do not undertake search operations  Gillan: The conflict is going on in some area near to the Gillan centre (Janda) where the first line of the fighting is located and Ground engagements has increased in these days. The AOGs gives prior warning. The air strikes also has increased recently the night ambushes are also increased. There are increased search operations by government

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forces. When asked about the attitude of government forces they said they do not know. The AOGs do not undertake search operations.  Jighatoo: The conflict is going on in some area inside the Jighatoo district where the first line of the fighting is located on the way from Ghazni to other 4 districts and Ground engagements has increased in these days. The AOGs gives prior warning when they plan to operation for community or when they put mine on the road. The air strikes also has increased recently the night ambushes are also increased. There are increased search operations by both government forces and AOG. When asked about the attitude of government forces and AOG they said they do not know. The AOGs and ANSF both undertake search operations in this district  Khwaja Omari: The conflict is going on in some area near to and some times in the district near to Barakat and Kabul High way as well as on the way from Ghazni to the centre f district where the first line of the fighting is located and Ground engagements has increased in these months. The AOGs gives prior warning to the community sometimes. Recently the night ambushes are also increased in Barakat area. There are increased search operations by government forces. When asked about the attitude of government forces they said they do not know. Sometime the AOGs undertake search operations  Muqur: The conflict is going on in some area near to the Muqur centre where the first line of the fighting is located around the city of Muqur and on the way to Kandahar which a custom (Gomrok) of AOG located and collect the taxes from the vehicles and Ground engagements has increased in these days. The air strikes also has increased recently the night ambushes are also increased. There are increased search operations by both government forces and AOG. When asked about the attitude of government forces they said they do not know. Sometimes The AOGs undertake search operations.

Ground engagement has increased in this year, in 2019. AOGs warned people to leave the areas in case of any anticipated fighting. But the government forces don’t warn such, thus high civilian casualty. Similarly, there is higher civilian casualties due to aerial strikes, which has increased in 2019. Night raids and ambushes are also increased across the province. The night searches are increased by the pro-government forces. The attitude and behaviour of the pro-government forces don’t go well with the local population. The shura representatives have complained of their mis-treatment and abuse. The Pro-Government forces, mostly the PGMs harass people and are hostile to local population. The AOGs do not undertake search operations.

Ghazni Province currently faces a phone network blackout for most part of the day. In the past, they have allowed the mobile networks to operate services between 7 AM to 7 PM. But for past one year or so, they have been active only for two hours in the morning and mostly between 09.00 to 11.00 Hrs. During the blackout, only the Salaam network is operational. On the other hand, although having a Salaam SIM card is common among the local citizens, AOG members might seize them at AOG checkpoints and there were many reports of punishment leased out by the AOGs for those who carry Salam SIM cards. More information related to security and access in the Section 5: Access Assessment of the report.

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Section 4 : Health Assessment For nearly 40 years, Afghanistan has been in a state of protracted crises underlined by on- going armed conflict, reoccurring natural disasters (ranging from small, medium to large scale), weak governance systems, scarce resources and underdeveloped livelihoods. For decades, Afghan women were denied education, which has led to a shortage of female medical staff to look after women in labour. Yet many families will only seek care from a female medical provider, i.e. a trained mid-wife. That’s partly why up to two-thirds of births take place at home without assistance, though this is contested by MoPH, but is a sad reality. Another reason is that, outside big cities, most women don't have adequate access to essential obstetric care, or can't afford it. The need for lifesaving trauma care is extremely high in Ghazni, where little quality medical care is available. The security situation remains volatile and medical needs will continue to increase. The assessment team looked into the data available at Provincial Public Health Directorate (PPHD), Ghazni; BPHS HMIS data; Provincial Hospital Data; Information from other health actors collected during individual interviews; verified this information with health facility staff and discussions with health shura of their perceptions related to health. The AADA supervisors also visited health facilities to observe the facility and administer Rapid Health Assessment Form shared by Health Cluster. Thus, a mix of quantitative data and qualitative data is used for presentation of this assessment.

4.1 Health Actors in Ghazni The current MoPH-World Bank supported BPHS (SEHATMANDI) project caters for the largest share of healthcare services provision in the province (see map 1 for distribution of BPHS healthcare facilities). Through AADA (in collaboration with the PPHD/MoPH), the BPHS is provided through 106 static Healthcare Facilities (3 DH, 3 CHCs+, 21 CHCs, 35 BHCs, 14 SHCs, 1 Prison Health clinic); and EPHS through provincial hospital.

With support from UNDP and technical support of HIV department of MoPH AADA currently manages HIV Counselling and Testing services in two sites (where of the total 5867 clients who were tested 12 have been identified positive to-date)

On the 22nd October 2019, MoPH/HHS has awarded a grant to AADA to provide immunization services to remote population in Ghazni. Overall objective of this project is to improve access to and increase coverage of immunization services in unserved children residing in white areas of the low performing districts. Through this action, AADA provide immunization services to isolated communities through five Community- Based Outreach Vaccine (CBOV) mobile teams to ensure access to immunization services for 206 unserved villages population located beyond the catchment area of a fixed centre and normal outreach vaccination program of existing functional HFs in Giro, Nawa, Qarabagh Muqor, Gillan, Ajristan, Nawor, Jaghori and Malistan districts showed in table 3 Table 3: CBOV team’s distribution:

CBOV Teams Name of based Districts of Estimated Number of Number of HFs operations Population Villages SDPs CHC Giro Giro 10,940 19 16.0 CBOV Team 1 Nawa Center Nawa 10,473 14 11.0 BHC + Tamaki Qarabagh 12,373 5 4.0 CBOV Team 2 Sangasy BHC Moqur 14,340 16 13.0 Patishi BHC Gillan 7,418 17 14.0

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Shinda CHC Malistan 15,659 38 31.0 CBOV Team 3 Sangar CHC Ajrjistan 7,974 12 10.0 CBOV Team 4 Gaghori DH Gaghori 16,481 43 35.0 CBOV Team 5 Garmab CHC Nower 14,499 42 34.0 Total 110,157 206 168

Afghanistan has high levels of child malnutrition, 9.5% of children under-five suffer from acute malnutrition and about 40.9% suffer from chronic malnutrition, i.e. Stunting (National Nutrition Survey 2013). In Ghazni province, the integrated nutrition and mortality SMART survey conducted by ACF in 12 out of 19 districts in February 2016 showed Global Acute Malnutrition (GAM) and Severe Acute Malnutrition (SAM) prevalence based on Weight –for- Height Z-scores (WHZ) at 10.3 % and 3.2 % respectively. The survey also revealed the prevalence of acute malnutrition among child barring age women based on MUAC cut off <230mm at 24.4%. In line with BPHS, severe acute malnutrition (OPD-SAM) service is available in all BHCs, CHCs, and IPD-SAM in DHs and provincial hospital (PH) and preventive cares such as screening, IYCF counselling, and growth-monitoring services in all type of HFs including health sub-centres

Currently, WFP through AADA is supporting TSFP through 66 HFs in Ghazni city and Wali M. Shahid (Khogiani), Khwaja Omari, Waghaz, Deh Yak, Jaghatu, Andar, Zanakhan, Rashidan, Nawur, Qara Bagh, Ab Band, Jaghuri, Muqur, Malistan, Gelan, Ajristan and Nawa districts. However, the project is going to conclude on 30 March 2020. It is WFP decision and HRP 2020 recommendation for phasing out from Ghazni. It means that there will not be complete

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package of IMAM components in target HFs to address the nutrition needs of AM PLW and children 6-59 months suffering from moderate acute malnutrition. Table 4: District-based BPHS Health Facility ratio per capita in Ghazni province (excluding non-BPHS HFs that are supported by other stakeholders), 2019 District Population District CHC BHC SHC Hospital (ratio per (ratio per (ratio per capita) capita) capita) Province 171,025 0 (NA) NA 1(171025) 2(2:85512) Center(Ghazni) Wali M. Shahid 21,953 0 (NA) 1(1: 21953) 0 (NA) 0 (NA) (khugyani) Khwaja Omari 20,733 0 (NA) 1(1:20733) 2(1: 10366) 0 (NA) Waghaz 41,102 0 (NA) 1(1:41102) NA 1(1:41102) Deh Yak 51,836 0 (NA) 1(1:51,836) 2(2: 1(1: 29,950) 51,836) Jaghatu 34,028 0 (NA) 1(1:34028) 3(3: 11342) 2 (2:17013) Andar 130,508 1(1: 2(2:65253) 3(3:43502) 3(3:43502) 130508) Zanakhan 14,147 0 (NA) 1(1:14147) 0 (NA) 2 (2:7073) Rashidan 19,758 0 (NA) 1(1:19758) 0 (NA) 0 (NA) Nawur 99,283 0 (NA) 2(2: 49641 ) 9 (9:11031) 5(5:19856) Qara Bagh 149,291 1(1: 2(2: 74645 ) 2(2: 74645 5(5:29858) 149291) ) Giro 39,029 0 (NA) 1(1:39029 ) 0 (NA) 2(2:19514) Ab Band 29,638 0 (NA) 1(1:29638 ) 1(1:29638 ) 1(1:29638 ) Jaghuri 184,297 0 (NA) 4(1:46074 ) 3(3:61432 ) 8(8:23037 ) Muqur 53,300 1(1: 53300) 0 (NA) 1(1: 53300) 2(2: 26649) Malistan 86,232 0 (NA) 2(2:43115 ) 3(3:28743 ) 3(3:28743 ) Gelan 61,106 0 (NA) 1(1:61106 ) 2(2:30552 ) 2(2:30552) Ajristan 30,979 0 (NA) 1(1:30979 ) 1(1:30979 ) 1(1:30979 ) Nawa 31,955 0 (NA) 1(1:31955 ) 2(2:15977 ) 2(2:15977 ) Total 1,270,192 3 24 35 42 BPHS 2010 1:100,000- 1:30,000- 1:15,000- 1:3,000- standard 300,000 60,000 30,000 7,000

Other healthcare service providers in the province include: Ministry of Public Health through its Provincial Hospital. The government has approved the regional hospital from MoPH funds but the construction is half-finished and not operational. Currently it was hired to a local health facility. Emergency, an Italian Health NGO runs two trauma centres, one in Ghazni city and another one in Andar district. Afghanistan Red Crescent Society (ARCS) runs 3 BHC and 6 SHCs in Ghazni and in addition, PPHD Ghazni runs 9 clinics. The details are in the following table.

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Table No.5: Details of health facilities currently present implemented by various actors in Ghazni Province

Sl. Name of RH PH BHCs SHCs CHC CHC+ DH MT Others Total No. the Agency 1 AADA 1 35 42 22 3 3 0 1 107 2 ARCS 3 6 0 0 0 0 9 3 PPHD 1 3 0 0 0 0 0 5 9 3 Emergency 0 0 0 0 0 0 0 0 2 2 4 Jaghori 0 0 0 0 0 0 1 0 0 1 Total 1 1 41 48 22 3 4 0 8 128 Source: Needs Assessment summary, AADA and Johanniter, December 2019

RH: Regional Hospital, PH: Provincial Hospital, BHC: Basic Health Centre, SHC: Sub-Health Centre (now known as Primary Health Centre), CHC: Comprehensive Health Centre, DH: District Health Centre; MT: Mobile Team, Others (are mostly Community Health Centres) Over the past 17 years, the coverage and the establishing HFs in Ghazni province have been increasing. According to HMIS, there is growth of government clinics in the province from 53 (2004) to 106 (2019) as showed in the following diagram.

Trend of Health Facilities Establishment in Ghazni 2004-2020 140

120

100

80

60

40

20

0 2004 2006 2008 2010 2012 2014 2016 2018 2020

Community-based Health Care (CBHC) is provided through a network of 847 Health Posts (HPs). This translates to one active Health Post (HP) to an estimated 1499 inhabitants (December 2019) and compared BPHS recommended standards of one HP which is meant to serve 1,000-1,500 individuals. In the past, there were First Aid Trauma Posts (FATPs) supported under UNOCHA funded Afghanistan Humanitarian Fund (AHF), then known as CHF and are implemented by ORCD. Currently none of these facilities are functional for trauma care due to shortage of trained staff and inadequate supplies. The case load of trauma cases is mostly dealt by Provincial Hospital and Emergency (the later do most of the transportation and referrals to their Kabul level main hospital).

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4.2 Health Facilities in Ghazni There are 105 health facilities managed under BPHS (SEHATMADI) in Ghazni province and is been implemented by NGOs selected through a competitive bidding process. In past six years, three agencies have implemented the BPHS package in Ghazni starting with BDN, MMRCA and ORCD, and now AADA is implementing the BPHS and EPHS package since January 2019.

Table 6: Details of Health Facilities in Ghazni Total Prison Sl.No. Districts PH DH CHC+ CHC BHC SHC MHT Health Clinic facilities Province 1 1 0 0 0 1 2 0 1 5 Center(Ghazni) Wali M. Shahid 2 0 0 0 1 0 0 0 0 1 (khugyani) 3 Khwaja Omari 0 0 0 1 2 0 0 0 3 4 Waghaz 0 0 0 1 0 1 0 0 2 5 Deh Yak 0 0 0 1 2 1 0 0 4 6 Jaghatu 0 0 0 1 3 2 0 0 6 7 Andar 0 1 0 2 3 3 0 0 9 8 Zanakhan 0 0 0 1 0 2 0 0 3 9 Rashidan 0 0 0 1 0 0 0 0 1 10 Nawur 0 0 0 2 9 5 0 0 16 11 Qara Bagh 0 1 0 2 2 5 0 0 10 12 Giro 0 0 0 1 0 2 0 0 3 13 Ab Band 0 0 0 1 1 1 0 0 3 14 Jaghuri 0 0 2 2 3 8 0 0 15 15 Muqur 0 1 0 0 1 2 0 0 4 16 Malistan 0 0 1 1 3 3 0 0 8 17 Gelan 0 0 0 1 2 2 0 0 5 18 Ajristan 0 0 0 1 1 1 0 0 3 19 Nawa 0 0 0 1 2 2 0 0 5 Total 1 3 3 21 35 42 0 1 106 Source: HMIS Report, BPHS, PPHD/AADA December 2019

In addition to these health facilities, a regional hospital is recently established in Ghazni with 100 active beds and with other specializations, but is not yet functional to its expected capacity due to lack of resources. The health facilities in BPHS programme are not adequate to meet the primary health care facilities and inadequately equipped and less human resources to manage trauma care and casualty management. Nearly 40% of the health facilities are run in temporary buildings or rental buildings and only 60% are run in permanent buildings. Few facilities were badly hit due to war and active fighting and thus operational in private buildings located nearby. Even in the permanent buildings, there are spaces related constrains and the buildings were either damaged or inadequate for trauma case treatment. The following table no.7, provides district wise information of the health facilities.

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Table 7: Status of health facilities Run in own Run in Rented No. of Health buildings S. No. Name of the District and temporary Facilities (permanent building building) 1 Province Center(Ghazni) 4 2 2 2 Wali M. Shahid (khugyani) 1 1 0 3 Khwaja Omari 3 3 0 4 Waghaz 2 1 1 5 Deh Yak 4 3 1 6 Jaghatu 6 4 2 7 Andar 9 5 4 8 Zanakhan 3 1 2 9 Rashidan 1 1 0 10 Nawur 16 10 6 11 Qara Bagh 10 6 4 12 Giro 3 1 2 13 Ab Band 3 2 1 14 Jaghuri 15 11 4 15 Muqur 4 2 2 16 Malistan 8 5 3 17 Gelan 5 2 3 18 Ajristan 3 2 1 19 Nawa 5 1 4 Total 105 63 42 Source: HMIS Report for the month of December 2019, PPHD Ghazni and AADA The reasons for having more private space which are mostly provided by the communities or rented out are due to high number of Sub-Health Centres (now called as Primary Healthcare Centres, PHCs), which constitutes 40% of the health facilities in Ghazni province.

Damages to Health Facilities Abband District: Abband Shamali village (HF) is not working for past 14 years (Govt. Building Hospital and was closed since then). Conflict between Taliban and Government (Taliban control) please fill the details related to the two villages where the conflict is between Taliban and the Government in identification of the health facility. Ajirestan District: In Sangar clinic was affected due to ANA aerial bombing as the district which was under the control of Taliban for one week (two years ago). Damaged (two rooms were damaged fully) equipment were damaged. BPHS and PPHD(MoPH) have repaired under Sehatmandi project. The clinic was closed for a week; however, the services were restored using neighbourhood facilities. Andar District: Abdul Zahir Shaheed Hospital at the District Centre-Merai, the building is not standard. It needs some (Some rooms are mud houses /rooms) - Merai Town/Bazar (Oldest centres, built years and years ago). 80 and 90 years ago it was the capital of Ghazni. Dey Yak District: Most of the clinics in this district are located on the Highway of Ghazni to Gardez Espalt Road. Taliban on times planted mines on the road, which was cleared by ANSF. This road is very kinetic for security incidents and Taliban have high control over the road and divert traffic movements both for security reasons and for tax collection.

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Gillan District: Health Facility in Jahangir village is located in the Bazar. The facility is run in a private building of two and three shops put together to have the clinic at the bazar. It was bombed by ANSF/IMF air strikes. Many shops were destroyed (mostly the telecommunication ones, suspecting that Taliban were in communication with their counterparts in Pakistan). Now the clinic was shifted to a private house provided by the community. Giro District: At Batur CHC facility, a community elder who supported in opening the clinic was killed by pro-government forces/ANA. Guests of operations killed him, air attack. Including (roof) guests were sleeping. His son is the in charge of the hospital. Ghazni District: In Ghazni prison, in 2018 August, all the prisoners were released by Taliban after their attack on Ghazni. However, some of the prisoners escaped but returned back to complete their punishment. Majority were released but some of those returned were killed by ANSF when they recaptured the prison. (people felt that this was not a good gesture) Nawa District: Nawa CHC+ used to be referral point for the IEA, five-hour drive from this place to Quetta. It was attacked killing many Taliban fighters who were undergoing surgical treatment and the building was entirely damaged (the part of building which was meant for women ward) Nawa District: Khawat HR, this location has recorded regular conflict between Hazara and the Kuchis. This building was damaged partially, door, windows and glasses. Building was built by PRT (PRT, Poland). Now is not repaid. There is conflict still with Hazara and Kuchis. Qarabagh District: Qarabagh DH locality is attached directly to the District Police Command post. It is high risk of attack. At the entrance of the clinic, stop (small streets of the compound, street is shared by the clinic and police. They do search, female can't come due to, they made another separate building for CHC-MCH vaccines and mother and children care.

Table: No 8 % HF severely damage due to S.No. District conflict or natural disaster 1 Ab Band 50% 2 Andar 18% 3 Dehyak 0% 4 Gillan 5% 5 Jaighatoo 28% 6 Muqor 11% 7 Qarabagh 3% Source: Assessment of Hard to Reach District Fact sheet, REACH Aug 2019 When triangulated from the other sources of information, Ab Band, Jaighatoo, Andar and Muqur districts, the people have responded that the health facilities were damaged either due to conflict or natural disasters. In context to Ghazni, most of the health facilities damaged were due to conflict. The only heath facility which was damaged to years of neglect (14 years of not in use) was Abband Shamali. ICRC is planning to revive this clinic in consultation with Taliban. This clinic was closed and not used due to conflict between two commanders (both are from Taliban) who hail from two different villages. The dispute was over the location of the clinic. The PRT of that date (Polish PRT) has built the clinic in the current village which was not accepted to other villages and thus didn’t allowed any one to use the clinic building. The services meant for this location was carried out from neighbouring village. This dispute now seems to be resolved after community elder’s initiative and ICRCs recent efforts.

AADA and PPHD in Ghazni have conducted a detailed damage assessment. The details of Damage Assessment and security related impact will be discussed further in Access Assessment of this report.

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The condition of the proposed FATPs in Ghazni province is as follows. The infrastructure assessment was carried out to all the proposed health facilities for FATP where the teams have identified the need.

Table No 9: Infrastructure assessment of the proposed FATPs Space for Vehicle Facility Waiting Conducting parking S.No. Districts Clinic Type space Triage Stabilisation Treatment space yes Yes No No (Dressing Yes 1 Abband Abband CHC room) 2 Andar Ibrahim Zai CHC Yes No No Yes Yes 3 Dehyak Laghabad BHC Yes No No Yes No 4 Gillan Patishi BHC Yes No No Yes Yes Bazar-e- BHC Yes No No Yes Yes 5 Jaighatoo Sadaqat 6 Muqor Sangansy BHC Yes No No Yes Yes 7 Qarabagh Moshaky CHC Yes No No Yes Yes Source: Needs Assessment for FATP proposed sites, AADA /Johanniter, December 2019 The above statements show that the proposed clinics for FATPs have adequate space or the communities are ready to provide additional space for the health facilities located within the existing health facility building locations. They are inadequate for proper services under FATP. Thus, the buildings needed support to function as a full-fledged FATPs.

4.3. White areas and challenges Ghazni province have many districts located in difficult mountainous terrains and the health facilities are scattered in these districts. This geographical isolation and marginalisation is very difficult for the people to access basic health facilities for treatment of illness. It is also difficult for the BPHS implementers to run clinics in these remote areas where the standard practice of establishment of Health Posts, Primary Health Centre, Basic Health Centres are clearly defined in the MoPH’s Sehatmandi project guidelines. In exception cases, the BPHS do come up with additional facilities like we have noticed in Ghazni in 2018 and 2019, where additional Health Posts and Sub Centres were opened up to cover most of the communities. This may be due to the increased demand for extending the services of Taliban’s Health Commission in Ghazni province.

Despite of these increased facilities, there are few communities/villages which are not in reach of formal health services in the province. (See the section on health actors in this report in 4.1 for further information). Rural populations are more likely to have to travel long distances to access healthcare services, particularly subspecialist services. This can be a significant burden in terms of travel time, cost, and time away from the workplace. In addition, the lack of reliable means to reach and use services, such as transportation to services that may be located at distance, and the ability to take paid time off of work to use such services. Confidence in their ability to communicate with healthcare providers, particularly if the patient has poor health literacy. The following are the identified White Areas/underserved areas in Ghazni.

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Table No.10 Underserved/White Areas in Ghazni Province Estimated Distance of the villages total from nearest health facility S.No Name of the No. of population in District . Nearest HF Villages the catchment 16-20 21-25 26 Kms area Kms Kms & above 1 Ajirestan Sangar CHC 12 7974 4 8 2 Gillan Patishi BHC 13 5904 2 11 3 Gillan Rasna BHC 4 1910 1 3 4 Giro Giro CHC 19 10940 6 9 4 5 Jaghori Almaito BHC 19 7330 7 8 4 6 Jaghori Ghojor BHC 24 9151 4 12 8 7 Malistan Shinda CHC 38 15659 6 13 19 8 Maqur Sangasy BHC 8 10056 1 7 9 Maqur Maqur DH 8 4284 3 5 10 Nawa Nawa CHC+ 14 10473 14 11 Nawur Garmab CHC 22 5278 1 3 18 D. Yakhshi 12 Nawur BHC 20 9221 1 8 11 Qarabagh Qarabagh BHC 13 and Tamiki 1 3760 1 14 Qarabagh Janglaq BHC 4 8613 4 Total 206 110553 27 77 102 Source: Needs Assessment exercise, AADA and Johanniter with Extension workers, Dec. 2019

 100% of the locations in white areas are beyond 15 kilometres from the nearest health facility and 50% of them don't have any health post.  80% of the locations in white areas have reported of insecure roads  70% of the locations in white areas have reported of presence of Taliban  Only 30% of the locations in the white areas have reported of presence of government to some extent  Most of the white areas are cut-off geographically due to rivers and flooding, people living in these localities can't access health services during these seasons.  50% of the white areas are located beyond 25 kms distance. More such villages /communities exist in Nawa, Nawur and Gillan districts. 87% of the communities living in unserved areas/white areas located 14 districts are located beyond 20 kms from the nearest health facilities.

MSF survey carried out in 20151 still holds true related to performance of the health facilities in Afghanistan. The study states that, to access the health facilities nearly 72% of patients experienced obstacles. The combination of long distances, high costs and the conflict deprived people of life-saving healthcare. The closest public clinics were underused due to perceptions regarding their lack of availability or quality of staff, services or medicines. For one in five people, a lack of access to health care had resulted in death among family members or close friends within the last year.

11 Patients struggle to access effective health care due to ongoing violence, distance, costs and health service performance in Afghanistan, 2015, MSF

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In Ghazni, the Taliban have put pressure on government’s health service delivery system where in there are new sub-centres and health posts were established where in there is at least one health service provider made available to the communities for maternal health and for acute health condition. More details of how Taliban influence on health sector performance in Ghazni in Access Assessment section of the report.

4.4 Capacity in Health Facilities in Ghazni Province

The following table11 and 12 provides information related to the capacity of the health facilities in terms of beds, ambulance services and health professionals available in the districts. Based on the data, there are only 15 health facilities in this large province has capacity for inpatient treatment and have beds and the capacity put together (with exception to Regional Hospital) has171 beds only and this increase was due to upgradation of Khanabad CHC+ into District Hospital. There are only 17 ambulances available for entire population in the province which caters to the emergency cases includes trauma, emergency transportation for referrals and referrals and transportation of critical pregnancy cases.

Table 11: Capacity of Clinics with beds, ambulances Sl.No. Districts Total Health No. of Active Beds and Facilities Beds Ambulances Ambulance availability in HFs 1 Province 4 0 0 0 Center(Ghazni) 2 Wali M. Shahid 1 10 1 1 (khugyani) 3 Khwaja Omari 3 10 1 1 4 Waghaz 2 10 1 1 5 Deh Yak 4 10 1 1 6 Jaghatu 6 10 1 1 7 Andar 9 50 3 3 8 Zanakhan 3 10 1 1 9 Rashidan 1 10 1 1 10 Nawur 16 20 2 2 11 Qara Bagh 10 50 3 3 12 Giro 3 5 1 1 13 Ab Band 3 10 1 1 14 Jaghuri 15 32 4 4 15 Muqur 4 20 1 1 16 Malistan 8 18 2 2 17 Gelan 5 10 1 1 18 Ajristan 3 8 1 1 19 Nawa 5 10 1 1 Total 105 303 27 27 Source: HMIS- BPHS Programme, PPHD & AADA, December 2019 Under BPHS, there is at least one ambulance available in each district. However, it is not sufficient to meet the trauma case load due active fighting and high casualty reported. The government don’t report the casualties’ despite of the more demonstrations by the communities who display the casualties especially those who were stumbled to the war related

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injuries. Whereas, the Taliban focal points in the districts report higher number of the civilian casualties which is very difficult to verify. But the reality is that the casualties reported in the regular health system is lower than the reality. Most of the casualty don’t receive timely transportation facility and thus high casualties. Even in provincial centre, BPHS don’t have ambulances but EPHS i.e. Provincial hospital have ambulance services (4) and Emergency Hospital (4) has ambulance services. ICRC is introducing new approach based on their learnings from Herat and Kandahar related to provisioning cash for taxi and may pilot it in Andar district where they have plan to support few health facilities in restoration of services in few health facilities which were badly affected due to conflict and aerial attacks. Relating to the staff and categories of the personnel at the clinics (Table No.12)  50 Medical Doctors (46 men and 4 women). Of them 26 (23 men and 3 women) are located in 5 so called District Centre (DAC) level health facilities. Only 38% of the health facilities have a qualified doctor working in the clinic.  100% qualified women doctors and Female nurses (39) are working in 18 DACs/Ghazni city which constitute only 19% of the health facilities in province)  There are only three male surgeons available in entire BPHS and those are located in 3 Clinics  There is huge short fall of technicians in BPHS. Anaesthetics are only five for such a large province, and only three physiotherapists and one Pharmacist for entire BPHS in Ghazni province. 100 percent of psycho-social care providers are present in 19 centres out of 106 clinics run by BPHS. Table 12: Health Facility Infrastructure and Professional personnel Coverage Population

Doctors Nurse Paramedics Physiotropist Psychosocial Consultants Anesthetist Pharmacy Tech. Pharmacist Lab.Technician No No of HFs Dental Tech. District

Physician MD Pediatricia X-ray Tech. S.No Surgeon Dentist General n

M FMFMFM F M F

1 Province Center(Ghazni) 4 171025 2 0 0 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 2 Wali M. Shahid (khugyani) 1 21953 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 3 Khwaja Omari 3 20733 1 0 0 0 0 0 0 0 0 0 0 3 1 1 1 1 0 0 4 Waghaz 2411021 0 000000 0 0 0 2 1 1 1 1 0 0 5 Deh Yak 4 51836 2 0 0 0 0 0 0 0 0 0 0 3 1 1 1 1 0 0 6 Jaghatu 6 34028 1 0 0 0 0 0 0 0 0 0 0 6 1 0 2 1 0 0 7 Andar 91305085 1 1 0 1 0 0 0 1 0 1 127 1 4 4 1 2 8 Zanakhan 3 14147 1 0 0 0 0 0 0 0 0 0 0 3 1 1 1 1 0 0 9 Rashidan 1 19758 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 10 Nawur 16 99283 3 0 0 0 0 0 0 0 0 0 0 14 2 1 2 2 0 0 11 Qara Bagh 10 149291 6 1 1 0 1 0 0 0 1 1 1 13 7 2 5 3 1 2 12 Giro 3390291 0 0000000 0 0 30 0 1100 13 Ab Band 3 29638 2 0 0 0 0 0 0 0 0 0 0 2 2 1 1 1 0 0 14 Jaghuri 15184297 4 0 0 0 0 0 0 0 0 0 0 15 4 2 4 4 0 0 15 Muqur 4 53300 3 1 1 0 1 0 1 0 1 0 1 7 5 0 2 2 1 0 16 Malistan 8 86232 4 0 1 0 0 0 0 0 1 0 0 9 3 2 4 2 0 0 17 Gelan 5611064 1 000000 0 0 0 2 1 1 1 1 0 0 18 Ajristan 3 30979 1 0 0 0 0 0 0 0 0 0 0 3 1 1 1 1 0 0 19 Nawa 5319553 0 000000 1 0 0 60 1 1 1 1 0 Total 105 1270192 46 4 4 0 3 0 1 0 5 1 3 108 39 18 34 29 4 4

Source: HMIS Report of BPHS, AADA and PPHD, December 2019

Capacity in EPHS programme. The Provincial Hospital at Ghazni City is located in the centre of the city and is currently operational in a pretty old building dates back to 50 to 60 years’ construction. Ghazni Provincial Hospital is the Tertiary Care health facility in the province. It has 150 Beds with 9 Departments includes Internal Medicine (Physician), General Surgery,

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ENT, Paediatric, Gynaecology & Obstetrics., recently opened Orthopaedic, Dental and Physiotherapy units. It has fully equipped Intensive Care Unit with 10 beds, two Operation Theatres, with 150+ staff, 17 Specialists and 17 GP Doctors (Post-graduate specialisation doctors), The Provincial hospital has capacity of 38 doctors, 30 technicians and 52 nurses and has a capacity of 150 beds of which 20 of them are in Emergency Ward. It has two Operation Theatres. There is shortage of ambulances (only 4) and the case load for higher level treatment of trauma patients to Kabul Emergency Hospital is quite high and there are few ambulances with trained staff exist. Even the Emergency FAP clinic in Ghazni’s two ambulances is inadequate in most part of the year. Table : Capacity of Provincial Hospital., Ghazni City

# of Active Ambulances Nurses # of Available bed Surgeon doctor Anesthesiologist Gynecologist Obstetrician and Pediatrician Medical Specialist Practitioner General Dentist /psychologist Councelor and sterilization Operating theater ward Nurse Anesthestic ER and nursesOPD Technicians Midwife

M F M F M F M F M F M F M F M F M F M F M F M F

150 4 70200230201741012 6 0 22142 0 5 0 30 15

Source : Provincial Hospital HMIS data, PPHD and AADA December 2019 The capacity of PH is inadequate to current demand of the services. MoPH currently constructing a regional hospital nearer to the Airport and the work is in progress for past five years. Some structures are come up but is not adequate to handle cases and thus provided to one of health facilities managed directly by PPHD (not under BPHS package).

Trauma Cases details in Ghazni Province All the stakeholders have mentioned that there is reduction in the fighting during the assessment period except for few locations in Ab Band, Andar, Dehyak, Gilan, Jaighatoo, Khwaja Omari and Nawa, where ongoing fighting was reported and displacement of local population were reported. The below table shows that there is increase of trauma cases since 2014 (above mentioned of use of Afghan solar calendar, March to March, 1393 means 2014- 15). For the current year, some of the trauma cases were not reported due to its remoteness and insecurity. The trauma incidents are on rise since 2015 due to intensified fighting for territorial controls between the actors of conflict, the AOGs and ANSF/IMF. Ghazni was under Taliban influence since 2006, but it got consolidated over the years and then fell in August 2018 and since then there is intensified attacks and thus increase in trauma cases in almost all the districts in Ghazni province. With active fighting in the province, the figures may cross even 2018 figures as estimated by the health actors in the province.

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Table 12: Trauma Cases in the Health Facilities of BPHS (1394-1398 [6 months])

Sl.No. Districts No. of 1394 1395 1396 1397 1398 (six Total Clinics months) 1398 (till end of (2019) October 2019) 1 Province 4 1616 2537 3792 4053 2095 14093 Center(Ghazni) 2 Wali M. Shahid 1 438 507 243 549 192 1929 (khugyani) 3 Khwaja Omari 3 534 506 640 1133 438 3251 4 Waghaz 2 1448 1273 1725 1376 1143 6965 5 Deh Yak 4 3525 3635 3912 2881 1277 15230 6 Jaghatu 6 1833 998 1091 1052 480 5454 7 Andar 9 18747 17448 12750 11025 7482 67452 8 Zanakhan 3 1378 664 619 1595 324 4580 9 Rashidan 1 326 409 549 701 433 2418 10 Nawur 16 2399 1897 2246 2305 1849 10696 11 Qara Bagh 10 18504 10940 9283 14200 8554 61481 12 Giro 3 0 0 0 318 456 774 13 Ab Band 3 665 1235 2933 2501 861 8195 14 Jaghuri 15 3568 3818 4685 5265 3716 21052 15 Muqur 4 12213 14193 8806 11069 7660 53941 16 Malistan 8 2387 4261 3168 3816 2161 15793 17 Gelan 5 3019 3644 4318 5095 2898 18974 18 Ajristan 3 1077 1485 1598 908 1159 6227 19 Nawa 5 2326 2981 3435 4768 2016 15526 105 76003 72431 65793 74610 45194 334031 Total Source: Trauma Cases reported by BPHS and PPHD, AADA, December 2019 The trauma incidents in Ghazni province has increased over past four to five years and the above table and the graph below shows that the trauma cases are consistent over all last four years and the data of 2019 (only reported for six months) still show higher than the previous years. The trend is due to severe Arial strikes and ground level combating in some districts. The recent fighting in Giro district where the casualties have been reported for past two years. The higher trauma incidents are reported from Ab Band, Andar, Nawa, Qarabagh, Gelan, Kyogyani, Dehyak and Muqur districts. The DHs /CHCs are not fully equipped for meeting the increased causalities. There were few humanitarian funded projects established FATPs for a short duration but for past one year, only Emergency’s two FAPs are functional along with DH, CHC+ and Provincial Hospital taking the load of trauma cases. Many cases related to trauma are managed by unskilled /semi-skilled health facility staff as Taliban couldn’t transport the war wounded to some of the clinics and to Provincial Hospital.

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Trauma cases reported in the BPHS HFs (1394-1398) in Ghazni province

80000 76003 74610 70000 72431 65793 60000 50000 45194 40000 30000 20000 10000 0 1394 1395 1396 1397 1398 (six month only )

The above graph clearly states that the trauma cases were consistent throughout 2014-19 period and the conflict has increased in 2018 and by end of 2019 year, it may increase more that 2019 (the 2019 report here is only for 6 months’ information). Table 13: Trauma inpatient details for 2019 The first six months of 1398(Apl- Trauma indicators 1397 (Apl2018-Mar 2019) Oct 2019) F>5 F<5 M>5 M<5 F>5 F<5 M>5 M<5 Total Weapon Wounded 71 11 268 25 73 8 515 29 1000 Road Traffic Accidents 53 39 217 73 23 26 151 51 634 Occupational Injuries 0 0 0 0 0 0 0 0 0 Burns, scalds and frost-bite 76 204 64 280 24 99 57 123 927 Fractures and dislocations 184 272 356 456 99 117 303 261 2048 Cerebral Concussions 89 100 188 96 54 60 184 111 882 Other Injuries 123 177 172 245 91 120 92 161 1181 Total 596 803 1265 1176 364 430 1302 736 6672 Source: HMIS Report October 2019, AADA, the BPHS implementing agency As per mid- October HMIS data, of overall IP trauma cases in Provincial hospital, 53% of the cases are children, (with 27% girls and 73% boys). 67% of the trauma victims reported in Provincial hospital were male. Among the trauma cases reported in last two years at Provincial Hospital, 33% were related to war/conflict, weapon wounded and mines related. Among this war related trauma which were reported under weapon wounded and other injuries (mine related mostly), 65% of them were children of which 75% were boys. Overall male is reported high at 69% and boys are exposed to this risk (48%) The assessment team triangulated the data collected from various HMIS and other reports of all the health stakeholders working in Ghazni province and met the key functionaries of these health facilities to discuss on the emerging need for trauma units in BPHS system and to be considered as a humanitarian need to for seeking support from humanitarian actors. The team discussed in detail with health Shuras of these seven districts to understand how the ongoing conflict has increased trauma cases and need for trauma posts within their districts and nearer to conflict locations to get immediate treatment to the causalities and reduce death and loss

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of limbs. Based on the perceptions of the health shura members, the following analysis per district was collated.

Districts Practices observed Barriers

Ab Band There are three HFs (one CHC, one BHC and They do not bring their injured to the one PHC) which the BHC is semi functional govt HFs because fear of being chased due to security reasons and arrested by the government The trauma cases have increased security forces. compared to previous years.

Trauma patients are carried to local The problem associated are clinics. For referrals, most to DHs/CHCs transportation during the fighting, less and Provincial/Regional Hospital in equipped and staffed lower level HFs, Ghazni. However, in Taliban occupied roads blockade during the fighting’s, areas, the patients were carried to some shortage of equipment and supplies of the clinics located within the district. and staffs, skills of surgery in the lower - People perception about HFs and level of HFs. Mines on the roads, HFs staffs is good as the meeting with checkpoints, delays due to long community taken place sometime in investigation by the checkpoints and each HFs but There were no exit other security risks. interviews and patient satisfaction survey done investigation by the security check - They complain about shortage of points cause delay and sometimes drugs. Some people had death of the injured on the way. complaints from different staff. Due to cultural barrier, women have - Persons with disability are faced restriction in movement alone and they with transportation, transportation need Mahram when going to HFs. Some costs, structural problems in some areas are mined and the people do not areas are not friendly, no travel on those routes physiotherapy services in most of Active fighting is going on near to some the HFs. specific area like old and new building of the governor office in Ab Band Shamali and on the main road, mines on roads, distance from HFs, and lack of transportation.

Andar Andar: There are 9 HFs (2 CHC, 3 BHC and  Restriction on women’s 3 PHC and one DH) which all HFs are mobility and should be functional and properly staffed. Sometimes access will be affected by active fighting in accompanied by Mahram when some area like Zakuri and Ibrahimzai area visiting health facilities.  Sometimes, there are mines on the way to clinics laid by AOGs. AOGs do warn people not to use these roads. The mines are

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The trauma cases have increased with put on main roads targeting escalation of war and use of artillery and mainly ANSF. The auxiliary air strikes by the government. roads are difficult and takes longer time than the main Referrals: Andar Moshaki and Shahid Mohammad Zahir District Hospital & roads. There are check points Emergency’s First Aid Post (FAP) in the auxiliary roads as well. - People perception about HFs and  Another important problem is HFs staffs is good as the meeting with the absence of women community taken place sometime in vaccinator in the outreach and each HFs but There were no exit male vaccinators are not interviews and patient satisfaction allowed to vaccinate women. survey done The NGOs cannot afford - They complain about shortage of female vaccinator mahram to drugs. Some people had send female vaccinators to the complaints from different staff. outreach work. - Persons with disability are faced Due to cultural barrier, women have with transportation, transportation restriction in movement alone and they costs, structural problems in some need Mahram when going to HFs. areas are not friendly, no physiotherapy services in most of Some areas are mined and the people do not travel on those routes. the HFs. Also active fighting is going on near to some specific area (and on the main road, mines on roads, distance from HFs, and lack of transportation.

Deh Yak The trauma incidence has increased in Problem associated include targeting general in the district with increase in the by AOGs when bringing government fighting especially in the last few months. patients, blockage due to rains and snow, mines on the roads. There are 4 HFs (one CHC, two BHC and one PHC) which all of them are functional for the Due to cultural barrier, women have time being but sometimes the night duty restriction in movement alone and they performance interrupted in this year due to need Mahram when going to HFs. Some heavy fighting near to Dehyak CHC areas are mined and the people do not travel on those routes For minor injuries patients are taken to the

CHC, BHC and even SHC. For major Also active fighting is going on near to injuries they have to take case to the some specific area like Dehyak and regional/provincial hospital. Laghabad and on the main road, mines on roads, People do not take cases to private

doctors because there are no skilled distance from HFs, and lack of doctors and people are poor and cannot transportation. afford private doctors. There are some restriction for women to

have immediate access to HFs while it is allowed to access HFs with mahram( should be accompanied by one of his male family member) and there is no any

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limitation for men to access to HFs even during the night in Deh Yak Shamali CHC Gilan There are 5 HFs including on CHC, 2 BHC transport problem during the fighting, and 2 PHC that all of them are functional. mines, airstrikes risk, checkpoints and The people has access to all of these HFs normally delays due to their longer investigations, insecurity and road blocks. The number of the trauma cases has increased this year comparing it to the last Due to cultural barrier, women have year. People take the injured to: restriction in movement alone and they need Mahram when going to HFs as. DH in the district itself and some health Some areas are mined and the people do facilities like BHC and CHCs. not travel on those routes Active fighting is going on near to some  Restriction on women’s mobility specific area like old and new building of and should be accompanied by the governor office in Gillan and on the Mahram when visiting health main road, mines on roads, distance from facilities. HFs, and lack of transportation.  Sometimes, there are mines on There is some restriction for women to the way to clinics laid by AOGs. have immediate access to HFs and to AOGs do warn people not to use health services while it is allowed to access these roads. The mines are put on HFs with mahram (should be accompanied main roads targeting mainly by one of his male family member) and ANSF. The auxiliary roads are there is no any limitation for men to access difficult and takes longer time than to HFs even during the night in Gillan the main roads. There are check Janda CHC points in the auxiliary roads as well.

 Another important problem is the absence of women vaccinator in the outreach and male vaccinators are not allowed to vaccinate women. The NGOs cannot afford female vaccinator mahram to send female vaccinators to the outreach work. The AOGs take the cases to other locations and clinics in areas under their control.

Jaighatoo The number of the trauma cases has Fighting, main roads between the increased this year comparing it to the last district year. check points in some locations There are 6 HFs (one CHC, 3 BHC and 2 delaying patient transfer to appropriate PHC) which one of the BHC is located in the locations. Bazar Sidaqat that mostly receive the injured people during the fighting and the people has There is some restriction for people to have no regular access to other HFs due to security immediate access to HFs during the night reasons

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while it is allowed to access HFs during the day and there is no any limitation. The AOGs take the cases to other locations and clinics. Fortunately, the people including women and children have access to the health services in normal situation while there is no fighting and there is no any restriction except security to avoid men and women for accessing the health services and there are no any cultural barriers even women can seek medical care without any attendant or Mahram Some areas are mined and the people do not travel on those routes Also active fighting is going on near to some specific area and on the main road to Nawur district. Mines on roads, distance from HFs, and lack of transportation Muqur The number of the trauma cases has Active Fighting, increased this year comparing it to the last Fear of aerial attacks during the year. transportation, checkpoints and delays during checking at the check points,

People take the injured to: roads blocks

The AOGs take the cases to other locations and clinics.

Qarabagh The trauma related to fighting has The barriers are that during the fighting decreased because the front lines has the cases cannot be transported, roads gone away from the residential places and get blocked, poverty and people can they are near the military bases. not afford for transportation. There are check points on the way who delays

cases for investigations and interrogations.

Khwaja There are 3 HFs (one CHC, two BHC) which There is some restriction for people to have Omari all of them are functional for the time being but immediate access to HFs during the night sometimes the night duty performance in while it is allowed to access HFs during the Sabzposhan CHC interrupted in this year due day and there is no any limitation. to heavy fighting near to Khawja Omari District The people including women and children government office have access to the health services in normal situation while there is no fighting and there is no any restriction except security to avoid men and women for accessing the health services and there are no any cultural barriers even women can seek medical care without any attendant or Mahram

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Some areas are mined and the people do not travel on those routes Also active fighting is going on near to some specific area and on the main road to Nawur district

Mines on roads, distance from HFs, and lack of transportation

Muqur There are 4 HFs including on DH in the city of  Due to cultural barrier, women Muqur which is the first referral site for other have restriction in movement three neighbours districts as Gillan, one BHC alone and they need Mahram and 2 PHCs that all of them are functional. The when going to HFs as. Some people has access to all of these HFs normally areas are mined and the people do but sometimes interrupted by fighting and not travel on those routes Also during night the access to these HFs will be active fighting is going on near to restricted by both parties some specific area like Sanagnsyin area in Muqur and on the main road, mines on roads, distance from HFs, and lack of transportation. There is some restriction for women to have immediate access to HFs and to health services while it is allowed to access HFs with mahram (should be accompanied by one of his male family member) and there is no any limitation for men to access to HFs even during the night in Muqur DH

4. 5 Increase of deaths, wounds and injuries due to mines in Ghazni

Given the high incidents of mine detonations which take place in remote areas or when performing solitary tasks, such as grazing livestock or collecting firewood, it is reasonable to surmise that victims are never found, or only discovered after such an extended period that cause of death is neither apparent nor an issue. An unknown number of Afghans who fall victims to mines in remote areas where there are no rescuers, or even witnesses, nearby. These victims are young boys grazing flocks of sheep or goats, it is apparent that, untreated and stranded, such victims die slow and painful death from loss of blood, shock or exposure.

A study on the human cost of explosive remnants of war (ERW) in 2010-18 period, where the casualties are reported as 4,820, which almost 48% of the casualties occurred due to three types of explosive devices used in Afghanistan (Landmines, ERW and Abandoned Improvised Mines). During the recent ground engagement between the government forces and the anti- government elements in Ghazni province, many areas have been contaminated by ERW which threatened the limbs and lives of the civilian population in the province. Those hazards, had to be cleared to allow the safe returned of the displaced civilian population.

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There are reports of the road get mined during the night by Taliban to avoid deployment of army and restricts the movement of ANSF ground operations. However, Taliban warn the people living in their area of control of the landmines been laid to reduce the civilian casualties. However, there are reports of casualties mostly children.

The Mine Action Program of Afghanistan, in an emergency response provided humanitarian services to the conflict affected civilians in Ghazni Funded through the UN Common Humanitarian Fund, implementing partners provided mine risk education and destroyed explosive devices.

4. 6 Recommendations: The assessment team after analysing the findings and based on the suggestions made by the stakeholders summarized this section. a. Increase access to Health Facilities for trauma care in remote areas/hard to reach districts in Ghazni province by establishing trauma units in BPHS health facilities

All the stakeholders include PPHD Ghazni, Provincial Hospital, ICRC/ARCS, and Emergency have suggested for establishment of trauma units, at least one per district in active conflict prone districts in the province. There is greater demand from the health shuras and also from Taliban to increase the number of trauma care centres. Currently only the Provincial Hospital, few DHs and CHCs and Emergency FAP are catering to the high case load of trauma patents. There were reports of deaths of the patients who were transported to Kabul Emergency Hospital due to long journey and heavy traffic congestion in Kabul city. There was a demand to have at least 11 FATPs. The assessment team felt that, establishment of first aid and trauma posts in existing health facilities in the conflict affected locations will increase access to the emergency health care for the affected population.

Establishment of First Aid Trauma Post (FATP) within the existing health facility with rapid response teams (Ambulance services (two shift drivers) + 2 nurses, one for Day and another for Night shifts), conduct triage, categorise the priorities for emergency transportation and referral to higher trauma care posts (Provincial hospital, Emergency Hospital/FAP) and District Hospitals based on the location’s accessibility and distance.

The following clinic sites are identified through the consultations held with PPHD, BPHS team members, ICRC, ARCS, Emergency and IEA’s shadow health directorate. These clinics will also have in addition to FATPs, ambulance facilities for emergency transportation and use for referrals to higher grade clinics for treatment of emergency cases (RED and Yellow). The FATPs will act as first aid and stabilization centres and carry out minor wound care based on triage conducted at the hospitals. Only emergency cases (RED and Orange) will be transferred to identified referral sites or the District Hospitals, Provincial Hospital in Ghazni and Emergency Trauma care facility at Ghazni and Andar and to Kabul if needed. Based on the agreements with different stakeholders, the following options are presented for intervention of FATP and Response Teams (Ambulances).

Table No -14 Proposed Health Facilities for First Aid and Trauma Posts (FATP) in BPHS facilities

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Type of Coverage Coverage FATP location Total Catchment S.No. District Health villages/ Health Facilities Proposed Population Facility CDCs nearby 1 Ab Band Abband Jonobi CHC 67 Chory SHC 54860 2 Andar Ibrahimzi CHC 43 Jan Abad BHC 40575 3 Dehyak Laghabad BHC 24 Robat SHC 22254 4 Gillan Patishi BHC 51 Jahangeer SHC 31720 Bazare Sarab BHC, 5 Jaighatoo BHC 45 51150 Sadaqat Jarmato SHC No any HF near 6 Muqor Sangansy BHC 41 11667 to this HF Askarkoot CHC, 7 Qarabagh Moshaki CHC 88 82585 Jangalak BHC

The referrals sites were discussed with the health facilities and also with the shadow health commissions of Taliban. Due to sensitivity and confidentiality purpose the referral sites of the Taliban is not mentioned in this report and this was suggested by the BPHS staff and the communities. Thus, the following table only state the referrals generally refereed from their facilities

Table No:15 Referral site for proposed FATPs in Ghazni Province FATP location S.No. District Referral Stes Proposed

1 Ab Band Abband Jonobi Qarabagh

2 Andar Ibrahimzi Ghazni PH

3 Dehyak Laghabad Ghazni PH

4 Gillan Patishi Moqur DH

5 Jaighatoo Bazare Sadaqat Ghazni PH

6 Muqor Sangansy Moqur DH

7 Qarabagh Moshaki Qarabagh

For emergency health care, referrals are provided to for Provincial Hospital for Andar, Dehyak and Jaighatoo district location FATPs. For FATPs in Gilan and Muqur districts, it will be referred to Muqur DH, FATPs of Qarabagh and Ab Band will be referred to Qarabagh DH. In Andar, Emergency FAP is another source for referrals. Emergency FAP and Provincial Hospitals are referred in Ghazni city. Upgrading health facilities to meet the increased trauma cases and reduce caseloads over the provincial hospital and Emergency Hospital in Ghazni, Andar and Kabul. Thus quality health services can be offered and reduce casualties. During the assessment, a response plan was also discussed with the stakeholders in addition to the problems.

Supporting Referral Sites with capacity to respond mass casualty WHO under its Emergency Health Services supported by CERF, AHF and their own grants have increased the capacities to trauma care services in high-risk areas, including supporting hospitals at regional and provincial level to deal with mass casualty management (MCM), provision of additional space, equipment and capacity building to the staff. However, these hospitals have no mechanism to fund the supplies needed for mass casualty and generally

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prescribe to the patients to fetch these supplies essential for treatment and surgery. The poverty conditions of the patients make them to shift to BHCs and SHCs (now PHCs) for low quality services and risk of fatal incidents. The health shura and the health facility staff have suggested of having provisions for supplies essential for casualty management as buffer stock/contingency. It can also be explored if the facility can provide cash vouchers to the patients to buy the products from the open market and medical shops if they exist in the towns or cities. We found out that only in Ghazni such facilities are available and thus recommend for stocking the supplies as buffer stock/contingency at the referrals. Provision of life-saving medicines and supplies is considered The BOQs will be developed accordingly in consultation with health actors and the cluster.

Coordination with relevant health actors at Ghazni and Kabul The current MoPH-World Bank supported BPHS (SEHATMANDI) project caters for the largest share of healthcare services provision in the province (see map 1 for distribution of BPHS healthcare facilities). Through AADA (in collaboration with the PPHD/MoPH), the BPHS is provided through 106 static Healthcare Facilities (3 DH, 3 CHCs+, 21 CHCs, 35 BHCs, 14 SHCs, 1 Prison Health clinic); and EPHS through provincial hospital.

Other healthcare service providers in the province include: MoPH runs the Regional Hospital that started recently and three BHC (one BHC in city and two BHCs for Kochi); Emergency (two trauma centre in Ghazni city and Khawaja Omari district), Afghanistan Red Crescent Society-ARCS 3 BHC and 6 SHCs in Khogyani, Waghaz, Andar, Giro, Zanakhan, Jighatoo and Center of Ghazni districts and PPHD

There is need for coordination between different health actors and other agencies for effective programming. The following table states the on-going programmes in the proposed FATP locations. Table:16 Health Actors in the province Sl. Name of the Regional Mobile PH BHCs SHCs CHC CHC+ DHs Others Total No. Organisation Hospital Teams 1 AADA 1 35 42 22 3 3 0 1 107 2 ARCS 3 6 0 0 0 0 9 3 PPHD 1 3 0 0 0 0 0 5 9 3 Emergency 0 0 0 0 0 0 0 0 2 2 4 Snjbada 0 0 0 0 0 0 1 0 0 1 Total 1 1 41 48 22 3 4 0 8 128 Source: PPHD, Ghazni

Only few actors exist in health sector in Ghazni. UNICEF, WHO and UNFPA have field monitors based in PPHD office to monitor and support the health actors in reaching out to the parallel health activities in the province, like immunization, family planning, outreach services and health education. For Trauma care, only Emergency, PPHD and AADA are the actors. It was discussed that there will be coordination committee at PPHD with these health actors to closely collaborate in managing trauma cases.

Coordination with different actors of health is essential for effective Mass Casualty Management. The assessment team agreed in principle with the different health actors on the following lines

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Provincial The focal point for health related programmes in the province. The Director will be Public Health heading the advisory committee for this project and provide all support to the Directorate implementing agencies in operationalisation of the project and other linkages with ongoing health programmes of EPHS, Regional/Provincial Hospital and with the provincial Governor's office

Provincial Referrals to Regional Hospital Hospital, - Use of technology by the FATP staff before sending any referral to Regional Ghazni Hospital o Form a Viber Group – FATP Viber Group and include Regional Hospital and referral hospital focal points o Send the details of the patient and photographs of case sheet/referral sheet and vehicle details o The referral sites will make arrangements with emergency kits and be ready to see the patient immediately on arrival o This real time coordination and reporting will help in preparing for MCIM at referral points o During Emergency: the current 6 beds in Emergency ward will be converted into 12 beds o Operationalise the Emergency Management Plan exist with the facility 0 Coordination related to the project

Monthly/bi-monthly programme coordination committee meeting to update the core steering group (PPHD, Project Director of Provincial Hospital, Emergency Focal point, ICRC/ARCS representative and AADA/Johanniter to this meeting) Afghanistan ARCS have quite a good number of volunteers covering all the villages of Ghazni Red Crescent Province. They are usually the first responders and were trained in First Aid and basic Society, triage. They are deployed in case of emergencies and are also the ones who conduct Ghazni joint needs assessment in any natural disasters. These volunteers will be high potential in case of any support for conducting first aid and triage in any hospital/health care facilities. This can be coordinated with ARCS Ghazni office which coordinates with the volunteers. The project can also coordinate with ARCS regional office related to dignified transfer of any dead upon request of the relatives of the diseased, especially in case where there are difficulties of the relatives for a dignified transfer/transportation. The health facility staff can contact ARCS so that the volunteers will respond (but the official request should come from the relatives of the diseased).

In addition, ARCS runs 3 BHCs and 3 SHCs in hard to reach districts. They coordinate in conducting first aid and transportation of the patients. They are planning to get ambulance services soon. Emergency Emergency is one of lead agency for referrals to trauma patients. Many patients and stakeholders prefer to refer the trauma patients to Emergency FAP which are located in Andar and Ghazni city. The referral is also sent to Emergency’s Trauma Hospital in Kabul. Emergency, AADA and Johanniter will coordinate in information sharing of the trauma cases dealt at FATP/BPHS level and referral cases. AADA AADA has 106 clinics under BPHS and 1 Provincial Hospital (EPHS) directly under BPHS/EPHS their implementation of the basic package of health services/EPHS. The facilitation implementer support is there till mid-2021. Thus, there is greater scope to work with AADA for the FATPs in the BPHS clinics. They have established working norms with Taliban and the government in implementation of health programme and thus have access to all these clinics. Thus, the project coordinates with their programme team and medical staff in the clinics for joint planning and coordination.

Johanniter Johanniter international assistance will bring in the support of Pscycho-social care International (Mental health PTDS) support to the health facility staff and also hire services of Assistance TABISH for health staff safety (related to stress management) in the proposed FATPs. JUH will also bring in the services of training the physiotherapists. The first aid training to CHWs will be carried out through their trainers. Johanniter in Afghanistan is one of the First Aid Training since 2002.

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Swedish SCA has a stabilisation unit in entire region covering Ghazni, Zabul, Paktika and Committee for Uruzghan and even Wardak. Orthopaedic and prosthetic centre in Ghazni. They act Afghanistan as referrals. Johanniter and AADA will coordinate with SCA related to PWD referrals.

 Coordination of health actors, it is proposed that, regular meetings of all health actors like AADA, Johanniter, Health Net, ARCS, EMERGENCY and PPHD (all technical-medical leads) to discuss on the type of services needed for the trauma treatment in Ghazni and who should do what.  AADA to update the provincial council office regularly on quarterly bases on the progression of the current project activities, achievements, challenges and recommendations for the sake of well coordination and accountability, as recommended by the Provincial Council

Recommendations from the stakeholders on the recruitment of qualified staff Stakeholders shared that AADA and Johanniter to consider the following while recruiting staff - Staff should be local - Familiarity with the locality, context and cultural norms - Familiarity with the conflict actors and situation - Ability to work in these conflict zones and work in stressful conditions - Ability to work with both sides and should be independent (that is not to take sides) - Experience of doing Trauma care or relevant clinical experience and trained (qualified staff, approved by MoPH certification) The recruitment should be done transparently - Not only rely of written test, the final short-listed should be chosen based on their clinical skills (conduct clinical tests)

Training of Health Facility Staff on Triage, First Aid and First Responder’s training and Mass Casualty Management Training to the medical staff and community health workers (CHWs) on Basic life support (BLS), triage, ambulance services, safe blood transfusions, mental health and health risk assessment at the FATPs and Mass Casualty Incident Management at the referrals sites. These trainings will be coordinated with MCIM Trainers in Ghazni from WHO or MSF and Provincial Hospital in Ghazni

ICRC and PPHD Ghazni reiterated the training of the staff. The staff working in Trauma centres should be trained on how to conduct Triage in all phases. Primary Assessment and triage should categorise patients who are sent for referral to higher health facilities like Provincial Hospital of Ghazni - Preliminary Assessment should be done o In time o Efficiently o Effectively - Patient prioritization at the scene important for casualty distribution - Separates victims into easily identifiable groups. Prioritization of patient distribution and transportation. Identifies patients who need rapid medical care to save life and limb - The nurse accompanying the patient should conduct secondary triage and assessment of the patient - All the assessments should be recorded in a specific format and tagging

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Advocacy related to health and trauma care - The BPHS programme implementation has undergone lots of changes in the new phase of the project implemented by MoPH and the donor’s (The World Bank) conditions/guidelines. The implementing NGOs /partners will be paid based on performance of each of the health indicators. If the indicators are not met, the payments will not be made. In case of Ghazni or other provinces where Taliban have greater control, the EPI indicators are not fully accomplished. The targets were set when there was low conflict or no conflict. Now, the situation has changed and there is high level of displacement and access related issues due to ongoing fighting. The targets can’t be achieved even if the population utilise the services to its fullest extent. Thus, there is need for advocacy with MoPH and the donors. The NGOs can use the forums like ACBAR to rise the issues. - Due to unaddressed gaps in the international donor-funded public health system, trauma provision is almost exclusively delivered by humanitarian partners in Afghanistan. Indeed, despite the high prevalence of mass casualty incidents, basic and essential surgical care remains outside the seven major elements of the BPHS. The programme sustainability is always a challenge for humanitarian supported FATPs and trauma care. There is need to lobby with MoPH and the donors related to support the emergency health care under their ongoing BPHS and EPHS programmes. Thus, the development programmes should also incorporate emergency health care systems which can be part of the comprehensive health care. Need to lobby with the donors related to the concerns of coverage of medical emergencies under BPHS and EPHS - AADA, ICRC, Emergency, MSF and other health actors to work together to lobby and communicate of the risk of causing harm to the patients, health facility staff and the equipment in the hospitals/clinics due to conflict. Need to lobby with all conflict actors that the facilities should not be attacked (though no guarantee is given in the condition, if the facilities been frequented by the armed groups by IMF). It is found that some of IEA groups visit clinics in the name of supervision and monitoring and also carries patients to the clinics. We have to communicate that they should also be aware of the risk of causing harm to the patients and the facility and staff. We (JUH, AADA and Emergency) will involve other health actors and will advocate with IEA that they should protect the hospital staff and equipment. - All the health facilities, include the FATPs proposed should have a communication display which adheres to neutrality and independence. The principles are to be displayed for adherence. The violations of them are to be reported to HAG/OCHA/WHO, so that humanitarian actors lobby with the actors to negotiate such violations are reduced and stopped. o Not to occupy and pose threat to the common public places like Mosques, schools, clinics o No weapon policy (no one should carry weapons inside the clinic) o No high profile visits to the health facility o No communication phone or radio inside the clinic o No vehicles belong to them should be inside the compound o No involvement in the recruitment of the staff o No use or misuse of the clinic’s equipment include ambulances o No armed convoy of the health faculty or ambulances

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Johanniter and AADA will periodically conduct the principles violation assessment and share the findings with ECHO and other relevant actors, like INSO, HAG at Kabul (Both INGO’s HAG and NNGO’s HAG). It is planned to have a forum on Peace Forum of NGOs in ACBAR and both the agencies will contribute from the learnings of our association in Ghazni with ACBAR for advocacy efforts with actors who can lobby with those involved in negotiations to place that health and education services are to be kept neutral.

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Section 5: Access Assessment

The discussions with various stakeholders in Ghazni, in its neighbouring provinces and in Kabul, discussions in different forums at the national level and review of recent research of Taliban’s governance structure as the talks were evolving in July-September 2019 period. Summarising the findings of these discussions were placed here as part of the access related assessment.

5.1 Strong and structured leadership

Ghazni had a strong Taliban presence as early as 2002/03 period in post-2001 era conflict. A range of sources for the period from 2003 – 08 indicated that there was a significant increase in security related incidents across the province. Overall security incidents shave increased by at least three or four times in the period between 2003-8 period itself. Thus, Ghazni has become the hot bed for Taliban and they have slowly emerged as a strong force and started most of their military and political-civilian structure in Ghazni and then expanded them to rest of the country. This report doesn’t explore of the leadership structure of its central, its military and other structures other than the provincial and district level structures. The Taliban governance structures have sectoral civilian commissions which were evolved over time in Ghazni since 2007/08. The assessment is entirely based on the secondary literature available and as per the oral descriptions and narration of the health facility staff and communities who interacted openly with the assessment team. One of the assessment team member also met the minority Hindu/Sikh communities located in Ghazni city to understand the dynamics and security situations in the province. The assessment report outlines the “rules” for the health sector primarily and to some extent the NGOs working in Ghazni province, analyse the trends and makes recommendations on how the NGOs should respond to these new emerging governance structures. Ghazni had a shadow Taliban administration since 2007, has been under virtually complete Taliban control since October 2018. The Afghan government continues to provide services despite the fact that all of the government offices of the districts, with exception three (Malistan, Jaghori and Nawur) have relocated to Ghazni city, while the Taliban supervise their work. The influence is so much that, couple of kilometres away of Ghazni city is under the influence of Taliban. Ghazni is located at a strategic location, connected with Kabul-Kandahar High Way (High Way 1), the major road connectivity in the country and Ghazni to Gardez and to the border to Pakistan which further leads to Quetta in Pakistan. The Taliban have also expanded their structure of governance in Ghazni gradually. From 2013 onwards, the Taliban established a local finance commission responsible for tax collection, a commission for civilian casualties, a commission for prisoners, a commission for inviting government forces to surrender, a commission for cultural affairs and a commission for dealing with international NGOs. These are in addition to the much earlier established commissions on religious affairs, Judges/legal system, health and education. This structure reflects the way the Taliban organises its administration nationally. It coexisted with the official local government structure until October 2018, when the Taliban took complete control of the province (now the Government has attempted to free few districts like Jaghori, Malistan by forming local defence forces, but this is further deteriorating security situation). In most of the districts, the only interaction people still have with the government is related to obtaining national ID cards. As these registration processes are now carried out in Ghazni city, people need to travel down to the city for registration.

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The following table provides an overview of control of districts in Ghazni based on information provided by various sources and was triangulated with the communities/shura members during our focused group discussion held in December 2019. The data was collected from Afghanistan Security Situation, Country of Origin Information Report, June 2019, European Asylum Support Office (EASO), 2019. This data was used to write the report as compared to what communities perceived of who controls districts in Ghazni province

Community US Military US Military LJW Taliban (end S. Perception BBC (end of (SIGAR) (SIGAR) (April of 2018 No. District (Dec 2019) 2017) mid-2018 Oct 2018 2019) claim) Abband Government - Open Government Government Contested Taliban 93% 10% Taliban Taliban Influence Influence Govt.7% 90% Presence- 1 Medium Ajirestan Taliban Open Contested Contested Taliban Taliban control Taliban Control Control Presence- 2 Medium Ander 90% Taliban, Open Contested Contested Taliban Taliban 10% Taliban Control Control Government Presence – (district centre High only) 3 Dehyak 90% Taliban, Open Government Government Taliban Taliban 10% Taliban Influence Influence Control Control Government Presence – (district centre High only) 4 Gillan 90% Taliban, Open Contested Contested Contested Taliban 94% 10% Taliban Govt.6% Government Presence - (district centre Medium only) 5 Giro Taliban Open Government Government Taliban Taliban 99% control Taliban Influence Influence Control Govt.1% Presence - 6 Medium Ghazni Government - Open Government Contested Contested Taliban 90% 40% Taliban Taliban Influence Govt.10% 60% Presence – 7 High Jaghatu Government Open Government Government Taliban Taliban controls 40% Taliban Influence Influence Control control Taliban -60% Presence – 8 High

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Jaghori Mostly under Government Government Government Contested Government Government Control Influence Influence control 80%, Control, but Taliban 20% few villages adjacent to Ajirestan pay taxes to Taliban and Taliban's Lahya is followed 9 Khoja Government Open Contested Cone Taliban Taliban Omari controls 60% Taliban Control Control Taliban -40% Presence – 10 High Malistan Government Government Government Government Contested Government Control Control Influence Influence control 80%, Taliban 20% 11 Maqur Government Open Government Government Contested Government controls 25% Taliban Influence Influence control 5%, Taliban -75% Presence – Taliban 95% 12 Low Nawa Taliban Taliban INS activity INS Activity Taliban Taliban 13 control Control Control Control Nawur Government Open Government Government Taliban Government Control Taliban Influence Influence Control control 80%, Presence – Taliban 20% 14 Low Qarabagh 80% Taliban, Open Contested Contested Contested Government 20% Taliban control 5%, Government Presence - Taliban 95% (district centre Medium only) 15 Rashidun Taliban Open Government Contested Taliban Taliban control Taliban Influence Control Control Presence – 16 High Waghaz Taliban Open Contested Contested Taliban Taliban control Taliban Control Control Presence - 17 Medium Wali Moh. Taliban Open Government Government Taliban Taliban Shaheed control Taliban Influence Influence Control Control Presence - 18 Medium Zanakhan Taliban Open Contested Contested Taliban Taliban control Taliban Control Control Presence – 19 High Source: Multiple sources, include the Afghanistan Security Situation, Country of Origin Information Report, June 2019, European Asylum Support Office (EASO), 2019, where Column 3, is from the community consultations and rest of them are from the report of EASO.

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Ever since the third quarter of 2019 is that Taliban governance is more coherent than ever before, commissions to oversee sectoral functions like finance, health, education, judiciary and taxation, with clear chains of command, which runs from outside the borders to provinces till village level. Reportedly, since the peace talks kicked off in late 2018, the NGOs need to liaise with different IEA commissions to ensure their acceptance. Engaging only with one sector commission, e.g. Health Commission, might not guarantee acceptance by other IEA members. The state programmes and the co-opted programmes by the NGOs like citizen’s charter, BPHS, EPHS etc., are mostly re-organised to suite Islamic Rules and monitored by Taliban. IEA members usually require access to health facilities, medicines, and might also ask the NGOs who are operating closer to one of the IEA’s fund facilities to facilitate support from that specific NGO. In addition, AOG members usually require NGOs to hire employees from their area of control and with whom they have connections or close ties and are confident that they don’t spy on them. Moreover, a common requirement includes the submission of a list of the NGO staff who will be present in the AOG-controlled area (both permanent staff and those who only go on mission, required to communicate this in advance and wait for their approval). In some cases, the government service delivery institutions have struck deals or come to operational understanding with the local Taliban governance structures like health and education. In some cases, few NGOs and institutions have formal or informal understanding on how they operationalise their programme with clearly outlining the terms of cooperation in their controlled areas in Ghazni Though unconfirmed, but few also stated that the ANSF members usually try to interfere or block the NGO work in AOG-controlled areas, and NGOs sometimes need to contact ANSF high rankings to guarantee their access when they go on missions to AOG-controlled areas (this happens even when NGOs have proper documentation signed by GOA/ANSF). There is a monthly meeting at Provincial level chaired by the Provincial Governor and one of the agenda of it is how to coordinate humanitarian work with ANSF.

HEALTH FACILITIES IN GHAZNI

% of HF under Taliban Control Area % of HF under Govt. Control area

56

54 54 52 52 50

48 48 46 46 44

42 2018 2019

The Taliban over the years have gained territorial control. They in fact made many attempts to capture the provincial capital, Ghazni which finally fell in August 2018 for temporarily and were driven out after aerial bombing and ground attack. Taliban have made an attempt to

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take control over “so called, safe districts”, Jaghori and Malistan along with neighbouring Khas Uruzghan which is the door way for Hazara, ethnic minority region of Daikundi and Bamyan provinces. The attempt was also prevented after series of air strikes and ground engagement. Currently these districts are secured from Taliban but the friction and tension continue to exist. More details in Access Assessment section. Based on the health facilities coverage in their controlled areas, it is estimated that Taliban control less than 50% in Ghazni province. However, the health facilities in Taliban controlled area are in 13 districts out of 19 districts. These can’t be physically verifiable and was based on the perceptions of the health shura representatives of these districts during a consultation meeting held in Ghazni in December 2019. Based on the health facilities control, the following table was generated. IN December 2018, BPHS implementer AADA conducted similar access and protection assessment and in December 2019 AADA and Johanniter have conducted a detailed health services assessment related to trauma care

Table No. 17: Health facilities under the control of IEA/AOGs in Ghazni Province Total Total health facilities Number of BHC and Number of CHC, Name of the number of under IEA controlled SHCs in IEA controlled CHC+ and DHs in S.No. District HFs area area IEA controlled area Dec-18 Dec-19 Dec-18 Dec-19 Dec-18 Dec-19 Province 1 4 1 1 1 100 Center(Ghazni) Wali M. Shahid 2 1 1 1 0 011 (khugyani) 3 Khwaja Omari 3 3 1 2 110 4 Waghaz 3 3 2 1 111 5Deh Yak 4 4 3 3 310 6Jaghatu 6 6 3 5 211 7 Andar 9 8 8 5 533 8 Zanakhan 3 3 3 2 211 9 Rashidan 1 1 1 0 011 10Nawur 16 1 1 1 100 11Qara Bagh 10 1 6 1 501 12 Giro 3 2 2 2 201 13 Ab Band 3 2 2 1 111 14 Jaghuri 15 0 0 0 000 15 Muqur 4 3 3 3 300 16Malistan 9 0 0 0 000 17Gelan 5 4 4 4 400 18 Ajristan 3 3 3 2 211 19Nawa 5 5 5 4 411 Total 107 51 49 37 37 13 13 Source: AADA and Johanniter’s assessment of December 2019 The above table clearly specifies that there is no major shift of territorial control of the province in general towards Taliban, with exception to Jaghatoo district which has moved under Government control and Qarabagh moving into Taliban control. The control of territory means that their influence in governance. They regulate utilities and communications, collecting on the bills of the state electricity company. They are controlling

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around a quarter of the country’s mobile phone coverage. Justice provision has also become increasingly far-reaching. The reach of Taliban governance demonstrates that they do not have to formally occupy territory to control what happens within it. Governance does not come after the capture of territory, but precedes it. The Taliban’s influence on services and everyday life extends far beyond areas they can be said to control or contest. E.g. Case of Land dispute of an influential government authority in Ghazni province: A narration goes out in Ghazni city, which is not under Talban’s direct administration and the person concerned is a powerful person and is highly influential. However, their(Taliban’s) norms and rules do have a sway over. The party mentioned here had a personal dispute over the property he held in the province, which few claimed that the person has illegally occupied it. The Taliban local judge/land tribunal declare that the person in question was asked to vacate the land and hand it over to the people who filed the case. This person was not happy with the decision and now appealed to the higher court in Quetta (Pakistan) where the legal cases are dealt. Despite being an influential person in the government, this person still need to follow the rules of Taliban when he and his family have to live in the province. The Taliban’s governance approach is both civil and military and it is sometimes difficult to understand. The differences between these two as very thin layer that actually differentiates between the two and on some occasions both the functions are held by a single individual. However, there is a significant change in these structures in recent times where the civilian administration has spread widely with new recruitments and responsibilities clearly defined and separated from military functions, especially at the lower levels of administration. The Taliban Code of conduct (known as lahya) is changed based on their experiences from the past. The Taliban’s posture gradually changed as they gained more territory and internal control. The Afghan delegates attended Doha conference state that the Taliban representatives present there were polite, well behaved and well informed of the situation and were seems to be highly trained on how to conduct negotiations. The orientation and training to these Taliban leadership has changed their postures towards aid workers, schools and clinics. In the past, Taliban used to attack schools like burnt them or attack the clinics and aid workers. But, now they deal with these institutions more systematically. The assessment report looks at two components, one is on health and another to some extent on taxation.

5.2 Health: At Provincial level, there will be governor and has a deputy, provincial commissions and Shura comprising elders or religious scholars. The provincial structure is replicated in the districts, with a district governor and is supported by a deputy and a civilian commission of elders or religious scholars of the district. District governors are often the first port of call for dispute resolution, particularly for lesser cases (land or resource disputes, civil cases). Elders play an important role, akin to the government’s district councils, in advocating on behalf of ‘ordinary’ Afghans and providing a connection to local Taliban officials. In Ghazni, the provincial head of the department of the health commission is well acquainted with the health apparatus of the province and a practitioner (not sure whether he has a professional degree to practice medicine. He was holding this position for past couple of years. He has health focal points for the districts and specific clinics. Near areas of frequent fighting, some clinics had dedicated focal points to monitor the clinic and mediate between Taliban patients and clinic staff. Taliban health focal points monitor clinics, checking whether staff show up for work, docking their pay when they do not and inspecting equipment and

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medicine stocks. They also put pressure on NGOs to expand healthcare access in rural areas and improve the quality of services. There are totally 128 healthcare centres in Ghazni province of which 115 of them are served by NGOs, include those who implement the government’s health programme, and controlled by the Taliban. All services are provided (indirectly) by the government, implemented by NGOs and monitored by government, NGOs and the Taliban. According to local sources and the health department head over see the functions of all the hospitals. The emergency clinic is for war victims only The government provides health services through the Agency for Assistance and Development of Afghanistan (AADA), an NGO responsible for the payment of salaries, procurement and supply of medicines and all other activities related to the health sector, including the monitoring of all health-related activities in the province. This means that AADA implements all health-related projects with the health department (only remotely observing their implementation). The NGO also provides transport for female nurses and midwives who live in remote areas. All respondents, including the government’s health department head, said the Taliban did not cause problems with the implementation of health-related projects. The NGO is able to work unhindered and there are no problems with the monitoring of health- related activities, whether the observers belong to an NGO or to the health department. A local doctor who run private clinics in the city said that the Taliban allowed only low-level officials from the health department and NGOs to monitor healthcare centres. Senior officials from the health ministry were not able to go to the districts where there is reports of active fighting and controlled by Taliban. The Taliban are said to actively monitor the health centres themselves. Officials say they are sometimes even helpful in resolving problems. If a doctor is consistently absent, for example, or nurses ask patients to pay illegal fees, the Taliban make enquiries and tell them to change their behaviour. Vetting of Staff: Taliban insists that the staff working in the clinics should be generally from the area where they are working. There are some exceptions given to specific posts like physiotherapy, lab technicians and surgeons. they should be professionally qualified for their role and they should be recommended and approved by the local health Shura. In some instances, there is pressure from local health shura to hire some of their health experts (most of them were called as hafiz or ‘haji doctors’, who are not qualified). The health commission will also send a couple of CVs among which the NGO must select their personnel. The BPHS implementers negotiate with the health shura related to the qualifications and the standards to be met by BPHS parameters. During or after recruitment the Taliban conduct background checks. Objections to appointments are usually based on the individual having ties to the government. Monitoring staff attendance. Attendance of staff is monitored and reported to the responsible NGO or Health official at the provincial level, with the recommendation that commensurate salary be deducted for periods of absence. In some instances, there was also pressure on clinic staff to conform to Taliban appearance requirements (beard length and traditional dress). Monitoring clinics. Health focal points check whether medicine stocks have expired and whether equipment is functional. They may also monitor and advise on clinic construction or renovation. In some cases, where there is shortage of funds from BPHS implementing agencies, the Taliban mobilised people to contribute hasher (voluntary contribution) and build additional rooms for the facility. They try to control prices, if the medicines are not given for free, and stocks. The assessment team also noticed that the Taliban also regulate the prices

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of medicines and some specific services not only in their area of control but even in Ghazni city. The government functionaries also monitor the clinics but through the health shuras and with the Taliban’s permission, but not as frequently as the Taliban does in areas under its influence. Health staff and local shura members said that the Taliban visit the reconstruction site of a healthcare centre in Ibrahim Khel village in Andar district every week to check on the process. Currently there is few construction works been carried (repairs as stated by few) Abdul Zahir Shahid Hospital. They would tell the workers to use quality materials. Health department officials said that, in other cases, when NGOs were sending medicine to local healthcare centres, the Taliban were called on to help ensure that the medicine arrived safely and was distributed equally among the health centres. The Taliban also checked the presence of doctors and other staff at healthcare centres. Gender segregation. While gender segregation is usually already in place in most clinics, the Taliban reports of female health workers should have their mahrams accompanying them to the work place. Also insist of female patients visiting the clinics to have their mahrams present during consultations. The male mahram can only stay if the female staff is not accompanied by other women.

PROPORTION OF HEALTH STAFF IN GHAZNI

Male Female

35%

65%

In Ghazni, there is high level of drop out of female staff and also male staff due to these close monitoring and intimidation. The BPHS implementing agency is working out with the staff and health shura in finding a middle way where both the parties are compromised to minimum standards needed at these clinics. There are instances where the Taliban objected when a female health worker departed and was replaced by a man because women would not be able to access the clinic unless another woman was recruited. In such cases, the Taliban argued that a woman be designated to the position as per the BPHS recruitment guidelines. If there are problems with the Taliban, health providers generally resolve them through health shuras. With all the interviews with health staff in the province, they felt that the Taliban interfered excessively with healthcare or impeded access; however most pointed to government interference and occupation of and theft from clinics by Afghan security forces and militias as being more problematic than Taliban interventions. The role of health shuras are very critical. At each district level a health support council was established by Taliban

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made up tribal elders, imams, teachers and influential figures, that supports the health sector in the area. This council advise the district focal person and discuss health-related issues, checked the attendance and behaviour of doctors (making sure they were not asking patients for bribes or mistreating them) and help doctors if they have security concerns. For example, if the Taliban attacked a government post near a clinic, the council members would intervene and ask the Taliban to stop. If there was a lack of medicine in a health centre, council members would go to the NGO for medicine supply. If one visits the NGO’s office, one can find large section of community elders and shura members present over there to discuss related to medicine supplies and staff related issues. There were at times Taliban shift the health facility due to ongoing fighting. It is these shura members who bring back the clinic to its original building/location soon after the fighting ends. It is these shura council who seek people to contribute “hasher” to make repairs to the clinic if it is damaged during fighting so that the services are resumed. Access to health centres for the patients and health facility staff The discussions with the health facility staff and the outreach workers include community health supervisors, it was stated that almost 50% of the clinics were under the control of Taliban and rest of them are under government or pro-government groups. There is various access related issues emerge in these control areas. There are no major access concerns for the people or patients in the health facilities located in Taliban control areas. They only check the people who are outside the locality and all the locals don’t face any problem.

Table No 18 Presence of health facilities currently controlled by IEA or GoIRA Anti- No. of Health Pro-Government Districts Government Contested Facilities Forces Forces Province Center(Ghazni) 4 1 0 3 Wali M. Shahid (khugyani) 1 1 0 0 Khwaja Omari 3 1 0 2 Waghaz 3 3 0 0 Deh Yak 4 3 1 0 Jaghatu 6 3 0 3 Andar 9 8 0 1 Zanakhan 3 3 0 0 Rashidan 1 1 0 0 Nawur 16 1 0 15 Qara Bagh 10 8 0 2 Giro 3 3 0 0 Ab Band 3 2 1 0 Jaghuri 15 0 0 15 Muqur 4 3 0 1 Malistan 9 0 0 9 Gelan 5 4 0 1 Ajristan 3 3 0 0 Nawa 5 5 0 0 Total 107 53 2 52

However, in the government controlled areas, the health facilities face huge problems as they are located nearer to the approach roads to the towns and main villages. The roads are critical for both ANSF and Taliban for greater control of the movement of the vehicles and act as taxa

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collection for Taliban. Thus there are Security Posts and Checkpoints located nearer to the health facilities. Thus, patients do face huge problems in the facilities which are mostly under the government control in active conflict districts. In districts like Jaghori, Malistan and others don’t face such problems as there is no active conflict at the moment. In Jaghori, for example, there is near-universal girl’s education, and the number of boys attending school is higher than the national average. Women also work outside their homes and can drive cars, as is the case in most urban areas of Afghanistan but which is banned in areas under Taliban control. The districts of Jaghori and Malistan in Ghazni Province are strategic because they are considered the gateway to the Hazara-dominated provinces of Bamiyan and Dai Kundi, peaceful areas where the Taliban currently has no influence. The Taliban may want to try their chances at wresting control of the Hazara areas from the government as they already control large parts of the non-Hazara districts in Ghazni Province. It briefly overran Jaghori, Malistan and neighbouring Khas-Uruzghan in November 2018. Since then there are tensions between the communities in these region and Taliban front posts in the surrounded areas which makes the people to negotiate access and safety from Taliban.

Attacks on the health facilities from late 2018 till date based on the community/health shura members who shared these during the discussions on access. Andar: No any attacks to the schools in this districts reported by community shura and Community health supervisors during their interview. In this one-year period, the ANA Forces had military operation in some targeted area near to Andar DH and some other buildings in Andar District, Ghazni Province that some parts of the HFs destroyed and damaged, the windows and doors had been broken. They added that existed HF staff, who were on their duty inside the clinic at the time of the incidence have been arrested and then getting free. None of them injured. Dih Yak: During this year, the Security Forces had military operation in in the centre of the district and some other targeted area near to Deh Yak CHC in Deh Yak District. Finally, this district occupied back by the ANSF. During this operation some parts of the Dih yak CHC destroyed and damaged, all windows and doors had been broken, the governmental ambulance which was on duty and parked at the time inside the HF was damaged, the solar system damaged and the routine services interrupted. Gillan: There are many attacks done to HFs in this year, Unfortunately, Rasana Khano Khil BHC in Gillan district of Ghazni province was hit by the government airstrike and the building of the HF destroyed and damaged, all windows and doors had been broken, The HF services performed in a rental and private building near to its own building till the building reconstructed by AADA and None of the staff injured. Jighatoo: Since some part of this district occupied recently, so some rockets hit the building of Bazar sidaqat HF which is located near to the first line and now the sub government office of the district is shifted near to this HF During this year, the Afghan National Security Forces had many times military operation in some targeted area near to Bazar Sedaqat and Jirmatoo HFs in Jighatoo District. The report added that existed HF staff, who were on their duty inside the clinic at the time of the incidence have been threated and after hitting the were getting free. None of them injured Khwaja Omari: During this year, the Security Forces had military operation in in the centre of the district and some other targeted area near to Sabz Poshan CHC in Khawja Omari District. Finally, some part this district including the centre of the district occupied back by the ANSF. During this operation some parts of the Sabzposhan CHC damaged, some windows and doors had been broken, the solar system damaged and the routine services interrupted for two days

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Muqur: There are many attacks done to HFs in this year, Unfortunately, Rasana Khano Khil BHC in Muqur district of Ghazni province was hit by the government airstrike and the building of the HF destroyed and damaged, all windows and doors had been broken, The HF services performed in a rental and private building near to its own building till the building reconstructed by AADA and None of the staff injured.

Warlords presence In most of the districts assessed, the presence of war lords is totally missing except in non- Taliban control areas like Jaghori, Malistan, Nawur, Ajirestan, Ghazni and Zhina Khan districts. Most of the war lords have moved out of the country or living in Kabul. Ssometimes warlords present in the rea that came from other part of Ghazni that not belonged to AOG neither to government In some districts, the Arbakis people act as warlords in this district.

The assessment has focused on the elements of risks for health workers and to the civilian population living in the area. Other than the attacks from AOGs, ANSF and pro-government militia (PGM), checkpoints located nearer to the health facilities restrict civilian population, especially women and girls in accessing health services.

Barriers to access to health services

In general, the Taliban have good attitude towards people and no harassment but sometimes interrupted in the staff of the Health Facilities and location of Ab Band Shamali (Check points). Sometimes interrupted in the staffing of the HFs and location of Deh Yak Shamali (Dih yak) Interrupt HF staff work, change or remove the HF staff in the clinics by force (Gillan, Jighatoo, Khwaja Omari and Muqur), In Khwaja Omari, they also interfere in school administration. In Muqur, there are some military base of AOG near to the city of Muqur and even they have a custom on the highway to Kandahar and collect the taxes from vehicles

During the interactions with health shura representatives from all the districts of the province as part of the assessment, the following barriers were identified.

 Restriction on women’s mobility and should be accompanied by Mahram when visiting health facilities. The Taliban strictly apply a rule that women cannot go to a health facility without a male relative. This is the most serious problem women face, most respondents said. Some of the interviewees also complained about the lack of female doctors in the district, as well as the number of health facilities in the district. Generally, female doctors are not interested in working in insecure, Taliban-dominated districts and a district not educating most of its girls even to twelfth class will not be producing ‘locally-grown’ female doctors. Respondents said the only female health workers available in the district are local midwives and nurses who graduated from two-year medical courses in the government-run medical institute. But it is difficult for them to work in Taliban control areas due to fear factor.  Sometimes, there are mines on the way to clinics laid by AOGs. AOGs do warn people not to use these roads. The mines are put on main roads targeting mainly ANSF. The auxiliary roads are difficult and takes longer time than the main roads. There are check points in the auxiliary roads as well.

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 Another important problem is the absence of women vaccinator in the outreach and male vaccinators are not allowed to vaccinate women. The NGOs cannot afford female vaccinator mahram to send female vaccinators to the outreach work.  In Ab Band, due to cultural barrier, women have restriction in movement alone and they need Mahram when going to HFs. Some areas are mined and the people do not travel on those routes Also active fighting is going on near to some specific area like old and new building of the governor office in Ab Band Shamali and on the main road, mines on roads, distance from HFs, and lack of transportation. There is some restriction for women to have immediate access to HFs while it is allowed to access HFs with mahram (should be accompanied by one of his male family member) and there is no any limitation for men to access to HFs even during the night in Ab Band Shamali CHC.  In Andar: Due to cultural barrier, women have restriction in movement alone and they need Mahram when going to HFs. Some areas are mined and the people do not travel on those routes. Also active fighting is going on near to some specific area (and on the main road, mines on roads, distance from HFs, and lack of transportation. There is some restriction for women to have immediate access to HFs while it is allowed to access HFs with mahram (should be accompanied by one of his male family member) and there is no any limitation for men to access to HFs even during the night in Andar Moshaki and Shahid Mohammad Zahir District Hospital  Dih Yak: Due to cultural barrier, women have restriction in movement alone and they need Mahram when going to HFs. Some areas are mined and the people do not travel on those routes Also active fighting is going on near to some specific area like Dehyak and Laghabad and on the main road, mines on roads, distance from HFs, and lack of transportation. There is some restriction for women to have immediate access to HFs while it is allowed to access HFs with mahram (should be accompanied by one of his male family member) and there is no any limitation for men to access to HFs even during the night in Deh Yak Shamali CHC  Gillan: Due to cultural barrier, women have restriction in movement alone and they need Mahram when going to HFs as. Some areas are mined and the people do not travel on those routes Also active fighting is going on near to some specific area like old and new building of the governor office in Gillan and on the main road, mines on roads, distance from HFs, and lack of transportation. There is some restriction for women to have immediate access to HFs and to health services while it is allowed to access HFs with mahram (should be accompanied by one of his male family member) and there is no any limitation for men to access to HFs even during the night in Gillan Janda CHC  Jighatoo; There are some restriction for people to have immediate access to HFs during the night while it is allowed to access HFs during the day and there is no any limitation. Fortunately the people including women and children have access to the health services in normal situation while there is no fighting and there is no any restriction except security to avoid men and women for accessing the health services and there is no any cultural barriers even women can seek medical care without any attendant or Mahram Some areas are mined and the people do not travel on those routes Also active fighting is going on near to some specific area and on the main road to Nawur district , mines on roads, distance from HFs, and lack of transportation

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 Khwaja Omari: There are some restriction for women to have immediate access to HFs during the night due to insecurity on the way while it is allowed to access HFs with mahram( should be accompanied by one of his male family member) in Qalai Noq BHC and Barakat BHC and there is no any limitation for men to access to HFs even during the night in Sabzposhan area All people have normally access to the HFs in all villages but due to cultural barrier, women have restriction in movement alone and they need Mahram when going to HF in Qalai Now and Barakat area but there is no any restriction for in Tormai and Sabzposhan . Some areas are mined and the people do not travel on those routes Also active fighting, on the main road, mines on roads, distance from HFs, and lack of transportation also affect the accessibility.  Muqur: Due to cultural barrier, women have restriction in movement alone and they need Mahram when going to HFs as. Some areas are mined and the people do not travel on those routes Also active fighting is going on near to some specific area like Sanagnsyin area in Muqur and on the main road, mines on roads, distance from HFs, and lack of transportation. There is some restriction for women to have immediate access to HFs and to health services while it is allowed to access HFs with mahram (should be accompanied by one of his male family member) and there is no any limitation for men to access to HFs even during the night in Muqur DH  Accessing higher health facilities in few District Hospitals and Provincial Hospital at Ghazni need transportation and related costs, mines on the roads and the existence of checkpoints of AOGs and ANSF.  There is high risk for people working with the government on the main roads connecting the various district centres to Ghazni and to other provinces, due to presence of check points and Taliban’s watchfulness for the government employees. So many of the government staff use auxiliary roads, but there was always a fear of a surprise checkpoints by AOGs.  Due to mines on main roads, people have to travel on auxiliary roads which are difficult and risky to travel on. There are check points in the auxiliary road and delays caused by the investigation by the check points.  Persons with disability: transportation, the structure in some HFs where there are no facilities for wheel chair and are not disable friendly. There are no physiotherapy services in most of the health facilities and the waiting time for the people with disability are not given special consideration. The Shura Members of Andar have shared that, there were cultural problems that prevented women from having better access. Some parents-in-law did not allow women to go to a health centre for treatment and would send a male member of the family to obtain medicine instead. The shura members consulted during the assessment said they were working to resolve these kinds of problems. According to a local doctor, women in Andar clearly did not have equal access to health services and what was available was only basic health care because of the lack of qualified personnel and sufficient health facilities. If female patients suffered from complicated problems doctors at the hospital or other clinics would refer them to Ghazni.

Districts Practices observed Barriers Ab Band The number of the trauma cases has The main Problem associated in taking increased in the HFs of this district than last injured to HFs are transport problem year and most injured people referred to Ab during the fighting, mines, airstrikes risk, Band Jonubi CHC and then referred to Muqur checkpoints and delays due to their longer DH. The AOGs take the cases to other investigations, insecurity and road blocks

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locations and clinics in areas under their control as Nawa and Andar DH. They do not bring their injured to the govt HFs because fear of being chased and arrested by the government security forces. The problem associated are transportation during the fighting, less equipped and staffed lower level HFs, roads blockade during the fighting’s, shortage of equipment and supplies and staffs, skills of surgery in the lower level of HFs. Mines on the roads, checkpoints, delays due to long investigation by the checkpoints and other security risks. investigation by the security check points cause delay and sometimes death of the injured on the way.

Andar The number of the trauma cases has The AOGs take the cases to Andar DH. increased in the HFs of Andar district than last The main Problem associated in taking year and most injured people referred from injured to these HFs are transport problem during the fighting, mines, nearby district to Andar DH because this is the airstrikes risk, checkpoints and delays due only functional DH under the control of AOG. to their longer investigations, insecurity and road blocks

Dih Yak The number of the trauma cases has Problem associated in taking injured to increased in the HFs of this district than last HFs are transport problem during the year and most injured people referred to Deh fighting, mines, airstrikes risk, checkpoints Yak CHC and then referred to Ghazni PH or and delays due to their longer Andar DH. The AOGs take the cases to other investigations, insecurity and road blocks locations like Janabad BHC and clinics in areas under their control as Andar DH. Gillan The number of the trauma cases has The main Problem associated in taking increased and referred in the HFs of this injured to HFs are transport problem during district than last year and most injured people the fighting, mines, airstrikes risk, referred to Muqur DH. The AOGs take the checkpoints and delays due to their longer cases to other locations and clinics in areas investigations, insecurity and road blocks under their control as Nawa and Andar DH. Jighatoo The number of the trauma cases has Active Fighting, increased in the HFs of this district than last Fear of aerial attacks during the year because there is active fighting in some transportation, checkpoints and delays part of the district and most injured people during checking at the check points, referred to Jighatoo (Bazar Sedaqat or Sarab roads blocks BHCs) and then referred to Ghazni PH in the . The main Problem associated in taking centre of the city. The AOGs take the cases to injured to HFs are transport problem other locations and clinics in areas under their during the fighting, mines, airstrikes risk, checkpoints and delays due to their longer control as Rashidan CHC and Waghaz CHC investigations, insecurity and road blocks and Khogyani CHC Khwaja The number of the trauma cases has The barriers are that during the fighting the Omari increased in the HFs of this district than last cases cannot be transported, roads get

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year because some part this district recently blocked, poverty and people cannot afford occupied by government and most injured for transportation. There are check points people referred to Barakat and Sabzposhan on the way who delays cases for and then referred to Ghazni PH. The AOGs investigations and interrogations. take the cases to other locations like Rashidan CHC and barakat BHC and clinics in areas The main Problem associated in taking under their control injured to HFs are transport problem during the fighting, mines, airstrikes risk, checkpoints and delays due to their longer investigations, insecurity and road blocks

Muqur The number of the trauma cases has There is transport problem during the increased and referred in the HFs of this fighting, mines, airstrikes risk, checkpoints district than last year and most injured people and delays due to their longer investigations, insecurity and road blocks referred to Muqur DH. The AOGs take the

cases to other locations and clinics in areas under their control as Nawa and Andar DH

A case of Checkpoint and presence of Checkpoints and Security Post

In the above diagram depicted by the Health Facility Staff of Qarabagh, it explains that the main health facility exists just across the Police HQ of the district. The patients need to cross the huge barricades and checkpoint and travel into the narrow lane which leads to the clinic. Police personnel harass women, girls and even female health staff. Thus, many women don’t access the services. The health commission/shura discussed with BPHS implementer and rented out (with major contribution from the health shura members) a private building on the main road a bit far away from the existing health facility and Police HQ where the MCH services are carried out. The trauma and other surgical works are carried out in the main clinic near the Police HQ. however, the very presence of Police HQ is a major concern for the patients as the armed conflict stops the health services till the

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fighting ends. There were many occasions the fighting lead to damages to the clinic. As narrated by health facility staff and community shura member to one of the assessment team member

Impact on Health Services in Ghazni - The outpatients have reduced in the health facilities in the active conflict areas in the province due to displacement of population fearing attacks from ANSF and PGMs, economic migration due to drought and low economic growth, thus impacting the health targets set by the MoPH for Ghazni. This is impacting the release of instalments for the BPHS implementing agency as the payments are linked to performance at the health facilities. There was no instalment released for the BPHS implementing agency thus most of the health facility staff have not received their salaries for past three to four months. This is impacting the motivation levels of the health facility staff. - The number of health workers is grossly inadequate to meet the needs of the existing population that has many trauma cases includes injuries due to the aerial strikes, as collateral damage to the cross firing, attacks during raids by the ANSF and PGMs and due to mines laid in the field and roads. There are only 8 trauma care centres located in entire provinces during the assessment and is entirely inadequate to meet the case load. Lack of access to medical supplies (those in the clinics are inadequate as well), makes it impossible for these clinics to provide even the bare minimum care to patients. - Taliban Health focal point in Ghazni repeatedly mentioned that there is need for improved health care across the province. The Taliban also demonstrated comprehensive knowledge of the Basic Package of Health Services (BPHS), the national healthcare programme led by the government and implemented by NGOs. Though, the new conditionality of the MoPH and the donors of performance based payments were not known to them. Part of the problem with health access is that most major facilities, as per BPHS planning, are located in cities and district centres. (Please see the table no.) This makes sense to the extent that this is where the most people live, but these areas are also generally controlled by the government. The Taliban’s Health focal person’s argument was that government areas had better access and better-quality healthcare than Taliban areas. Taliban demands included more staff, new equipment and the establishment of hospitals or sub-centres in areas with inferior facilities. If these are not adhered to, then they would close down these facilities (it was demonstrated in some cases). However, in Ghazni province, these challenges were addressed through negotiations and settlements were quietly reached. - There has been clear pressure on NGO health providers to provide trauma care, and doctors and nurses are routinely called in from nearby cities to treat fighters in remote areas. Another common practice is compelling nurses or clinic staff to perform minor surgeries beyond their qualifications or the capacities of the facility. - Taliban rules based on lahya, impose a tighter restriction on women’s visibility and participation in life outside the home. In health facilities, the main rules are segregation of rooms for men and women, all women include women health workers should wear burkha or chador, should be accompanied by her male relative (Mahram). The following diagram shows, the districts where such measures are imposed. It is important to note that even the district like Aliabad which is outside Taliban control but impose the rules strictly. Impact on Vaccination, Taliban commanders suspect that the health workers especially the vaccinators collect information used to find and kill Taliban supporters and leaders in

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special forces raids and air strikes. The Taliban every year block or ban the WHO and ICRC from operating in areas under their control, so too the vaccinators of BPHS. The vaccination outreach was discussed extensively with the health shura representatives from all the seven districts of the province. The following were their observations on the issue. People perception and access to vaccination  In general, there is positive opinion of the vaccination and immunization programme among the people, government officials and also with the Taliban.  Taliban don’t have any problem in administering vaccination at the clinic, but have some reservations of the polio campaigns carried out the government in the villages. Taliban banned the campaign entirely for about two and a half months from 4 November 2018. The Taliban then told vaccinators they were not allowed to go house- to-house to vaccinate children, but could vaccinate children in the village mosque. The last polio campaign was implemented around mid-March 2019. In a WhatsApp interview to a news agency and widely shared in social networks, the Taliban spokesman, Zabihullah Mujahed, said ‘the enemy’ (by which he meant the government) was misusing the polio drive in Helmand, Kandahar, Ghazni, Uruzgan and other places where fighting was intense and the Taliban had arrested several people who had entered Taliban-controlled areas as vaccinators. “Such people were appointed,” he claimed, “to identify the houses of Taliban commanders and leaders. They would leave chips in the houses, so that the enemy could identify that house and locate it as a target.” The Taliban blame the National Emergency Action Plan for Polio Eradication of 2019, where the campaign states to “maintain dialogue with Taliban at local, provincial and highest level on the programme’s neutrality for polio eradication”.  This suspicious of the vaccinators who make house to house visits. The AOGs does not allow polio campaign because they think there may come some government informers among these people. They worry that they were either threatened or lured by the ANSF and international forces in sharing information of the Taliban leader’s presence in the villages. Thus, Taliban imposed total ban on Polio Campaigns in Ghazni province. However, after negotiations by WHO and UN at different levels, the ban is lifted. However, they have laid new rules for vaccination.  There is problem with outreach because AOGs does not allow men in the outreach to immunize female. The NGOs cannot afford the Mahram of female and therefore do not send female to the outreach.  Taliban have banned NIDs and vaccination of women by men.  Women cannot get vaccine in the outreach site because there are no female vaccinators, traveling long distances and having mahrams are some of the barriers  There were media reports stated the misuse of the vaccination campaign. One of them by the vaccinators themselves not reporting honestly the vaccination coverage. There were some instances found where the vaccinators simply dumped vaccines in the garbage, but counted them as administered, in order to reach their targets. This is possible because there were no means to verify the number of vaccinated children.  Another research document2 quotes a former Taliban official involved in discussions around the Taliban’s code of conduct stated, “with the lahya, we needed to show we could be accountable” and thus impose such restrictions in their area of control. Negotiations at various levels, that includes, Doha and Quetta Shura, the attitudes

2 Ashley Jackson- Life under the Taliban shadow Government, ODI, 2018

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towards aid agencies and service providers appear to have shifted. Taliban leaders gave the World Health Organisation (WHO), the UN Children’s Fund (UNICEF) and their implementing partners permission to conduct polio campaigns; a letter issued with directives for subsequent campaigns, instructed fighters to allow vaccinations and urged parents to have their children vaccinated. Polio vaccinations helped demonstrate the benefits of engaging with the international community on humanitarian issues.3 But, in Ghazni province, the vaccination drive is restricted only at the clinics and don’t encourage outreach services, i.e. vaccinators are blocked to do door to door vaccination. The Taliban health focal points at the districts instruct the vaccinators to administer vaccines at the village mosque. The health agencies like WHO and MoPH officials in Kabul state that such measures would not reach enough children to stamp out the virus. Taliban lifts the ban on WHO vaccination campaign in their controlled areas in Afghanistan Taliban militants in Afghanistan have lifted a ban on World Health Organization (WHO) activities in areas they control, another apparent move by the extremist group to improve their image following the collapse of peace talks with the United States. The move announced on September 25 reversed a decision made in April when the extremist group barred the WHO and the International Committee of the Red Cross (ICRC) from operating in its occupied territories, accusing the groups of carrying out "suspicious" activities associated with polio-vaccination campaigns. "After realizing its shortcomings and following constant contact and meetings with our representatives, the WHO received permission for their activities," Zabihullah Mujahid, a spokesman for the Taliban, said in a statement. The ban had threatened to intensify a major humanitarian crisis in Afghanistan, one of three countries in the world where the disease is endemic.

Source : https://www.rferl.org/a/taliban-lifts-ban-who-red-cross-polio-operations- afghanistan/30183907.html (dated 24 September 2019)

Active Fighting in Ghazni The shura representatives consulted in Ghazni, stated that, the ground engagement has increased in this year, in 2019. AOGs warned people to leave the areas in case of any anticipated fighting. But the government forces don’t warn such, thus high civilian casualty. Similarly, there is higher civilian casualties due to aerial strikes, which has increased in 2019. Night raids and ambushes are also increased across the province. The night searches are increased by the pro-government forces. The attitude and behaviour of the pro-government forces don’t go well with the local population. The shura representatives have complained of their mis-treatment and abuse. In Qarabagh district, the Pro-Government forces, mostly the PGMs harass people and are hostile to local population. The AOGs do not undertake search operations. Active conflict continues to threaten the physical safety and health of Afghans, disproportionately so for women and children. Attacks against health facilities, patients, medical staff and vehicles continue to disrupt and deprive people of life-saving treatment. As per Afghanistan Needs Overview (2020), around 4,00 hours of health care delivery have been lost and 335,000 consultations missed due to the forced closure and destruction of health

3 Ashley Jackson- Life under the Taliban shadow Government, ODI, 2018

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facilities, as attacks against health workers and medical assets mount in both frequency and deadliness.4 In the first six months of 2019, 68 attacks on healthcare were reported resulting in the closure of 101 health facilities, where only 27 of them were re-opened. 18 healthcare workers and patients were killed and 33 others injured.5 Another problem is that donors have often funded misguided programmes in this area, such as teacher training colleges in provincial capitals that most rural women have no hope of ever getting to. A multigenerational approach that trains rural women teachers from the communities they work in is urgently needed, similar to approaches to training community midwives in conservative (mostly Taliban) areas of the country. During the armed conflict and occupation of Ghazni, an NGO run community midwifery education and Nursing education centres were completely destroyed in bombing and fighting. In most provinces aid agencies were able to reduce Taliban demands through negotiation. Much depended on the cohesiveness of local Taliban command structures, and how good the aid agency involved was at negotiating. Fewer demands were placed on smaller Afghan NGOs, which pleaded poverty while making some minor upgrades or accommodations. Other NGOs appeared largely to accede to Taliban demands, pointing to the fact that access to healthcare was indeed worse for civilians in areas under Taliban influence. There was also a concern that the Taliban would simply shut them down if they refused their demands. Few aid agencies pressured by the Taliban coordinated or shared experiences; most kept the demands they faced to themselves and negotiated unilaterally. Most donors to the BPHS appear to have little or no knowledge of the Taliban’s campaign. Was the push for better healthcare about battlefield concerns or about services to civilians? The answer is probably a little of both. Better treatment for fighters and their families improves battlefield resilience, morale and recruitment, and the Taliban have certainly got better in this regard. In the past fighters were transported to Pakistan, but this was dangerous and insufficient to address critical trauma. Now each of the Taliban’s ten military command zones has medical treatment corridors and mechanisms with dedicated focal points to manage transport and treatment.56 There has been clear pressure on NGO health providers to provide trauma care, and doctors and nurses are routinely called in from nearby cities to treat fighters in remote areas.57 Another common practice is compelling nurses or clinic staff to perform minor surgeries beyond their qualifications or the capacities of the facility. The Taliban and its NGO and government counterparts are generally in direct communication, with contact usually initiated by the Taliban when there is a specific issue to discuss.

Violations of Health Facilities noticed in the assessment by the actors involved in conflict. The assessment was carried out based on similar exercise done by Johanniter in Ghazni few months back. The methodology was developed based on the principles followed by MSF in Ghazni. Based on the checklist, a matrix was developed and discussed with health facility staff and Shura members together and thus assess the situation. The assessed 14 facilities include proposed FATPs, referrals sites and other facilities which were considered by Shuras for FATPs. 1. The hospitals which are under the government control, but the AOGs are located at about 1-2 KM radius from the hospital 2. Out of 14 facilities assessed, 11 under AOGs control and 3 in Government control)

4 https://reliefweb.int/sites/reliefweb.int/files/resources/afg_2019_humanitarian_needs_overview.pdf 5 http://www.emro.who.int/afg/afghanistan-infocus/situation-reports.html (August 2019 Situation report)

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3. There is no IMF presence in the province but are seen in operations in some of the districts and mostly through aerial attacks 4. The above statements are true for the only clinics assessed and as per the Health Facility Staff and focal points

High Violations by Taliban/AOGs  86% of the health facilities assessed stated that AOGs involve in the recruitment of the staff  86% of the health facilities assessed have stated that AOGs do bring communication materials like radio into the clinic posing threat to IMF/ANSF aerial attacks  86% violates the principle of No weapon policy (no one should carry weapons inside the clinic).  86% of the health facilities assessed mentioned of violation of the principle of not using the health facility for their night stays/ or place of safety.  86% of the assessed health facilities have mentioned that vehicles belong to AOGs enter inside the compound occasionally. Some have mentioned that if the health staff requests them not to bring the vehicles inside the clinic compound, they adhere, unless it is a high profile visit.

Table No. 20: Summarised assessment of 13 health facilities assessed in nine districts of Ghazni province on violations of principles to be adhered to protect the health facility and health workers’ safety in conflict.

Common principles to be adhered by all parties of conflict in Health Facility Violations by Taliban/AOG Violations by ANSF Violations by IMF Violated not Violated not Violated not regularly, regularly, regularly, due to due to due to community/ community/ community/ S. Regularly Health facility Regularly Health Regularly Health No. Principles Violated rules Violated facility rules Violated facility rules No weapon policy (no one should 12 1 4 2 1 carry weapons inside the clinic) No high profile visits to the health 12 4 2 facility No radio communication or stations 12 1 4 3 inside the clinic No vehicles belongs to them should be 12 4 2 4 inside the compound No involvement in the recruitment of 12 2 2 5 the staff No use or misuse of the clinic’s 12 4 6 equipment include ambulances No armed convoy of the health faculty 12 4 7 or ambulances Not to use the clinic as place of 12 4 8 safety/night stays No Clinic staff is intemidated (e.g. take 12 4 9 staff to treat the injured)

Related to armed convoy is not brought to the health facility too often (86%) due to fear of air attacks and drone strikes. The high profile visits have caused damage to the health facilities

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and its infrastructure. With regard to the Taliban’s monitoring of healthcare centres, one respondent explained that the head of the Taliban’s health commission, who was killed in a drone strike on 25 May 2019 in Andar district, would visit all clinics, where he checked the nurses and doctors, the medicine depot and laboratory, hygiene, patient complaints, staff attendance and medicine expiry dates – just like the government monitor would. (Source: was shared by health facility staff and also verified in AAN reports on Ghazni) For more details on the violations by conflict actors can be seen in the table no. 22 above. The summary of the table as follows. Top four violations by ANF  No weapon policy (no one should carry weapons inside the clinic)  No communication phone or radio inside the clinic  No vehicles belong to them should be inside the compound  No Clinic staff is intimidated (e.g. take staff to treat the injured)

5.3 Control over Roads

The asphalted Kabul-Kandahar and Paktika-Ghazni highways, and a separate, unpaved road that passes through the rural parts of the centre of the district. Although the Afghan National Army (ANA) still has bases along the two highways, the Taliban can exert considerable control on them. For example, the Taliban can divert traffic whenever and at whichever section of the highway they want. One source said that, while in the past, the government had control over parts of the Ghazni-Paktika highway, the Taliban have been blocking this road since spring offensive of 2018, diverting all traffic to an unpaved road through the Sultanbagh area to isolated locations a bit far away from the road, so that all trucks must now drive through these villages. At the same time, the Taliban have been trying to divert traffic from the main Kabul- Kandahar highway/ They collect taxes from both side roads and highways.

5.4 Closure of Institutions

Closure of Religious Institutors/Madrasa: Andar district is home to the renowned and prestigious madrassa Nur ul-Madares al-Faruqi,. Several religious figures have either taught or studied Islam there. One of the most well-known teachers was Mawlawi Muhammad Nabi Muhammadi, the leader of the mujahedin faction popular with Sunni clerics (many of whose members went on to join the Taliban), Harakat-e Enqelab-e Islami-e Afghanistan, the Islamic Revolution Movement of Afghanistan, known as Harakat. Another renowned figure who taught here was the Emirate-era deputy minister of Justice, Mawlawi Abdul Sattar Seddiqi. As recently as 14 May 2019, the madrassa was officially closed due to night raids by Afghan and foreign forces. Afghan forces have occasionally made mass arrests of pupils and teachers from this madrassa.(source is AAN research)

5.5 Taxation Information on the fiscal and financial aspects of Taliban governance is both closely guarded and routinely distorted, both in the Taliban’s own accounts and by others in their own shaky estimates of Taliban revenues. While the Taliban are seeking to expand their tax base, trying to compel any entity they can to pay taxes through coercion, threats and violence, in numerous cases they have either relented, at least temporarily, or reduced their demands where they encountered sufficiently organised and determined resistance. In Ghazni province, the Taliban actively collects taxes from almost all local businesses as well as any landowners who earn an income from their land. The demands are sometimes

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communicated in writing and sometimes face-to-face. There seem to be fixed rates for shops (1,000 Pakistani rupees, roughly 6.60 USD, per year) and land. Tax on land seems to increase when the owner installs irrigation pumps (diesel or solar powered (3,000 rupees). However, these amounts can be negotiated. The Taliban hand out receipts for paid taxes E.g. Even in the health sector where the Taliban have given exception for services and supplies, but due to recent changes in their guidelines, Lahya, where the NGOs were brought under the commission of Companies and NGOs and thus considered them as profit agencies. A truck load of humanitarian materials meant for supplementary nutrition was stopped which was meant for villages of Jhagori district in one of the check point, they have demanded 36,000 Pakistan Rupees as tax and the community shura members are currently negotiating the release of the truck.

The case mentioned by the communities of Jhagori, which is surrounded by areas which are entirely Taliban controlled area. Thus, the communities should maintain good relationships with Taliban to make their life safe. In 2018, due to security changes made by the Afghan government, the Talibans made a push towards the Hazaras and attempted to take control of the district driven many Hazara families to displace themselves to Kabul and Daikundi. Many villages pay tax to Taliban for ensuring safety of their business. Thus Taliban tax people in maintaining security, thereby allowing businesses to operate safely. These businesses, including retailers, tailors, carpenters, and dentists, are then taxed to fund the local administration. In keeping with Afghan practice, the Taliban imposes a general tax on production and capital as well as specific taxes on regulated activities, such as transportation. Development and construction projects can be held up for months or even years where requests to pay taxes (10% tax) are refused, and road-building in particular can be blocked if it is deemed to threaten the Taliban’s military objectives, no matter how lucrative the potential tax revenues might be.

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The recent trend is that the NGOs have to register themselves with the NGO directorate of Talibans who them based on the type of project will refer to that specific commission, e.g. education to Education commission, health to health commission. The recent abduction of NGOs’ staff in north-eastern region demanding payment of Emirate Tax (10%) by the NGOs working in community development work include the national priority programme of Citizen’s Charter is one of such examples where the Taliban demand from NGOs. Zakat and oshr Zakat refers to the religious obligation on Muslims to donate 2.5% of their disposable income to the poor. Some described the Taliban’s collection of zakat as a mandatory 25 Kaldari (Pak Rs) from every 1,000 Kaldar earned, (in most part Ghazni, it is Kaldari/Pakistan Rupees are the main denomination) while others explained it in more voluntary terms, or described it as arbitrary. Some Taliban indicated that it might be used to support the families of poor Taliban fighters, but no one could explicitly outline how it was redistributed. Oshr is a tax of one-tenth of whatever produce or harvest is being brought to market, collected in kind or in cash. However, it is not necessarily as precise in practice as the one-tenth rule might suggest. Collection might involve looking over a truck’s load and asking for a flat fee, as was reported to be the case at quarries in Ghazni (where a flat rate of $350-$500 USD for large trucks and $50-$70 USD for smaller trucks). Businesses, ranging from shops in the bazaar to private clinics, are routinely taxed at least one-tenth of their income, including in district centres and cities not commonly considered as under Taliban control. These taxes may or may not be referred to as oshr and sometimes they are referred as Emirate Tax (Taliban Tax). Electricity, media and telecommunications: there is no government-run provision of electricity and households mainly use solar panels; there is no mobile phone coverage at night; electronic media operate across the district, but is used by only the limited number of people with access to electricity and other devices (TVs, mobile phones) Telecommunication companies only operate during daylight and that too between 9.00 AM to 11 AM. The Taliban have forced mobile companies to switch off the network at night for security reasons. When asked why this was, all respondents said the Taliban have forced telephone companies to stop operating beyond this limited time. If network operators did not heed the Taliban’s demands, they would destroy their telecom towers. Respondents said the Taliban took this decision because they believed the companies were being used by the US military to locate their fighters. When the Taliban stopped the companies from operating, people installed additional antennas on their rooftops to boost coverage. There are four active private mobile network operators in the district, Roshan, Afghan Wireless, Etisalat, and MTN. Salaam (a government network) is the only network that occasionally operates beyond the two-hour limitation. The Taliban do not allow Salaam mobile network because it is a government-run company. They have also instructed people to avoid using the Salaam mobile network. They warned people that if they were caught with a Salaam SIM card, they would break the card and beat the holder. People might be able to use Salaam SIM cards at home, but it is risky for them to carry them outside. Many residents, particularly the educated youth and those who have relatives abroad, use smartphones (which are not banned in all districts, some district like Andar, Ab band people still use it) to have online conversations, for instance with their relatives who are working in the Gulf or other countries. Most people get in touch with their relatives via WhatsApp or Facebook. Most of the interviewees for this assessment said that telecommunication companies have complied with the Taliban’s instructions, implementing their orders immediately upon request,

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for fear of having their antennas destroyed by the insurgents. The Taliban also collect taxes from the companies. According to all of the respondents, the Taliban’s finance committee regularly receives money – amount unknown –from telecommunication companies. Taxes, in theory, imply a social contract. Taliban taxes are not arbitrary, although they do vary and are open to negotiation. They are designed to make the Taliban look like a state. When they meet resistance, whether from individuals, NGOs or private companies, they often argue that they provide security in return.

5. 4 Implications for NGOs: dealing with the Taliban

The effect of taxation-related conflict activity has a direct impact NGO security management and operations. Telecommunications outages make movement planning and staff/vehicle tracking more difficult and can slow down response time in case of an emergency. Outages also impact an NGO’s ability to contact local sources and community members prior to field movements. Power outages may impact NGO security infrastructure including compound lighting and CCTV systems, as well as the ability to keep cell phones or other communication devises operational. The impact of taxation-related conflict activity on the road also affects NGos. Having this parallel system operational in the districts increasingly place the NGOs in a position to directly start the negotiations which on many times made the NDS visiting the NGO compounds and also taking NGO’s staff from their homes for inquiry. There were many discussions among the humanitarian and development NGOs, but most of these discussions are pragmatic and have many dilemmas in dealing strategically with the Taliban. Most of the information were not shared fully to avoid any kind of leakages which may impact these agencies access to their programmes in their provinces. There are many donor RED LINES like that of DFID and USAID of high level restrictions of cash programming in the hard to reach districts fearing aid diversion. NGOs worry about the unclear attitudes of the Afghan government on engaging the Taliban. Local staff often do not share information with NGO managers about the compromises they make to keep programmes running, and nor do agencies subcontracted by international NGOs and the UN to implement programmes. Only few NGOs talk about these issues frankly with each other. Donors, which provide nearly all of the funding for basic services in Afghanistan, face similar dilemmas. There are many government programmes like the World Bank supported Citizen’s Charter and BPHS which has different strategies for hard to reach areas and are technically and strategically not allow to support work in ‘Taliban-controlled areas’. If one sees the coverage of CCAP in Afghanistan, most of their first phase coverage districts are mostly in government controlled areas. NGOs and UN agencies are discussing on access issues, but are hesitant to engage the Taliban directly, worried this may lead to ‘legitimise’ the Taliban or encounter legal or funding penalties. There were other subtle deviations from official policy evident at the local level. Senior and provincial Taliban leaders asserted that where an aid agency obtains its funding does not influence access. In practice, however, many local commanders exhibited negative attitudes towards and suspicion of funding from International Security Assistance Force (ISAF) troop contributing countries.

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In general, but particularly pronounced at local level, there is deep and prevalent hostility towards aid organisations and a general difficulty in distinguishing between different actors (NGOs, UN agencies, the UNAMA6) for-profit contractors.

Recommendations The assessment findings demonstrate that there is need for NGOs and its donors include the ministries and their back donors to enhance their understanding on the current changes in the governance and the rules of engagement, and pursue more structured approaches of working in Taliban controlled or influenced areas (their influence is high even outside their controlled areas). There is high level development and humanitarian needs in the Taliban controlled areas of Ghazni province (that’s where the study focuses more into) and thus there is need to engage with the Taliban. The following recommendations are based on the context to Ghazni and reflect more of the health sector needs.

For NGOs - Improve internal transparency and openness, particularly between the senior management in Kabul (also in their HQs) and staff /partners at the local level, on the risks, policies and tactics for engagement –directly or indirectly, through “acceptance”, “neutrality”, “independence”, or other approaches- with the Taliban. - Keeping in view of Taliban’s engagement with the local shuras (elders and clergy), it is important to have local level transparent and open communication with these local shuras at the village, district and provincial level. Taking clue from the health and education programmes, it is found successful to engage these community institutions in negotiations for access in Taliban controlled areas. - The Taliban NGO focal points and the NGOs in the field are generally in direct communication, with contact usually initiated by the Taliban when there is a specific issue to discuss. The messages should be very simple and clear to ensure consistency and transparency. - Simple communications without any hidden agenda and consistency in its communication and approach will enable the NGOs to work safely in Taliban controlled areas. Evolving such guidelines could substantially improve access negotiations over the long term – if adhered to.  NGO networks like ACBAR to play a valuable role in assisting NGOs to communicate their mandate and to monitor the risks and opportunities for humanitarian engagement with the Taliban. ACBAR should continue to publicly communicate the role and mandate of aid agencies.  Johanniter and its partners, JACK and AADA will review their SOPs and contingency plans and make adjustments where necessary when it is related to telecommunications outages such as a backup communication devises and having power-banks made available and operational.  Johanniter and its partners will ensure that when contracting private companies to transfer goods, all costs involved in the transportation are covered by the private company and detailed as such in the contract. JUH/AADA should ensure that the

6 There is a notion of Blue UN and Black UN, which means that Blue UN means the humanitarian mandated UN and the Black is the military and political one. This understanding is different for the local Taliban authorities where they see both as one, i.e. that they are sided with the Western backed government in Afghanistan

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companies don’t pay the tax to Taliban by unduly inflate the prices of the goods or transportation.  In case of any direct contact by Taliban for payment of taxes, Johanniter will first report to Humanitarian Access Group, local OCHA focal point and INSO to determine if the demand indeed originated from IEA or from other groups. IF the demand is sounded genuine, then Johanniter should discuss with HAG and OCHA in finding responses. Under the proposed project of the Johanniter/AADA there should be one focal point for access and communication with Taliban counterparts in NGOs and Health. These community focal points should negotiate with community shuras in finding solutions to resolve any such situation.

To the UN:

- UNOCHA should do more in developing information, coordination and management to help the NGOs and aid agencies about the risks of, and prospects for, talks with the Taliban on humanitarian access. OCHA should keep aid agencies abreast of any relevant political developments that may affect their work. - OCHA should do mapping accessibility and providing greater understanding, even simple mapping of agencies present, local needs and the prospects for intervention, could greatly assist aid agencies in planning appropriate and safe programming.

To the Government, here in this case for MoPH

- Protect the independence and neutrality of NGOs who are working in the Taliban controlled areas from harassment and prosecution. - There were violations by security forces (ANSF and IMF) for the health workers and the ambulances used to bring patients from Taliban controlled areas to the urban clinics. At the provincial and district level, coordination to be headed by the Governors to ensure safety of health workers and ambulances and reduce harassment of civilians seeking health services. - MoPH to review their financial plans and release of funds linked to performance especially in these hard to reach districts and on-going conflict, like in Ghazni and thus not impact the BPHS implementation as the performance based payments and targets (which were laid when the conditions were normal and currently there is high displacement, security issues which restricts civilians accessing health services, and thus has low achievements to revise the targets based on the realistic figures). - MoPH should lobby with the donors like The World Bank, USAID and the European Commission to consider the real situation in the country and redesign their implementation methodology.

To donors and its HQs:

- Provide funding and support for further research on developing approaches on access. Encourage frank and confidential discussions about the risks and prospects of intervention, and provide support and guidance to assist agencies in efforts to maintain and expand access. The donors should not create an environment of withdrawal or restrict their funding in fear of aid diversion. - Provide greater clarity on counter-terror restrictions. Providing clear guidance on engagement with the Taliban would be a positive step.

Through Shuras and negotiators, to request Taliban, that

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- To stop all attacks on humanitarian and development NGOs (as most of the NGOs do both of them). Create enabling policies and procedures down to the villages so that all the concerned authorities in their controlled areas adhere to improve access to humanitarian work without any levy of taxes. - Continue to disseminate the rules clearly and routinely down to the rank and file

Key Activities considered for the proposed project - Discuss with other stakeholders and UNOCHA at the regional HAG on introducing Joint Operating Principles or Red Lines for humanitarian actors with both the government and the armed opposition groups and their commissions. This JOPs need to be operationalised once it is agreed with the humanitarian actors and discussed with both IEA commissions in Doha and with the government in Kabul. Johanniter, AADA and JACK are members of the Humanitarian Access Group both in INGOs and NNGOS. - AADA will recruit community Liasioning officer who is mutually agreed by IEA commissions and the community shuras in the province and will discuss with the Health Shuras and the community elders related to access and gaining movements in the districts where FATPs are operational. - AADA/Johanniter will follow their own organisational policies related to recruitment and please look at the recommendations of Health Section where the stakeholder’s recommendations were considered. - AADA and Johanniter will report to HAG and Health Cluster related to any violations by either parties and also at the national NGO’s HAG (AADA is a member of this HAG) for any support needed for access and security and safety of the staff - Johanniter will develop Actor wise risk mapping for the proposed locations and districts and come up with mitigation plans. The mitigation plans will be shared with HAG, concerned clusters and donors.

Based on consultations held with HAG, INSO and with donors include ECHO, Johanniter and AADA has developed Risk Analysis and Risk Mitigation plans per each district keeping in view of the district specific dynamics. These documents were shared with HAG and INSO for their inputs and advisory.

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Section 6 : Protection Assessment

The protection assessment was entirely based on the discussions the assessment team had with health facility staff of BPHS including women staff, consultations held with Health Shura representatives for all the districts of Ghazni, visit to health facilities and interactions with Psycho-social counsellors, discussions with protection actors in Ghazni, like UNHCR and their protection monitoring partner, Watan’s Social and Technical Services Association (WSTA). Some sections of this report will be repeating of what was written in access assessment section. However, only relevant information and tables are used for analysing the protection concerns in Ghazni province. The methodology used was doing desk research related to GBV and protection violations recorded in PSS counselling sessions in health facilities, review of the reports from protection partners in Family Protection Centres and Women Friendly Space (WFHS) In addition, discussions were held with Health Supervisors, core health facility staff and from the interviews held with Shura members. Thus, this exercise is summarising the findings from different sources and collated the analysis and presented in this report. The analysis includes the following sub-sections.

1. Protection concerns emerging from the conflict 2. Barrier analysis (based on community’s perceptions) 3. Protection Risk Analysis 4. Protection Response

6.1 Protection concerns emerging from the conflict Taliban clearly have greater control of the province which has increased the high rate of fighting reported in almost entire province for past two years and more so in 2019 with increased use of air strikes, ground operations, night raids and increased use of mines (the latter was mostly by the Taliban). The analysis was done with the BPHS implementing teams and cross verified the data with other health stakeholders and UN agencies. Increase of the conflict scenarios

- Increased checkpoints by the government and AOGs (in most cases, it is the check point occupied by either AOG or Pro-Government armed forces or ANSF) - High night rides (thus, Taliban has banned the services of telecommunication services for most part of the day except for two hours in the morning and mostly operated between 9 AM -11 AM. This is to reduce the impact of day/night operations of ANSF and reduce their communication mechanisms. The use of radio by army can be tracked through the same frequency) - Increased bombardment through air strikes (which is increased in 2019) - Occupation of schools, health facilities and madrasa /mosques by armed forces and Taliban. - People are caught in severe cross fire - Recruitment of young people on rise by both the parties, mostly by the Arbakis *Pro- government militia

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The following table shows the influence of IEA/AOGs over the territories where the health facilities exist. Table No. 21: Who controls what (health facilities) in Ghazni Province

No. of Anti- Pro-Government Districts Health Government Contested Forces Facilities Forces Province Centre(Ghazni) 4 1 0 3 Wali M. Shahid 1 1 0 0 (khugyani) Khwaja Omari 3 1 0 2 Waghaz 3 3 0 0 Deh Yak 4 3 1 0 Jaghatu 6 3 0 3 Andar 9 8 0 1 Zanakhan 3 3 0 0 Rashidan 1 1 0 0 Nawur 16 1 0 15 Qara Bagh 10 8 0 2 Giro 3 3 0 0 Ab Band 3 2 1 0 Jaghuri 15 0 0 15 Muqur 4 3 0 1 Malistan 9 0 0 9 Gelan 5 4 0 1 Ajristan 3 3 0 0 Nawa 5 5 0 0 Total 107 53 2 52 Source: Based on the discussions with Community Supervisor, Programme Coordinator of BPHS implementing agencies, cross verified with other actors and community representatives in health shuras of all seven district (December 2019) This table shows that the Taliban occupy almost 50% of the territory in Ghazni province however they have sway over 80% of the province by their rule/lahya. Government though have almost rest of the fifty percent, it controls around the DACs (district Administration Centres) and DHs/CHCs in these centres. The lower level of health facilities doesn’t have trauma care facilities as they are basically for mother and child health care and overseeing institutional deliveries and basic primary health care. Thus, there is greater pressure from the communities, Shura members and armed opposition groups to have increased number of FATPs in the BHCs and SHCs so that the trauma cases in the remote locations can be mobilized to the nearest health facility rather than shifting to urban centres which are mostly under the government control and the patients may face harassment and arrests in the name of suspicion.

Summary of Impact of IEA/AOGs controlled areas on health facilities and health delivery (more details in the previous section on access)  Affecting Vaccination outreaches and patient flow to the clinics  Affecting patients to visit the clinic and damaging assets of the clinic

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 Disruption of services during the fighting period, as the clinic is closed and staff are moved into safe location in the community. Only after the fighting is closed the clinic services and ambulance services are resumed work  During fighting, the roads connecting to the towns and cities are blocked and closed  During fighting period, the communications get closed. So people can't communicate about injury to others  Lack of transportation (Ambulance services) during fighting, disrupt the movement of patients  Access of women are sometime condition to having Mahram

As per the Health Shura members from all eleven districts consulted, the increased presence of check points and heavy presence of armed personnel near the clinics or approach road to clinics. - Reduced attendance of health seekers especially women, girls and children (though most of the Shura members stated that the clinic staff are available 24 hours some times and are sometimes mobilize staff from other neighbouring clinics in case of emergency and high case load of injuries). In some places which are under the government control - Ambulances are targeted and sometimes the ambulances are used by the AOGs and return back after few days (Source: BPHS team) and when it was used by ANSF, they don’t return it back but dispose it off in the field and most of the case it will not be usable for plying on the roads. - The following clinics were attacked by ANSF/IMF destroying either fully or partially the health facility o Khwaja Omari Dist.- Sabposhan o Dey Yak Dist. – Dah Yak DH clinic o Geroo Dist. Geroo Clinic o Nawa Dist. – Nawa Clinic o Ab Band Dist. – Abband Clinic o Andar Dist. – Nani clinic o Gilan Dist. – Rasana clinic (here one of the health facility staff was killed and the ambulance was destroyed by rocket attack)

Recruitments of young/children Shura members have reported of AOGs and Afghan local police teams forcefully recruiting children or teenagers, thus forcing the communities to displacement. In case of refusing to recruit their children, Taliban are imposing fines over the families – 10,000 to 100,000 Kaldars per family. - In all the districts, there is practice of recruitment of children in their armed forces, especially by the AOGs, PGMs and to some extent ALPs. Not much in the regular Afghanistan Army. - In some cases, young and teenage boys voluntarily join Taliban due to various factors

o Escape from increased work load at home o Feel like holding guns and ammunition as a hobby o Highly influenced by the teachers in madrasas during their talims

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o Attracted towards their ideology and see the failure of the government to solve their problems o No economic benefits and unemployment

Barrier Analysis 6.2.1 Barriers to access schools  Boys have no problem in accessing schools except during fighting period. However, girls can go to the school up to Sixth grade. The girl’s mobility is restricted to only village and thus can’t access higher grade schooling located at the district centres. This is due to lack of female teachers but more of social norms. In the centre of district which are controlled by government there are no barriers and girls attend up to 12 grade. Most importantly the lack of female teachers because the AOGs have put condition and without female teachers the girls cannot attend high grades, like in the case of Dasti Archi district. In addition, in Archi, the girls are not supposed to have Mahram while going to school because usually they travel in groups. But Hijab is mandatory in Taliban control areas.  Taliban restrict pupils’ movements into government-controlled areas. To this end, the Taliban education department head does not allow pupils to take documents from their school so they could, for example, continue studying at other schools in Ghazni city or elsewhere, unless there is a good reason, such as when the student’s entire family is moving out of their villages, only allows pupils to move from one school to another within the district. One reason is to prevent pupils from joining the Afghan security forces or the Afghan Local Police (ALP) while studying in government- controlled areas.  There do not seem to be any restrictions for high school graduates, on the other hand. Andar graduates are allowed to continue their higher education in universities in Ghazni or other provinces. However, most pupils who complete grade 12 do not take part in the university entry test, known as the kankur. Poverty is the main reason for that. In fact, many high school graduates go to foreign countries such as Pakistan, Iran or the Gulf or to other provinces in order to find work  In almost all the districts, the Shura representatives have mentioned that there are some mines placed on the main roads and girls go through long auxiliary routes  For people with disability there are transportation cost and transportation and some schools structures are not disability friendly for easy movement of people with disability.  Mullah Nuh Baba school in Andhar district was closed due to due to shelling by ANA soldiers which has killed students and teachers, though government reported quite a low casualties of children and no mention of teacher. In addition to the schools, few madrasas were also closed by the Taliban citing that they do not want it to be financially supported by the government.  The Taliban have their own monitor, the shadow education director for Andar, who began monitoring in Andar after the establishment of the Taliban’s education commission in 2006. Officials and local sources said that the Taliban’s monitoring was more active than that of government observers, partly because they enlist the help of teachers who accompany the director as he goes from school to school. There are therefore no teachers specifically appointed by the Taliban for supervision.  The Taliban have also changed the curriculum, adding more religious subjects, in addition to what is already in the curriculum, and banning civil subjects, such as the

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subject of social studies, which covers a variety of topics, such as the need for education, the significance of currency and so on. They instruct teachers to teach Quran recitation or other Islamic subjects in the hours that were previously allocated for civil studies.  Taliban scrutinised all school documents and removed all ghost teachers from the lists. These included, for instance, teachers who lived (and sometimes studied) in Ghazni city, but still received their salary as a teacher in one of Andar’s schools. They were mostly people who had connections with government officials and provincial council members 6.2.2 Barriers to access to health services  Restriction on women’s mobility and should be accompanied by Mahram when visiting health facilities.  Sometimes, there are mines on the way to clinics laid by AOGs. AOGs do warn people not to use these roads. The mines are put on main roads targeting mainly ANSF. The auxiliary roads are difficult and takes longer time than the main roads. There are check points in the auxiliary roads as well.  Another important problem is the absence of women vaccinator in the outreach and male vaccinators are not allowed to vaccinate women. The NGOs cannot afford female vaccinator mahram to send female vaccinators to the outreach work.  In Ab Band, due to cultural barrier, women have restriction in movement alone and they need Mahram when going to HFs. Some areas are mined and the people do not travel on those routes Also active fighting is going on near to some specific area like old and new building of the governor office in Ab Band Shamali and on the main road, mines on roads, distance from HFs, and lack of transportation. There is some restriction for women to have immediate access to HFs while it is allowed to access HFs with mahram (should be accompanied by one of his male family member) and there is no any limitation for men to access to HFs even during the night in Ab Band Shamali CHC.  In Andar: Due to cultural barrier, women have restriction in movement alone and they need Mahram when going to HFs. Some areas are mined and the people do not travel on those routes. Also active fighting is going on near to some specific area (and on the main road, mines on roads, distance from HFs, and lack of transportation. There is some restriction for women to have immediate access to HFs while it is allowed to access HFs with mahram (should be accompanied by one of his male family member) and there is no any limitation for men to access to HFs even during the night in Andar Moshaki and Shahid Mohammad Zahir District Hospital  Dih Yak: Due to cultural barrier, women have restriction in movement alone and they need Mahram when going to HFs. Some areas are mined and the people do not travel on those routes Also active fighting is going on near to some specific area like Dehyak and Laghabad and on the main road, mines on roads, distance from HFs, and lack of transportation. There is some restriction for women to have immediate access to HFs while it is allowed to access HFs with mahram (should be accompanied by one of his male family member) and there is no any limitation for men to access to HFs even during the night in Deh Yak Shamali CHC  Gillan: Due to cultural barrier, women have restriction in movement alone and they need Mahram when going to HFs as. Some areas are mined and the people do not travel on those routes Also active fighting is going on near to some specific area like

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old and new building of the governor office in Gillan and on the main road, mines on roads, distance from HFs, and lack of transportation. There is some restriction for women to have immediate access to HFs and to health services while it is allowed to access HFs with mahram (should be accompanied by one of his male family member) and there is no any limitation for men to access to HFs even during the night in Gillan Janda CHC  Jighatoo; There are some restriction for people to have immediate access to HFs during the night while it is allowed to access HFs during the day and there is no any limitation. Fortunately the people including women and children have access to the health services in normal situation while there is no fighting and there is no any restriction except security to avoid men and women for accessing the health services and there is no any cultural barriers even women can seek medical care without any attendant or Mahram Some areas are mined and the people do not travel on those routes Also active fighting is going on near to some specific area and on the main road to Nawur district , mines on roads, distance from HFs, and lack of transportation  Khwaja Omari: There are some restriction for women to have immediate access to HFs during the night due to insecurity on the way while it is allowed to access HFs with mahram( should be accompanied by one of his male family member) in Qalai Noq BHC and Barakat BHC and there is no any limitation for men to access to HFs even during the night in Sabzposhan area All people have normally access to the HFs in all villages but due to cultural barrier, women have restriction in movement alone and they need Mahram when going to HF in Qalai Now and Barakat area but there is no any restriction for in Tormai and Sabzposhan . Some areas are mined and the people do not travel on those routes Also active fighting, on the main road, mines on roads, distance from HFs, and lack of transportation also affect the accessibility.  Muqur: Due to cultural barrier, women have restriction in movement alone and they need Mahram when going to HFs as. Some areas are mined and the people do not travel on those routes Also active fighting is going on near to some specific area like Sanagnsyin area in Muqur and on the main road, mines on roads, distance from HFs, and lack of transportation. There is some restriction for women to have immediate access to HFs and to health services while it is allowed to access HFs with mahram (should be accompanied by one of his male family member) and there is no any limitation for men to access to HFs even during the night in Muqur DH  Accessing higher health facilities in few District Hospitals and Provincial Hospital at Ghazni need transportation and related costs, mines on the roads and the existence of checkpoints of AOGs and ANSF.  There is high risk for people working with the government on the main roads connecting the various district centres to Ghazni and to other provinces, due to presence of check points and Taliban’s watchfulness for the government employees. So many of the government staff use auxiliary roads, but there was always a fear of a surprise checkpoints by AOGs.  Due to mines on main roads, people have to travel on auxiliary roads which are difficult and risky to travel on. There are check points in the auxiliary road and delays caused by the investigation by the check points.

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People’s perception about HF: People perception about HFs in general is good and they are satisfied with the services. However, they complain about shortage of drugs. Some people had complaints from different staff. Persons with disability: transportation, the structure in some HFs where there are no facilities for wheel chair and are not disable friendly. There are no physiotherapy services in most of the health facilities and the waiting time for the people with disability are not given special consideration.

6.2.3 Protection issues of IDPs

 There are instances of domestic violence and gender based violence and protection issues for girls and women but mostly are not reported due to cultural factors  Overcrowding (5-10 families in one compound).  Repeated displacement. People displace to safer places as and when the fighting commence and return back to their place of origin when the fighting subsides. Now with Taliban having control over the territories in most of the districts, there is reduced displacement in 2019. During the conflict, many have lost their homes, destroyed and few were burnt by the pro-government forces and the aerial attacks.  Regarding health, most of the IDPs especially pregnant women and children miss their vaccinations and immunization schedules  The health Shura members and the BPHS health staff mentioned that ANCs and PNCs are missed out due to conflict  Face severe psychological stress and problems at the place of displacement  They displace to new locations with minimum assets and are entirely dependent on support and aid. Inadequate access to aid will lead to stress and may affect their coping mechanisms and adapt negative coping mechanisms  For disabled, there are no supply of specialized appliances. With the closure of ICRC centre, referrals for prostatic care exists in Ghazni city and is provided by SCA. However, the long travel and need for stay at Ghazni which are costly for the people to travel long distances to Ghazni. They are very difficult to access as the referrals needs advanced appointments.  Access to physio-therapy services are low for injured and persons with disability  The trauma incidents due to displacement (conflict) o Worrying o Flashback o Fear o Sleeplessness o Hopelessness o Helplessness Concerns expressed by UNHCR protection partners and health facility staff that there are number of reports of harassment by Police on ambulances at the entry points of the city. This reduces the trust of the injured people from the IEA operated areas in the province as they fear harassment and eventual arrest. Thus, there is greater demand from IEA and the health Shura members from the remote health facilities to establish FATP units in rural health facilities. As per AADA BPHS Programme Director, PPHD and ICRC team in Ghazni, there was a demand for establishment of 8-10 FATPs in Ghazni province.

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Protection Risk Analysis7 Based on the interactions with Health Shura members, BPHS staff includes RPH Officer, Community Health Supervisors, district focal points of BPHS, DoRR and NGOs – ICRC, ARCS and Emergency, the protection risk analysis was carried out by the assessment team as desk top exercise. The risk approach to humanitarian protection has become a standard approach adopted by the protection cluster and other donors (ECHO) and NGOs. Risks are understood wider than something that may happen; it also implies what is happening, has happened or might happen repeatedly. Risk analysis approach helps in identifying protection needs of a given target population by determining the threats faced, and the vulnerabilities and capacities possessed in relation to those threats. In this analysis, the threats are posed by actors who – with a purpose of pursuing their own interests- either target or negatively affect the target population (analysed population). Inter-relatedness of these factors can be illustrated through the following equation Threats X Vulnerabilities Risk = Capacities This is not a mathematical equation, but a tool that serves to illustrate that the protection risk faced by the target population is directly proportional to threats and to vulnerabilities and infernally proportional to capacities. The more the vulnerable the population is the greater the risks and vice versa.

Risk Reduced access to the health facilities for trauma care due to violation of basic humanitarian principles of Humanity, Neutrality, Impartiality and Operational Independence of humanitarian actors and patterns of threat/intimidation/extortion/restrictions Threat - During the fighting period, the clinics are closed and thus can’t access health facility - Land mine threats on the main roads which is meant for the armed forces but the same road is also used for ambulances and people for commuting to hospital/clinics - Vehicles don’t ply during the fighting due to road closures and increased checkpoint - Harassment of security forces while checking the ambulances (suspicious of the IEA fighters) - AOGs takes out ambulances to ply their supporters who were injured during the fighting and return them back to the BHC - Afghanistan armed forces will allow the injured patients for medical treatments but are closely observed and are arrested immediately after their release from the clinic - AOGs sometimes take medicines from the stock of the clinics and thus there are times that shortage was reported - US armed forces (especially the air attacks) attack the health facility or ambulances if they suspect of any high profile IEA (the usual practice of the PPHD of IEA visiting and visibly seen in some of the clinics) E.g. Airstrikes on Nawa Clinics and almost 7 clinics are totally/partially destroyed amounting to few millions of US Dollars.

7 One of the assessment team member underwent a training programme on Protection Assessment conducted by ECHO in 2017 at Kabul. Thus used the framework for the current assessment

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Vulnerability - During fighting, people have to travel longer distances and different routes to visit another health facility - Due to insecurity and local IEA commanders’ orders, the vaccination coverage is low and as a result, approximately 40-45% of rural population are outside of the vaccination coverage in Ghazni - Injuries and wounds (trauma) patients increase during the fighting which demands and very few stabilization and wound care facility exist in Ghazni - Mine risk - People with disability inability to travel to Ghazni from remote districts for health care and services. Capacity - 63 health facilities are run in well-built permanent buildings and are well connected by road - 303 beds in the province in different health facilities - Presence of over 1000 CHWs in the province - 11 Surgeons - Eight MD female (include 3 in Provincial hospital) - UNICEF’s (AADA), Health Net and ARCS mobile clinics/ clinics to cover white areas and underserved areas - Five community based outreach team that provide immunization there is no other MHTs to mentioned here - EMERGENCY’s presence in the district - People are aware of the landmines laid in certain location and always try to use different routes to reach the clinics - Health Shura to advise health administration of both parties, government PPHD and Taliban health commission and are influential - Community contribution in building additional rooms for trauma care in remote areas - Presence of Emergency NGO and Provincial Hospital (with expected improvements in Regional Hospital for Trauma Care Units in future as the current Regional Hospital is not fully functional) - Acceptance of health staff by all parties of conflict

Usually displacement, especially war-related displacement, is accompanied by several main stress factors. These include economic constraints, security issues, breakdown of social and primary economic structures and a consequent devaluation or modification of social roles, violence, persecution and discrimination, loss of loved ones, direct exposure to violent acts. Moreover, unstable and precarious life conditions in the host location, including vague legal status, difficult access to services together with the loss of one’s own social environment and system of cultural meaning, contribute to create a very uncertain future. Often these elements bring about a series of feelings, including grief, loss, and guiltiness towards the people who did not flee or other members of the family, a sense of inferiority in relation to the resident population, isolation, depression, anger, angst and insecurity-instability. In certain cases, they can cause depression and withdrawal.8

8 Study on Disability and Mental health by Handicap International, Kunduz 2018

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The below table clearly state that there is high number of PTDS and mental health related issues at the BPHS and EPHS in Ghazni. Discussions with TABISH, an NGO working in building capacities of health staff and NGO’s staff working in Psycho-social and mental health care in Afghanistan, where they state that nearly 50% of the population living in conflict prone areas like Ghazni struggle with depression, anxiety, and post-traumatic stress, but fewer than 10 percent receive adequate psychosocial support.

Table No 22.: Mental Health OPDs in BPHS clinics Total Nine months of 1397 First six months of 1398 Sl.No. Districts Health Facilities F>5 F<5 M>5 M<5 F>5 F<5 M>5 M<5 1 Ab Band 3 977 0 877 0 677 0 570 0 2 Ajristan 3 907 8 424 13 1247 6 380 1 3 Andar 9 5180 165 4124 124 4568 115 3911 95 4 Deh Yak 4 938 5 696 8 420 1 269 0 5 Gelan 5 1098 19 957 27 850 17 777 20 6 Giro 3 248 0 144 0 308 0 137 0 7 Jaghatu 6 156 1 179 0 123 0 122 0 8 Jaghuri 15 3307 28 1774 1 1737 50 1149 88 9 Khwaja Omari 3 116 13 116 9 130 0 75 0 10 Malistan 8 1094 1 899 3 693 0 482 0 11 Muqur 4 1849 23 1517 18 1458 44 1209 82 12 Nawa 5 1193 6 956 1 828 2 720 29 13 Nawur 16 620 11 526 19 529 9 381 4 Province 14 4 Center(Ghazni) 398 9 781 8 304 3 444 7 15 Qara Bagh 10 2129 14 1274 5 1213 2 794 32 16 Rashidan 1 51 0 69 0 55 0 71 0 17 Waghaz 2 345 0 531 3 122 0 232 0 Wali M. Shahid 18 1 (khugyani) 195 0 103 0 87 0 107 0 19 Zanakhan 3 260 7 287 8 215 3 188 0 Total 105 21061 310 16234 247 15564 252 12018 358 Source: Mental Health OPD and Hospital HMIS, BPHS, AADA December 2019

IN Ghazni, only at CHC and above level have psycho-social care providers and there are only ## of them present in the entire BPHS clinics. In addition, the Provincial Health, HN TPO support psycho-social service providers in the mobile health units. There is no. The psychiatrics department in Ghazni Provincial Hospital that can cater to mental health care for serious mental health and trauma treatment and counselling. PH have PSS counsellors at their clinic for generic and trauma care patients. The discussions with the Psycho-social counsellors held have the following outcomes and these are cross verified with TABISH. - Emotional problems include: sadness, grief, fear, frustration, anxiety, anger, and despair. - Cognitive problems, such as: loss of control, helplessness, worry, ruminations, boredom, and hopelessness are all widely reported, as are physical symptoms such as: fatigue, problems sleeping, loss of appetite and medically unexplained physical complaints.

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- Social and behavioural problems, such as: withdrawal, aggression and interpersonal difficulties are also common. The assessment identified following major symptoms about psychosocial aspects in IDPs families. - According to the Psychosocial counsellors, the main concerns which emerged from the counselling sessions that, the patient’s complaint that the traumatic/complicated grief is linked to the difficulties faced due to the war context. Change in sleeping pattern  Images reflect during sleep of the violent events experiences repeatedly  Feeling being isolated  Changes in appetite  Changes in behaviour According to the observations made by the PSS workers in Ghazni province, - Anxiety and worry of the household of the security situation, the loss of a stable environment, their home etc. - Anxiety and sadness due to the loss of a family member or relative during the conflict, sometimes coupled with household isolation - Some family members' shared their pain during the assessment (IDP situation, psychological distress.) couple sometimes with a lack of communication with the family - Parental anxiety and concern for children who cannot attend school and / or the inability to support the family - During our discussions with other warring elements and stakeholders working on health, there are some gaps or fears expressed by IEA for getting access to regional hospital o Many higher grade hospitals report of violations of principles and the armed soldiers do raid the hospital and search for relatives and wounded persons and suspect them to be a Taliban fighter or sympathiser. This pose risk for the pro- IEA injured to get treatment in the hospital. No one can guarantee the safety of the injured pro-IEA or people living in IEA controlled locations of the consequences in post-release of the patient from the hospital. The government forces also agree to have the treatment of the pro-IEA groups or people from IEA controlled areas get medical treatment but may like to question them after their treatment and mostly get arrested after coming out of the clinic. This concern is high among the IEA groups. o Thus, the IEA groups insist of having more casualty treatment mechanisms located in their controlled territories and convert the stabilization centre which they operate in few of the districts into surgical sites.

The following analysis is consolidated from the discussions held with stakeholders and review of our previous assessments. The following table illustrates how different people in the same location face different threats.

Category Protection Issues Health Youth (12-25 Increased pressure to join armed opposition Proper clinical and psycho- years) groups. social response mechanism is (teenage needed boys_ Harassment from security forces while they boys/young have moved to the cities. Health facilities with MH-PSS men in all 19 exist but not no skilled districts of counsellor exist in these which 7 clinics

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districts were Fear of arrest and harassment while analysed in transferring injured youth in ambulances or depth in private vehicles at check points Ghazni Forced out of school as Taliban suspect that if they graduate in any school outside their influence, the youth may join ANSF/ALP as they are mostly poor. Injured and Fear of accessing health centres due to Inadequate staffing and low traumatized harassment and fear of arrest capacity in health facilities to persons treat trauma patients Distance of the trauma facilities and lack of transportation Lack of adequate ambulance services for emergency Fear of Arial attacks by ANSF/IMF transportation for treatment or referrals Girls and SGBV in and outside. Need male relative to Adolescent Taliban instruct them to travel with a male accompany to access health Girls mahram (a close relative) while going to facility. health facility or education or for livelihood purpose Proper clinical and psycho- social response mechanism is needed

Women SGBV (*though not many of them are Constant fighting between reported to the agencies, but close government and opposition assessment of WSTA/UNHCR mentioned of groups has made them not to the increased incidents. access clinics

Need support of male relative/mahram to Proper clinical and psycho- accompany outside social response mechanism is needed, especially for PTDS

IDPs Increased occupation of their homes in the Increased diseases due to place of origin made them to displace, overcrowding, restricted constant fighting is making them to displace mobility of girls and women repeatedly, loss of livelihoods and livelihood thus poor access to health assets making them traumatized facilities. Proper clinical and psycho-social response Drought and conflict making them to flee mechanism is needed from their place of origin to cities, but in cities their living conditions are deploring and further displace to another urban setting for seeking employment opportunities.

The local leaders and Shura members do negate with both the warring groups to get access to health facilities especially for maternal health care and that’s one of the reasons why all the clinics have reported high institutional deliveries and is also confirmed by the Health Shura members and health staff of the clinics. However, the trauma cases treatment is still remains a challenge due to access issues and availability of capacitated health professionals.

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Protection response Based on UNHCR representative’s response, in Ghazni there are different levels of protection interventions/advocacies for IDPs, Refugee returnees and others through Protection Cluster Meeting, Sub- Clusters like GBV, meeting with local authorities including the ANSFs, Civil Military Coordination meeting, OCT, PDMC, IDP coordination, HAG at field level, and also refer to other clusters at regional and national level for further interventions.

Monitoring mechanism of UNCHR UNHCR has protection monitoring partner in all Central provinces, and they are monitoring the IDPs situation in different condition through focus group discussion, KI, regular protection missions, Baseline survey, joint assessment and multi-sectorial assessment.

UNHCR is a protection mandated agency leading Protection & ES/NFI clusters globally. Providing protection advocacy, emergency shelter, none food items, RHUs, and live saving assistances through its PSN project, and durable solution for refugee/returnee, IDPs, asylum seeker and statelessness people.

Gender Based Violence

 As it has been identified there is no other governmental and non-governmental agency in the districts or provincial level to address and refer the GBV cases into, but exempted WSTA, however, based on a basic research, for the time being the GBV survivors are going through a tough condition with many cases comprised of: o Physical and Mental abuses (moral scandals) o Force marriages o Child marriages o Rapes o Sexual harassments o Parental sex selection o Acid throwing o Domestic violence o Often forced prostitutions In order to figure out all the GBV cases in such a retarded province as Ghazni, there is a need for agencies and groups working specifically for GBV and implementing projects that covers GBV survivors under coverage. There is no Family Protection Centres or Women Friendly Spaces in the province. UNFPA is conducting an assessment with BPHS and UNHCR protection partners and will soon start the FPCs at the DH and Provincial Hospitals.

Recommendations and suggestions

Prostatic and Orthotics Care - The Shura members have clearly recommended for considering protection issues for disabled persons; not just for conflict affected but also naturally disabled population as ICRC in Ghazni has no mandate to support this specific care. However, the patients from Ghazni were given treatment in their orthotic centre in Kabul. SCA has a full- fledged workshop and rehabilitation centre in Ghazni/ however, they don’t have a residential facility. Access to physio-therapy services are low for injured and persons with disability. If an agency can cover the transportation cost and accommodation cost

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for the PwDs to get rehabilitation and appliance, it will be helpful for many needy people. The recent consultation of NGOs, WHO and MoPH regarding cash transfers in health sector, this options of conditional cash/voucher transfer mechanism for PWD and their care givers to meet their transportation and stay cost in Ghazni. - SCA has agreed to be a referral centre for Orthotic Care support services from BPHS / from proposed FATPs. o Referral to physio-therapy clinic of Swedish Committee of Afghanistan in Ghazni and Kabul o Referral to Orthopaedic and MH-PSS at Provincial hospital o Referral to ICRC centre in Kabul Here the equipment and appliances are satisfactory for the people. They are lighter.

Mental Health in counselling Post Trauma Disorder Syndromes (PTDS) and referrals - Getting effective treatment after PTSD symptoms develop can be critical to reduce symptoms and improve function. Psychosocial and physical rehabilitation should be combined in a care package tailored on the immediate needs of the person and their environment - Mental health and psychosocial support (MHPSS) support plays a particularly important role during armed conflict and emergencies and considered the limited time of the intervention in a situation of overwhelming needs and scarce resources, this support should be guided by a “do no harm” approach - Training the health workers in the health facility on PTDS and MHPSS is essential and Johanniter/AADA will collaborate with technical institutions like IPSO and TABISH to provide training, follow up and refresher trainings to the health facilities in the proposed FATPs and referral sites. - Higher referrals will be made to Psychiatric /Mental Health unit of Mental Health and rehabilitation centre in Kabul

Gender Based Violence  However, directly dealing in the health facilities GBV will invite wrath from the Taliban who have their own norms for women and men to behave socially. Thus, the discussions around gender based violence and protection concerns of women patients will take up by the PSS/Physiotherapist female in the proposed FATPs. Consultations with Health Shura, Family Health Action Groups (women members) and religious clerics (Mullahs) in developing appropriate gender messages and will refer the cases with UNHCR for further support.  Coordinate with WSTA organisation that are involved in assessing SGBV in the province and coordinate with them to identify cases of SGBV and use existing synchro-social counsellors available in the health facilities for counselling and follow up.  Both AADA and Johanniter will work with Family Protection Centre managed by Provincial Hospital/Regional Hospital and Home managed by Department of Women Affairs where the GBV victims are referred to and provided homes/ stay facility run by the State.

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Coordinate with UNFPA in their implementation phases with establishing FPC in Ghazni district’s and provincial hospital

Coordination - At Project Level: Johanniter and its sub-implementing partner, AADA in Ghazni will coordinate with different stakeholders includes, PPHD, DACAAR, DRC, ORCD, HNI TPO, SCA, WSTA, related to referrals and follow up of the PSS Trauma cases and GBV cases. These are covered under protection monitoring reports submitted to the UNHCR and the clusters on monthly basis. - National Level: Johanniter and AADA will take part in the protection cluster and its sub-clusters and in Mental Health-Psycho-Social Services Working Group (MHPSS WG) and share the progress and challenges of the proposed activities in the WG for finding solutions. - Capacity Building: Johanniter will engage with its technical partner in MHPSS in Afghanistan, TABISH in providing trainings to health facility staff in the proposed project area and coordinate with the partners in follow up of these capacity building action plans and study the impact of the increased capacities of the health facilities in dealing with PTSD and GBV incidents.

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Section : 7 Key Results from the Needs Assessment for consideration for programmatic intervention

This section, Johanniter and its partners have consulted stakeholders, clusters and donors related to who does what and what is the core essential programme development planned for response to the needs identified. The list of stakeholders met in Kabul is enclosed in annexure Johanniter has done a separate analysis for security and access was carried out with INSO, HAG and national partners and also sought help from Security Advisor from its HQ in Berlin.

Establishment of First Aid Trauma Posts in remote and hard to reach districts Increased trauma cases in conflict prone districts in Ghazni and shortage of health actors due to lack of resources and capacities to support trauma posts. Thus there is need for need for First Aid Trauma Posts in each in Ab Band, Andar, Dehyak, Gillan, Jaighatoo, Muqur and Qarabagh districts.

The remote rural health facilities don’t have the capacity to provide services related to trauma and injuries/wounds. The access to urban facilities are low as the roads leading to the urban clinics are either closed down or on going fighting denies access, IEDs prevent people to access during fighting time. Fear by the patients or injured/wounded persons going to health facilities in urban areas/district centres which are predominantly controlled by the pro- government forces (harassment, fear of arrest or prosecution) – Protection Issue.

Table No:23 Trauma Care coverage in proposed locations Ghazni (based on average 2014-19_ Total Coverag Coverage FATP Type of Catchme e Health m 18- M F S.No. District location Health nt F<5 M<5 F 6-17 M 6-17 F 18-49 villages/ Facilities 49 >=50 >=50 Proposed Facility Populati CDCs nearby on Aband 1 Ab Band CHC 67 Chory SHC 54860 142 125 304 170 384 215 112 63 Jonobi 2 Andar Ibrahimzi CHC 43 Jan Abad BHC 40575 1250 1138 1365 1061 1724 1341 503 391 3 Dehyak Laghabad BHC 24 Robat SHC 22254 88 81 295 120 372 152 109 44 Jahangeer 4 Gillan Patishi BHC 51 31720 192 185 116 96 146 122 43 36 SHC Bazare Sarab BHC, 5 Jaighatoo BHC 45 51150 24 17 90 44 114 55 33 16 Sadaqat Jarmato SHC No any HF 6 Muqor Sangansy BHC 41 11667 96 72 61 38 77 48 22 14 near to this HF Askarkoot CHC, 7 Qarabagh Moshaki CHC 88 82585 687 670 643 351 812 444 237 129 Jangalak BHC

359 294811 2479 2288 2873 1881 3629 2376 1058 693

Source: Based on the assessment by AADA, PPHD and Johanniter using the data from 2014-19 Trauma cases dealt in these clinics and the catchment facilities, December 2019

1. Based on the mapping, the analysis of trauma cases in the selected FATP and its coverage areas were calculated and assessed from 2014-2019 data sets from HMIS information available with PPHD and BPHS teams. Accordingly, the average Trauma cases were arrived at. The above mention Table No.23 about the average trauma cases recorded with the BPHS facilities for the period of 2014-2019 period is 17,277 persons per year.

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Among them, 4360 girls, 5161 Boys, 5161 men and 3069 women have used the trauma care facility. 2. Establishment of First Aid Trauma Post (FATP) within the existing health facility with rapid response teams (Ambulances) + 2 nurses, one for Day and another for Night shifts, conduct triage, categorise the priorities for emergency 3. Transportation and referral to higher trauma care posts (Provincial hospital at Ghazni and Emergency Hospital at Kabul/Ghazni) based on the location’s accessibility and distance), first aid and stabilization services, evacuation, referrals, minor wound care. - The discussions held with Provincial Health Directorate (both of Government and opposition groups), BPHS teams, ICRC, Emergency Field team in Ghazni and the health cluster, identified 11 health facilities in these districts and after consultations and negotiations, it was reduced to one FATP per district in active fighting zones i.e. in 8 clinics. Along with BPHS team and the health directorate, we have mapped the catchment of the health facilities i.e. no. of villages it covers and no. of other health facilities fall under their catchment area (see the table mentioned above 23). 4. In addition, these FATPs will have additional facilities provided like materials/equipment and medicines for trauma care, stabilization purpose and psycho-social counselling. The FATPs in all seven locations proposed in Ghazni need additional space and building for conducting Triage and Stabilisation and thus, request the donor to consider of building two room FATPs with two Toilets (one for men and another for women) in the proposed Health Facilities. The WHO standard FATP structure and the BoQs will be considered and there will be location specific plan for this assistance.

I. Strengthen the capacity of referral centres for improved trauma care within the districts of Ghazni province

1. The trauma referrals were calculated based on the assessment of emergency trauma cases in Provincial Hospital in Ghazni and through Emergency to their main trauma centre in Kabul, where about an estimated of 10% of the actual war trauma cases (this figure has derived from our previous experience in Ghazni and also that of MSF and Emergency’s information related to the case load for higher level trauma care needs) referred to them are emergency cases, about 60% of the case load falls within the criteria of treatment of wounds and minor surgical cases and rest of 30% are follow up cases. Table: No 24 Proposed Health Facilities covering PWD for referrals Type of FATP location m 18- F S.No. District Health M<5 F<5 M 6-17 F 6-17 F 18-49 M >=50 Proposed 49 >=50 Facility 1 Ab Band Aband Jonobi CHC 1111 11 00 2 Andar Ibrahimzi CHC 4343 54 21 3 Dehyak Laghabad BHC 1110 10 00 4 Gillan Patishi BHC 1100 00 00 5 Jaighatoo Bazare Sadaqat BHC 2 2 1 1 1 1 0 0 6 Muqor Sangansy BHC 1100 00 00 7 Qarabagh Moshaki CHC 2 2 2 1 2 1 1 0 11 11 9 7 12 8 3 2 2. Thus based on this data, Johanniter and AADA have proposed for critical referrals and for transportation of emergency cases, 10% of the Trauma cases were considered and thus

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arrived at the number of 1037 for the referrals to Ghazni City/Kabul. The catchment beneficiaries were calculated based on the general practice of BPHS OPDs and IPDs, which is covering about 40% of the catchment population for trauma and Psycho-social counselling. Thus the following table was developed (based on HMIS data) for the indirect beneficiaries from the catchment. 3. The following were the referral sites identified by all actors. These referrals sites will be regularly being consulted. Monthly meetings will be held with the referral sites to provide feedback and seek programmatic support. This data was shared in lots of confidence.

Table No.25: Referral sites identified by the actors

FATP location Referral Sites for Sl.No. District Referral Sites for ANSF Proposed Taliban Abband 1 Ab Band Nawa CHC+ Qarabagh DH Jonobi 2 Andar Ibrahimzi Shaheed Ab. Zaher DH Ghazni PH

3 Dehyak Laghabad Shaheed Ab. Zaher DH Ghazni PH

4 Gillan Patishi Nawa CHC+ Moqur DH Bazare 5 Jaighatoo Gulbawri CHC Ghazni PH Sadaqat 6 Muqor Sangansy Nawa CHC+ Moqur DH

7 Qarabagh Moshaki Shaheed Ab. Zaher DH Qarabagh DH

Source: Discussions with different stakeholders in Ghazni Province, December 2019

4. Based on Handicap International's vulnerability study (June 2017), about 0.5% of the population actually need referrals and treatment for prostatic and orthotic cares. Thus, the above table was estimated for targeting persons with special needs for referrals and prostatic and orthotic care from SCA Ghazni City and ICRC Kabul.

Improving access to Mental health care for PTDS and referral systems 1. There were many protection issues identified through protection risk assessment include, Increased checkpoints by Pro-government forces and IEA (denies access to the location due fear of fighting, harassment and IEDs on the way); High night rides; Ban on telecommunication by IEA during evening and night (no communication to share information related to emergency needs); Air strikes causing damage to property and life, increased injuries; Affecting patients visits; Damage to the assets of the clinic; 2. Disruption of health services in the community (clinic is closed during active fighting); 3. During fighting, roads connecting to the clinics are closed; Access to the clinics especially in rural and remote areas for women without Mahram is denied. This will be difficult of single woman, women headed households, women (whose husband or male relatives have migrated) to access health clinics. Gender based violence like, Domestic violence is increased as means of trauma by men (negative coping strategies – wife/daughter beating, drug addiction, etc.); Girls are not allowed to attend schools (especially in IEA controlled areas), even in case of IEA encourage, parents out of fear don’t send girls to school; Women are not allowed to go out even to clinics without Mahram

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4. Due to the above factors, Given the high incidents of mine detonations which take place in remote areas or when performing solitary tasks, such as grazing livestock or collecting firewood, it is reasonable to surmise that victims are never found, or only discovered after such an extended period that cause of death is neither apparent nor an issue. Awareness on mine risks education has emerged as the major felt need. Johanniter will coordinate with UNMAS in facilitating training of trainers for the health facility staff and provide awareness at health facility for men, women and children through facility staff and CHWs.

Coordination and Advocacy Health: Consultations held during the needs assessment and its follow up with the stakeholders both at the provincial level and at the Kabul level, the following generic agreement of support and cooperation will be planned with various stakeholders include National and International NGOs, UN agencies, Government authorities, Anti-Government groups and Clusters Table: No 26. Stakeholders work in the selected FATP locations District FATP location BPHS Hygiene Primary Nutrition and proposed and health care/ EPI Nutrition Trauma care Ab Band Abband Jonobi CHC AADA DACAR

Andar Ibrahimzi CHC AADA DACAR ARCS, UNICEF & WHO- Emergency Technical and Dehyak Laghabad AADA DACAR financial support Gillan Patishi BHC AADA DACAR of EPI program and surveillance Jaighatoo Bazare Sadaqat BHC AADA DACAR ARCS Muqor Sangansy BHC AADA DACAR Qarabagh Moshaki CHC AADA DACAR ARCS 1. At Ghazni: The project steering group is formed with Director, PPHD; Director, Provincial/Regional Hospital; Focal point of BPHS implementing agency (in this case AADA) and the Project Focal point of Implementing Partner (AADA). This steering group will be overseeing the implementation modalities and address any challenges faced by the project. The group will get monthly update of the project and also share the referrals cases and its follow up updates. AADA will have a focal person from the project to coordinate with various commissions include NGOs and Companies Commission, Customs & Tax levy commission, Health Commission of Taliban in smooth implementation. At Ghazni, for provisioning of mass casualty management trainings at the referral sites (mostly DH and CHCs) and triage & stabilisation in close coordination with ICRC and Emergency team. The referral services will be closely coordinated with Emergency Focal point in Ghazni who then alert their Kabul Trauma Centre, the Provincial/Regional Hospital and District Hospitals with BPHS. Referrals related to Psycho-social services (PSS) will be done through WSTA/UNHCR, HNITPO (if they continue their programme). Referrals for PwDs will be coordinated with SCA in Ghazni and ICRC in Kabul. All these referrals are recorded for follow-up. The partners will regularly attend and participate in OCT meetings at UNOCHA in Kabul and also coordinate in reporting to WHO and relevant stakeholders at Kabul. The details of local level coordination are as per the table No.26 mentioned above. 2. At Kabul: Johanniter and the implementation NGO partners coordinate with MoPH in registration of the project and submission of progress report regularly. Johanniter and the

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partners regularly attend the Health Cluster meetings and so too Protection Cluster and GBV sub-cluster meetings, MH-PSS working group meetings, to share the progress of the project and also related to the challenges of the project. Seek guidance from the stakeholders. Johanniter will coordinate with departmental heads and Head of missions of the NGOs working in Ghazni for close coordination of this project. 3. Access: The Implementing partners and Johanniter have discussed with the stakeholders include the armed opposition groups and sought acceptance of implementation of this project if approved by the donors. The relevant head of departments of the opposition groups and Director PPHD Govt. of Afghanistan were consulted while selecting the locations for FATPs. Though the government functionaries don’t admit in public but have acknowledged the presence of opposition groups and have their own communication channels for contact and operations. As the sub-implementing partner AADA has presence in Ghazni and is currently implementing BPHS project and thus have access strategy for all the health facilities. Similar access will be worked out with all conflict actors and regularly monitor the situation. AADA will appoint one Community Liaison Officer who will coordinate with community level shuras and coordinate in access and movements of the health facility staff and ambulances. Closely coordinate with INSO, Humanitarian Access Group (HAG) at Ghazni and Kabul in discussing the issues of access and also coordinate with the above group related sharing the Joint Operating Principles (JOPs) or red tape for NGOs working in humanitarian work to gain acceptance of all actors and seek their support. 4. There were many protection issues identified through protection risk assessment include, Increased checkpoints by Pro-government forces and IEA (denies access to the location due fear of fighting, harassment and IEDs on the way); High night rides; Ban on telecommunication by IEA during evening and night (no communication to share information related to emergency needs); Air strikes causing damage to property and life, increased injuries; Affecting patients visits; Damage to the assets of the clinic; Disruption of health services in the community (clinic is closed during active fighting); During fighting, roads connecting to the clinics are closed; Access to the clinics especially in rural and remote areas for women without Mahram is denied. This will be difficult of single woman, women headed households, women (whose husband or male relatives have migrated) to access health clinics. These issues will be brought to the discussion with the health shuras in the clinics and with commissions and with government stakeholders to find ways to access and improve the services in trauma care at the health facilities and at the referral points. 5. Jointly advocate with various networks and forums related to safety and security of staff and facilities in Ghazni, like ACBAR, HAG and HCT.

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Annexure 1 : Meetings with Stakeholders Stakeholders met by the Assessment Team members In Kabul - Dr. David Lai, Health Cluster Coordinator (before visiting Ghazni) - Dr. Abdul Rahman Shahab, Health Net - Sean Ridge, Brian and Nadja, HAG, OCHA - Frenz, SA NE-INSO - Julianna Westerblom, Head of Desk, Swedish Red Cross - Dr. Jawad. Dr. Farhat, Dr. Yasamin AADA - Fiona Gall, ACBAR - Dr. Mansoor Staniczai, Senior Health and Nutrition Advisor, Save the Children - John Morse, Director, DACAAR - MARTINEZ-BANDERA Juan-Carlos and Eng. Roohullah Shinwari, ECHO In Ghazni - Dr. Zahir Shah Nekmal, Director, Provincial Health Directorate, Ghazni - Dr.Ahmad Shah Mal, Deputy Director and Dr. Nasim, CDC Officer - Abdul Khaleq Ahmadi Head of Department of Refugees and Repatriation (DoRR) - Dr. Ahmed Shakiv, Incharge and Supervisor; Gul Mohammad *newly joined Supervisor, Qudratullah (Nurse), Najibullah (Nurse), all from EMERGENCY - Dr. Baz Muhammad Hemat, Project Manager, Provincial Hospital - Dr. Wakil Besmel, Swedish Committee for Afghanistan - Dr. Samim Nikmar, Programme Director, BPHS & EPHS, AADA - Dr. Abdul Matin Ahmadi, UNICEF - Dr. Fazel Ahmad Hanif, WHO - Balal Ahmad, Provincial Manager and Sultan Muhammad, Supervisor, ICRC - Sayed Sajed Sadat, Director (Field Office) and his colleague in ARCS - Dr. Hamidullah, Health Net - Communities of Eleven districts shura members (List is not enclosed due to security purpose, but is available with Johanniter and AADA), all from - Core Health Facility Staff of BPHS, AADA Ghazni - Health Facilities staff of AADA

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Annexure 2 : Checklist and Questionnaires used for the survey

1. Rapid Assessment for Health 2. Checklist for Focused Group Discussion with Health Shura representatives 3. Principles violation by conflict actors 4. Verification of Items

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Rapid Health Assessment Form – Afghanistan فورم ارزيابی سريع صحی توضيحات ساحه I. Site Description Name of reporting person: Name of Reporting Agency:______اسم نهاد زارش ری نام شخص زارشر 1. Date: GPS:N______E______تاريخ 3. District(s) affected: 2. Region: ولسوالی متاثر شده ساحه 4. Sub-district: 5. Town/village: قسمت ولسوالی شهر، قريه

7. Number of shelters: 6. Name of Camp : تعداد پناهاه اسم کمپ  Huts...1 ساختمان های  Block Buildings…3 خيمه  Tents...2 کلبه ها 8. Type of Shelter: بﻼک ساختمانی درحال ساختن  Block Building under construction.4 نوع پناهاه دير مشخص کنيد  Others: specify………………….…5

10. If Accessible, by هوايی  Air…2 سرک  Road…1 در دسترس Access to the area (please  Accessible…1 .9 (please tick): دست رسی به ساحه ل ُطفآ نشانی :(tick دير  Others…4 کشتی  Boat…3 ار قابل دسترس باشد ،لطفآ دردسترس نيست  Not accessible…2 نمايد نشانی نمايد بيخطر Security status in the area:  Secure…1 .11 12. If Insecure, explain (please tick): ار نا امن باشد توضيح بدهيد نا امن  Insecure…2 وضعيت امنيتی در ساحه

٢-آرزيابی نفوس - II. Population Assessment نفوس مجموعي :Total population .13 تعداد خانواده ها :Total Households .14

بيجاشده ان داخلی  IDPs…1 16. Origin of majority of Population مهاجرين Type of Population (please tick all  Refugees…2 .15 (Specify one Region): applicable): نفوس اصلی اکثريت ميزبان  Host Community…3 نوع نفوس ،لطفآ تمام موارد قابل اجرا نشانی نماييد لطفآ يک زون مشخص کنيد جامعه 18. Total New Arrivals (last 7 تعداد بيدون سرپناه :Total homeless .17 تعداد مجموعی ورودی جديد :(days 19. Total number of deaths (last 7 20. Number of births (last 7 days): تعداد مرګ ومير که درمدت ٧ روز ذشته فوت :(days تعداد نوزاد ها که در ٧ روز اخير تولد شده اند کرده اند 22. Total number of children under 5 تعداد مجموعی :(Estimated number of children under 5: deaths (last 7 days .21 اطفال فوت شده زير سن ۵ ساله درمدت ٧ روز تعداد تخمينی اطفال زير سن ۵ ساله اخير 24. Total number of females deaths تعداد :Estimated number of females .23 تعداد فوت شده اناث که در :(last 7 days) تخمينی اناث اخير ٧ روز فوت کرده

٣- آب وبهداشت III. Water and Sanitation 26. If available, specify the بلی Water supply available:  Yes…1 .25 source: (please tick)  Hand Pump…1  Engine well…2 ﻗسمی please tick)  Partially…2)  Pipe Water…3  Shallow well…4 ار موجود باشد،لطفآ منبع مشخص نخير  No…3 تامين آب در دسترس است  River…5  Water Trucking…6 کنيد 27. Walking time to the available source of water: 28. What is the cost of a Barrel:___ دقيقه min / 2 هزينه يک بيرل چند است مدت پياده روی به منابع موجوده آب

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29. Latrine available: (please بلی  Yes…1 tick) 30. Number of latrines تا حدی  Partially…2 تعداد بيت الخﻼ بيت الخﻼ موجود است، لطفآ نشانی نخير  No…3 نمايد 31. Number of Non- 32. Availability of garbage موجوديت :Functioning latrines: management مديريت زباله تعداد بيت الخﻼ غير فعال

مصونيت غذايی IV. Food Security :If available, type of food .34 بلی Food distribution in last  Yes…1 .33 تغذيه مرطوب  Wet feeding…1 (please tick) اهی month: (please tick)  Sometimes…2 غذا خشک  Dry food…2 ار موجود باشد ،نوع غذا نخير  No…3 غذا توزيع شده در مدت ماه اخير 35. Walking time to the available source of food: دقيقه min / 40 مدت پياده روی به منابع موجوده غذايی

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مشکﻼت صحی عامه V. Public Health Problems جواب بايد از طرف پرسونل صحی داده شود Answers to be given by the health facility staff

لطفآ نشانی نمايد (Main health problems affecting population/: (please tick .36 مشکﻼت اساسی صحی که مردم را متاثر ميسازد a. Diarrhea/AWD  Yes…1 If Yes; Number b. Injuries/trauma  Yes…1 If Yes; Number

( No…..2 (last 7 days جروحات، تروما ( No…..2 (last 7 days اسهاﻻت c. Suspected Measles d. Skin Diseases/  Yes…1 If Yes; Number  Yes…1 If Yes; Number Infections سرخکان مشکوک  No…..2 (last 7 days)  No…..2 (last 7 days) عفونت های امراض پوست e. Acute upper  Yes…1 If Yes; Number f. Acute Malnutrition  Yes…1 If Yes; Number Respiratory Infection ( No…..2 (last 7 days سوتغذيه شديد ( No…..2 (last 7 days مشکﻼت سيستم تنفسی علوی h. Pregnancy related g. Pneumonia  Yes…1 If Yes; Number  Yes…1 If Yes; Number conditions ( No…..2 (last 7 days)  No…..2 (last 7 days سينه بغل شرايظ مربوط بارداری i. TB  Yes…1 If Yes; Number j. Diabetes  Yes…1 If Yes; Number

( No…..2 (last 7 days شکر ( No…..2 (last 7 days توبرکلوز k. Eye Infections  Yes…1 If Yes; Number l. Hypertension  Yes…1 If Yes; Number

( No…..2 (last 7 days فشار خون ( No…..2 (last 7 days غفونت چشم n. Others: specify: m. Suspected Malaria  Yes…1 If Yes; Number  Yes…1 If Yes; Number دير مشخص کنيد ( No…..2 (last 7 days)  No…..2 (last 7 days مﻼريا مشکوک ______o. Urinary Tract  Yes…1 If Yes; Number Infections  No…..2 (last 7 days) عفونت های سيستم ادرار

خدمات صحی و تسهيﻼت ارزيابی VI. Health Services & Facilities Assessment (ONLY FOR FUNCTIONING AND ACCESSIBLE FACILITIES) 37. Distance to nearest health facility (KM): فاصله تا نزديک ترين مرکز صحی(کيلو متر) 38. Access to health facility / health services :Explain .39 بلی Please tick):  Yes…1)

توزيح نخير  No…2 دسترسی به تسهيﻼت صحی، خدمات صحی، لطفآ انتخاب نمايد

جواب ها که از طرف پرسونل تسهيﻼت بايد داده شود Answers to be given by the facility staff

b. No of d. No of Health Facility Type a. Name / Staff c. Services provided[1] Consultation e. Main diagnosis Agency تشخيص اساسی s /day خدمات ارايه شده تعداد نوع تسهيﻼت صحی اسم /نهاد تعداد مشاوره ها پرسونل 40. Health Post

پوسته صحی 41. Sub Health Centre

مرکز صحی فرعی 42. Mobile Health Team

تيم صحی سيار 43. Basic Health Centre

مرکز اساسی صحی

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44. Comprehensive Health Centre

مرکز صحی جامع

45. District Hospital

شفاخانه ولسوالی 46. Provincial Hospital

شفاخانه وﻻينی 47. Regional Hospital

شفاخانه حوزوي 48. Private Clinic

کلينک خصوصی

لطفآ حروف مناسب را انتخاب کنيد :(Please select appropriate letter(s [1] A. Outpatient services, . Growth monitoring/Nutrition G. Oral rehydration therapy I. Antenatal care / Delivery مراقبت قبل از وﻻدت دوا دهن ودندان نظارت بر رشد تغذيی خدمات صحی سراپه B. Inpatient services E. Distribution of food rations H. Wound dressing J. Drugs دوا پانسمان زخم توزيع جيره غذايی خدمات بستری C. Laboratory F. Immunization خدمات واکسين ﻻبراتوری

درمورد شفاخانه اين بخش را تکميل کنيد In case of Hospital, complete this part .49 b. Bed capacity: 250 بلی a. Specialized services: Specify Yes ظرفيت پذيرش خدمات تخصصی، مشخص کنيد

51. Referral service available: (please دولتی Health facility manager: (please tick)  Government...1 .50 tick) نخير  No…2 بلی  Yes…1 نهاد غير دولتی  NGO(s)…2 امر تسهيل صحی ،لطفآ انتخاب نماييد خدمات ارجاع موجود است، خصوصی  Private…3 لطفا نشانی نماييد

53. If Yes, specify the type of routine 52. Existence of routine immunization  Measles...1  Penta...2 vaccines: (please بلی  Yes…1 programme: (please tick)  Polio…3  BCG...4 (tick ﻗسمی  Partially..2  DPT...5  Tetra...6 نخير  No…3 موجوديت برنامه های معمول واکسيناسيون  Rota virus...7 ار بلی، نوع واکسين معمول را مشخص کنيد

55. Availability of safe 54. Availability of ambulance: water supply: بلی  Yes…1 بلی  Yes…1 نخير  No…2 موجوديت آب سالم نخير  No…2 موجوديت امبوﻻنس اشاميدنی

56. Availability of latrines: بلی  Yes…1

نخير  No…2 موجوديت بيت الخﻼ

موجوديت وسايل طبی Availability of medical supplies ار بلی ، مقدار b. if Yes Quantity موجود ?a. Available نوع Item

ﻗسمﻲ  Partially…2 بلی Antibiotics  Yes…1 .57

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نخير  No…3 ضد ميکروب ﻗسمﻲ  Partially…2 بلی Syrups (child)  Yes…1 .58

نخير  No…3 شربت(طفل) ﻗسمﻲ  Partially…2 بلی Analgesics  Yes…1 .59

نخير  No…3 ضد درد ﻗسمﻲ  Partially…2 بلی ORS  Yes…1 .60

نخير  No…3 او ار آس ﻗسمﻲ  Partially…2 بلی Ointments  Yes…1 .61

نخير  No…3 ملهم ﻗسمﻲ  Partially…2 بلی Iron for anemia  Yes…1 .62

نخير  No…3 اهن برای کم خونی ﻗسمﻲ  Partially…2 بلی Vitamin A  Yes…1 .63

نخير  No…3 ويتامين ای 64. Drugs for chronic diseases ﻗسمی  Partially…2 بلی  Yes…1 دوا برای امراض مزمن نخير  No…3

ﻗسمی  Partially…2 بلی  Yes…1 انواع دير Other Items .65 نخير  No…3

موجوديت برنامه های صحی تخصصی :Availability of specialized health programmes 66. Communicable disease surveillance: نخير  No…2 بلی  Yes…1 نظارت بر امراض عفونی 67. Health Education programmme: نخير  No…2 بلی  Yes…1 برنامه تعليمی صحی 68. Nutrition assessment and treatment programme: نخير  No…2 بلی  Yes…1 ارزيابی تغذيي و برنامه معالجه

۴-نياز سنجی VII. Needs Assessment 69. Health priority needs: نيازهای اولويت صحی a. Amount:

b. Amount:

c. Amount:

d. Amount:

70. Additional manpower needed: (please tick) 71. Specify نخير  No…2 بلی  Yes…1 مشخص کنيد نيروی اضافی مورد نياز است ، لطفآ نشانی نماييد 72. What must be put in place immediately possible to reduce avoidable mortality and morbidity? چه بايد انجام خواهد شد برای کاهش مرګ ومير و امراض ممکنه

نظريات دير Other remarks .73

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Annexure : Check List for Focused Group Discussions with Community/Health Shuras

Information provided by Health Shura Members through District Responsible Date: District Name: Shura Member(s) Facilitator/Presenter

SN Questions Responses A Location Situation 1 Security 2 Displacement 3 Drought 4 Water 5 Access to services 6 Barriers to Access to Health services 7 Barriers to Access to Schools 8 Conflict situation 9 Warlords Presence in the area 10 AOGss Presence in the area 11 Child involvement in war 12 People perception about HFs and staffs 13 Barriers to access HFs 14 Barriers in access to schools 15 Immunization perception and Barriers 16 Trauma cases 17 Negotiation 18 Perception about JACK People with disability participation in the program 19 Women and girl’s participation in the program 20 HF staffs Attitude 21 Attack on schools last one year 22 Attack on HFs last one year 23 Any other points hey want to share?

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Annexure : Principle Violated by Conflict Actors

Guidelines Implementation Status (based on MSF ) Assessed with health facility staff during the visited by JUH and JACK team 11-15 October 2019. Violations by Taliban/AOG Violations by ANSF Violated not Violated not regularly, S. regularly, due Principles Regularly due to Not Regularly No. to community/ Not Violated Violated community/ Violated Violated Health facility Health facility rules rules

No weapon policy (no 1 one should carry weapons inside the clinic)

No high profile visits to 2 the health facility No communication 3 phone or radio inside the clinic No vehicles belongs to 4 them should be inside the compound No involvement in the 5 recruitment of the staff No use or misuse of the 6 clinic’s equipment include ambulances No armed convoy of the 7 health faculty or ambulances Not to use the clinic as 8 place of safety/night stays No Clinic staff is 9 intemidated (e.g. take staff to treat the injured)

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WHO Format

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