Sylvia's Journal

Sometimes I marvel at the complexity of our work, and the implications of what seem to be very straightforward ideas back home in the US.

Take the branding issue. We want the beneficiaries of our donations to know who paid for them (you, the US taxpayer). This means that there need to be US government stickers on the boxes with medicines that we provide to the NGO clinics in the provinces that are supported with US government funds. That’s part of the deal: we pay and the Afghans get to see our good deeds and be grateful. (Funny, now that I think of it, US arms don’t need stickers or do they?)

But when being associated with America becomes a liability and truck drivers get kidnapped and their loads confiscated, this was no longer a good idea and we needed a waiver. So we got the waiver, which is, by the way, not at all easy to get.

And then there is the branding on the health facilities. It became soon clear that the US flag needed to be removed, no matter how patriotic we felt, from the entrance signs of health clinics.

The services are provided by NGOs, they do this on behalf of the Afghan government – they signed contracts to that effect and it is part of the deal. But in some places, even being associated with the Afghan government became a liability and some of the (mostly local) NGOs were balking at this requirement, stating that they are providing humanitarian rather than government services.

But this is how it works: the NGOs get grants from the US government which are channelled through the Afghan government. The idea is to show that the Afghan government cares for peoples’ health and provides services, however indirectly by way of these NGOs. It’s called government stewardship and contracting out. It’s a model that has worked fairly well in this country.

But enforcement of ‘serving on behalf of the government’ is hard to enforce. First many places are too dangerous to get to and second, if the NGO stopped serving people they would get even madder than they already are. It’s a bit of a pickle.

It gets even more complicated because the prescription pads, registers and other signs in the clinics say nothing about the Afghan government (or US government for that matter) and bear the logos of the NGOS. So should we be replacing all the prescription pads, internal signs, registration books? They should have the government logo on them and be provided by the government, but that is a logistical nightmare of untold proportions – what if they run out of the registration books, then patients don’t get registered and then we won’t know what is really happening on the ground. If you follow this thread for a while it gets hopelessly tangled.

In the end the big idea is that the Afghans will turn away from the insurgents and towards the government. It is of course a hypothesis of major proportions that has so far not been confirmed. So if we wanted to test it, confirm or disconfirm, we should ask the patients exiting the health facility. So let’s assume a fictitious patient leaving the clinic in a district in, say, Ghazni, an increasingly turbulent place. We approach him or her and ask, ‘Who attended to you today?’ How likely is it that they would say, ‘Oh, it was the Afghan government.’

We are all pretty sure that the patient walking out of the clinic would say, it was the doctor (nurse, pharmacist) who attended to my health needs. These patients would have no inkling about the thousands of processes and millions of hours of labor, combined efforts of the US and Afghan governments, that made this encounter with the Afghan health system possible. They would have no idea at all.