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Peer reviewed article

The impact of reproductive health services on armed conflict in Afghanistan

Stewart Britten and Wahida Paikan

First online: 24 May 2019

Stewart Britten is medical advisor to the Afghan programme to reduce maternal and under-five deaths in Afghanistan of the UK NGO HealthProm. He has developed and managed long-term government invited trainings for newborn survival in Uzbekistan and projects for improvement of social care of children in Russia. Previously he was an analytical psychologist and consultant child and adolescent psychiatrist in UK.

stewart.britten@zen.co.uk

Wahida Paikan worked for women’s empowerment and human rights in Oxfam, Save the Children and the Open Society Foundations in Kabul. She is currently studying the MA in International Relations and Security at the University of Westminster, London.

wahida.paikan123@gmail.com

Abstract

Reduction of child mortality while coverage of family planning services remains low may render Afghanistan a testing ground for the theory of demographic transition. Meanwhile there is a vicious circle: young men lacking employment join the Taliban and so increase national insecurity, discouraging industry and reducing employment opportunities. For progress towards peace to be made and sustained, family planning, education and employment need to be major parts of the peace effort, and UN reports need to emphasise more which way the scales tip.

Keywords: Armed conflict; family planning; demographic transition; Afghanistan.

Introduction

The observation that after reduction in mortality rates societies also experience reduction in birth rates is well established. However, for countries experiencing civil strife, such as Afghanistan, progress through the stages of this demographic transition is more problematic and uncertain. In particular the presence of a “youth bulge” in Afghanistan’s demographic structure, itself a result of the success of interventions to reduce child mortality rates, poses particular challenges to the ability of the country to move through its present stage of demographic transition towards stabilisation of population. We argue that Afghanistan’s youth bulge leads to a vicious circle where young men lacking employment opportunities join the Taliban, thereby increasing national insecurity and discouraging economic development which in turn further reduces employment opportunities.

This paper is divided into three sections. In the first we examine the notion of “youth bulge” and its relation to conflict. In the second section we explore the issues, problems and prospects of family planning provision in Afghanistan. Finally, we attempt to understand the possible consequences of Afghanistan’s increasing population and in particular of the “youth bulge”. We conclude that to achieve a lasting peace, family planning, education and employment are central. There is little hesitation amongst agencies in the provision of resources to reduce infant mortality. However, we argue that providing adequate and cost-effective family planning will be of comparable significance in securing the future welfare of Afghanistan’s citizens, and this needs to be said loudly and clearly by all agencies concerned.

  1. How a youth bulge may increase armed conflict

Improvement of mother and child health has led to significant reductions in under-5 mortality. Those reductions, with Afghanistan’s total fertility rate of approximately 5.3 live births per woman in 2015 (Central Statistics Organization (CSO), et al., 2017), the highest in South Asia (though earlier surveys have been inconclusive about the exact level of fertility), are leading to increasing numbers of young people. At this first stage of population transition, from high to lower mortality rates, the increased numbers of young men and women often lack productive land to sustain them or employment in cities. Some of the young men, frustrated at lack of earnings, especially given the high bride price and huge cost of weddings, which can lead to debt, can be expected to turn to insurgency, especially when armed opposition groups pay more than the Afghan National Army. Others emigrate.

There is evidence that a youth bulge – and here we use the definition of a youth bulge as a high proportion of those aged 15 to 24 in the total population – significantly raises the probability of civil conflict, at least while acting with certain other factors. A report of Population Action International states: “The likelihood of experiencing conflict is highest among countries with “very young” age structures, where up to 77 percent of the population is younger than age 30. Between 2000 and 2007, two-thirds of all new outbreaks of civil conflict occurred in countries with very young age structures…” (Madsen, et al., 2013, p.2). The US think tank, the Council on Foreign Relations, reported in 2007 that there were then 67 countries with youth bulges, of which 60 were experiencing social unrest and violence (Beehner, 2007). Youthful populations, some have found, are risky populations (Wilson Centre, 2013). Others have contested a causal link between a youth bulge and increased social instability. From their study of events of major political instability between 1955 and 2003 Goldstone et al. (2010) concluded that youth bulges reveal the level of pre-existing vulnerability by actualizing ‘potential’ instability that is already present and largely determined by other factors. In other words a youth bulge is not sufficient cause of armed conflict. However, the purpose of these authors was to identify factors predictive of civil conflict rather than causal factors. We do not suppose that a youth bulge is a stand-alone causal factor of armed conflict. It is, in our view, one of a number of interacting factors, such as poverty, but a significant causal factor. In an analysis of disorder in 55 major Asian and African cities Urdal and Hoescher (2009) similarly found that large male youth bulges were not generally associated with increased risks of social disturbance. However, the authors note that most armed conflicts take place in peripheral and often rural areas. Buhaug & Rød found that while territorial conflict is more likely in sparsely populated regions, conflict over state governance is more likely in regions that are densely populated and near the capital city (Buhaug & Rød, 2006). Buhaug and colleagues found that the risk of conflict is positively associated with the extent of rough terrain in the peripheral group’s home region and its distance from the political centre (Buhaug, Cederman & Rød, 2007).

Urdal and Hoescher (2009) also found that low secondary education levels among young males aged 20-24 and low economic growth consistently increased the risk of social disturbance and reflected that periods of economic downturn that limit new job creation are likely to affect youth the most since they have just entered the labour market. In summary, although the effect of population age structure is contested, there is an emerging consensus that economic stagnation, poverty and unemployment can lead to high levels of violence and unrest. All three factors are at work in Afghanistan, and poverty and unemployment are likely to impact youth the hardest.

The second stage of demographic transition, reduction of birth rate, has never happened without earlier reduction of child mortality (Dyson, 2015). The interval after the start of the first stage may be a generation, but can be reduced if reduction of child mortality is accompanied, or soon followed, by provision of family planning services to enable parents to space births and reduce the birth rate. There are strong indications that, in urban areas at least, Afghanistan has entered the second stage of demographic transition with decrease in the total fertility rate (UNFPA, 2015). But despite that, the reduction in child mortality leading to increase of youth population but without matching improvement of prospects for employment, poses increased risk of armed conflict.

The theory of demographic transition has by and large worked to date. But, by reducing child mortality and increasing life expectancy, healthcare enormously increases pressure on food resources. And the adverse effects that global warming is already having on food production may render past experience of population transition a poor guide for the future (Bourne, 2015). Afghanistan will be one of the testing grounds which will determine whether under these circumstances the theory of demographic transition holds true or there is a reversion to the Malthusian trap. Also, there is no certainty that increased birth spacing achieved by use of contraception, and improved child survival rates will result in any reduction in total numbers of surviving children a couple has.

  1. Family planning in Afghanistan and its obstacles

Family planning services, enabling parents to decide on family size or to space births, with information on the benefits, provides high value for the resources invested (Carvalho et al., 2012). Birth spacing enables women to recover their health before the next birth as well as improving the health and lives of children. Family planning enables parents to avoid pregnancy early and late in a woman’s reproductive life, which are the times of greatest risk. The Maternal Health Task Force at Harvard Chan School estimated that in 2008 contraceptive use averted approximately 44% of maternal deaths worldwide (Maternal Health Task Force, 2008).

Increasingly, however, new analyses have pointed to the conclusion that the primary barriers to use of family planning are large desired family size and fear of health effects of contraceptives (Ryerson, 2018). Researchers at the Guttmacher Institute found from a decade of data from 52 developing countries that actual lack of access to contraception accounted for only 5% of the reasons for non-use (Sedgh, Ashford, and Hussain, 2016). Fear of adverse effects on health or opposition to contraception made up 49% of non-use. In Afghanistan, as in many other countries, high fertility enhances self-esteem and standing in the community for men and women. In a patrilinear society people want sons to carry on the family name and, for rural people, to cultivate the family’s land. But Afghanistan stands apart from all other Asian countries in the small percentages of women wishing to have no more children (Central Statistics Organization (CSO), et al., 2017, p.91). When child mortality is high, people can’t rely on having only one son, and to have two sons they will on average need to have four children.

Islamic teaching has generally been interpreted as encouraging birth, but interpretations vary on contraception, which is approved in appropriate circumstances. The general principle in the Qur’an is to work for the welfare of humanity. It promotes two years of breast feeding, which reduces fertility. The general consensus of scholars is that family planning is permitted, but the preferable means are debated. There are limited prescriptive or proscriptive rules. Some hold a belief that Islam does not allow preventive measures, but other clerics claim, based on religious studies, that the mother’s health has priority and that contraception is generally permitted. Several Hadiths, the sayings of the Prophet Muhammad, suggest that he approved of azl, the withdrawal method, which apart from abstinence was the only means of contraception in his time. Scholars in Egypt argued that any method of preventing conception is acceptable according to Islam and indeed most Muslim scholars agree with the principle of family planning (Chaudhuri, 2018). Family planning programmes have been vigorously pursued in such Islamic countries as Iran, Indonesia and Bangladesh. However, some religious scholars have argued that contraception is sinful in Islam as it reduces the increase of the Muslim population (Shafiqullah, Keiko and Seino, 2018).

Lack of availability of public health education on family planning and of provision of contraception for much of the population of Afghanistan is, in our view, an important limiting factor in reducing fertility. Yet the cost of family planning is small compared with what is spent on aid and arms (Parsons, 1996). Supply of contraception may be the “low-hanging fruit” (Bruce and Bongaarts, 2010), and it makes sense to prioritise what can be delivered most cost-effectively.

Globally, family planning and population are contentious subjects and worldwide interest in both has declined, especially since the UN International Conference on Population and Development in Cairo in 1994, which resolved rightly that family planning was the responsibility of parents. But where there are no accessible family planning services, leaving decisions to parents is just a nice idea. Also, the Cairo conference tucked family planning away inside the wider concept of “reproductive health”, on which all could agree, largely removing any need to refer to it. A result was apathy. Population, has “sort of fallen off the world’s agenda” (Gerland, 2014, pp.234-237), though in more recent times the pendulum has swung back somewhat in favour of family planning. It is on the agenda in Afghanistan, but as in much of the world, lower down than it should be.

Since the Cairo conference transferred family planning into the domain of reproductive health services, the proper central person for its delivery has been considered to be the midwife. However, based on our experience of working in Afghanistan it is apparent that although many midwives have been trained, results have been limited by, as elsewhere, the reluctance of many midwives, after training in the city, to serve the 73% rural population in remote villages as well as by the distance of many villages from health centres and midwives’ lack of transport for outreach. Couples living three hours or more by donkey from a health centre are unlikely to make the journey for a month’s contraception.

The plan of the Ministry of Public Health (MoPH) is to train “community midwives” to provide services in their home clusters of villages (Mohmand, 2013). But recruiting midwives for all health centres is hard enough. In 2016 we were told of a recruitment shortage of 50 midwives in just one of the 34 provinces, and we have known of health centres which were nominally fully staffed, while the midwife was actually in the city most of the time. Added to that, in 2016 because of armed conflict 150 out of 360 districts were no-go areas for government contracted staff (Najafizada, 2017). Risks can be high even for health workers unless much work has been done to establish strong relations with the Taliban.

The Demographic and Health Survey 2015 found that 20% of currently married women used a modern method of contraception (Central Statistics Organization (CSO), et al., 2017). The Afghanistan Multiple Indicator Cluster Survey (AMICS) found a contraceptive prevalence rate of 21% of married women in 2010–2011 (World Bank, 2014). Reports on levels of use of family planning vary greatly; UNFPA reported that the use of family planning methods doubled in the decade to 2015 (UNFPA, 2015). However, the Demographic and Health Survey 2015 found that 25% of currently married women had an unmet need for family planning (Central Statistics Organization (CSO), et al., 2017). A more recent paper reports that contraceptive use by women has been stagnant since 2012, in part linked with the low average educational standard of women (Das et al., 2018).

The AMICS data showed a strong correlation between a girl’s or woman’s level of education and her use of contraceptive methods (World Bank, 2014). The Demographic and Health Survey 2015 found that women with more than a secondary education were more likely to use modern methods of contraception (30%) than those with no education (19%) (Central Statistics Organization (CSO), et al., 2017). There is a multiplier effect here; fewer pregnancies and births per woman can in turn enable improved education of her children (Carvalho, Goldie and Salehi, 2012). Conversely, that would mean that the more births a woman has, the less education her children will have, and when they reach adulthood, they in turn will have more children.

In the MoPH’s Basic Package of Health Services male and female Community Health Workers (CHWs), after training for 18 days, provide basic healthcare, including family planning, in their own villages on a voluntary basis (Ministry of Public Health, 2010). CHWs are better placed than midwives to provide family planning services to women in rural areas. Women have ready access to them and they know the reproductive status of all women in their village and can discuss contraception with them in the privacy of their homes, whereas a visit to a midwife in a health centre is more public. On the other hand, in a culture in which some women are afraid to cry out in childbirth because that would indicate to neighbours that they have had sexual intercourse, we may wonder whether all women are willing to divulge their contraceptive needs to a CHW who is a neighbour. Nevertheless, it has been found elsewhere that where other family planning approaches have failed, female CHWs have increased the uptake of contraception among rural women (Douthwaite and Ward, 2005).

We have found in two rural districts of Afghanistan that, when well-trained, sufficiently supplied, supervised and supported, CHWs pursue their work enthusiastically and effectively (Parsa, 2018). A study in rural Afghanistan which assessed the impact of health education and the delivery of injectable contraceptives by CHWs over an 8-month period in 2005 to 2006 found that contraceptive use increased by 24% to 27% across three sites (Huber, Saeedi and Samedi, 2018). Though many men and women had started with the belief that contraception carried more risk than pregnancy and that modern contraception caused infertility, men as well as women supported use of modern contraceptives once they understood their safety and effectiveness. Approximately 30,000 CHWs are listed as having been trained and as supported and supervised, but the Community Based Health Care Program, which is responsible for CHWs, does not have high priority within the MoPH and many women have no knowledge of a CHW working in their community. When CHWs are not well-trained, sufficiently supplied, supervised and supported, their work is sustained poorly or not at all.

  1. The tribulations of Afghanistan’s youth

Cincotta has said “The highest probability of civil conflict (often protracted) is associated with very young populations—the Afghanistan… situation” (Population Reference Bureau, 2011). Afghanistan has one of the most youthful age structures in the world. In 2014 63.7% of the population was below the age of 25 and 46% was below age 15 (Central Statistics Organization, 2014). Lacking a recent census, the population was estimated by the UN in 2011 to be 32.4 million. In 2014 the Central Statistics Organization estimated population growth rate of 2.03% per year (Central Statistics Organization, 2014a). The arithmetic is not rocket science. If the total fertility rate is five, and child mortality is reduced to 67.9 per 100,000 live births (UNICEF, 2019), the population will at least double in each generation unless war escalates. The 2017 UN population projections give a total population of 62 million by 2050 (United Nations DESA, Population Division, 2017).

It is unlikely that Afghanistan could sustain such a high population. Though there are fertile valleys and plains with irrigation, much of the rural population is in mountainous or semi-mountainous areas, where the soil is shallow loess, a sediment formed by accumulation of wind-blown dust. Snowmelt and spring rains often lead to serious erosion and in many parts there are few trees to hold back the loss of topsoil, a problem which is exacerbated by lack of other fuel for cooking and domestic heating. Where crops are rainfed, two droughts in succession can necessitate a family’s move to the nearest city. Most smallholders and sharecroppers can’t afford improved, drought-resistant seed and have to rely on their own homegrown seed, which attenuates from year to year. Afghanistan’s revenue still comprises well under half of total budget expenditure, most of which continues to be financed by aid (Byrd, W. and Payenda, M.K., 2016). If Afghanistan’s home-grown food stocks run out, at present it could not afford to import food crops to feed its population.

Poverty and lack of education are major determinants of armed conflict. UNFPA’s 2014 Afghanistan State of Youth Report (UNFPA, 2014) warns that youth employment has to be looked at in the context of poverty and the quality of available work – and the National Risk and Vulnerability Assessment 2011–2012 reports that 81% of jobs can be classified as vulnerable employment as they do not secure stable and sufficient income (National Risk and Vulnerability Assessment, 2014). The Afghan economy has not developed enough to be able to absorb the country’s 400,000 annual labour market entrants in the foreseeable future. With a high proportion of the population either poor or at risk of being poor (UNFPA, 2014), most people, in particular young people, who are expected to contribute to household incomes, simply cannot afford to be unemployed. Everyone has to find some way of gaining a living, but many are underemployed. As during the industrial revolution in Europe and the USA, child labour is much the cheapest for unskilled work which is not excessively heavy, and this militates against youth employment.

Mobility then becomes a key factor for employment, but young Afghans, with no or few qualifications and little financial support, are not welcomed in other countries and find migration to any higher income country so challenging that they may realistically feel imprisoned in Afghanistan. In time they could find themselves imprisoned in a country which will not have the resources to feed them, which would amount to famine enforced by border controls.

The UNFPA’s Afghanistan State of Youth Report 2014 speaks of a window of opportunity for a country arising from population change, strategic investment and accelerated economic growth (UNFPA, 2014), but in Afghanistan there is no prospect in sight of such a dividend. There is instead a vicious circle: young men can’t find employment and join the Taliban, and that increases national insecurity and discourages industry, contributing to unemployment. And there is an additional vicious circle: while fertility levels and population growth remain high, the dependency ratio, the ratio of people below 15 plus those over 64 to people of working age – between 15 and 65 – also stays high and families and governments typically do not have the resources to invest in their young population.

The Afghanistan Living Conditions Survey, a joint government and EU report, found the national poverty rate rose from 38% in 2011-12 to 55% in 2016-17 (Central Statistics Organisation, 2018). 41% of Afghan children had moderate or severe stunting (UNICEF, 2019). More than 20% of the population cannot afford to meet their minimum nutritional requirements. In a country where there is great poverty, relatively good payment is the main reason for families allowing their children to join the Taliban (Landinfo, 2017). It is unclear what the Taliban pay their recruits, but representatives of NGOs have estimated that it is in the region of 300 US dollars per month (Afghanistan Crossroads, 2009). Some, however, join the insurgency to fight for the Taliban’s interpretation of Islam and others to combat the US presence on Afghan soil.

It appears that reduction in child mortality has contributed to poverty, and poverty has increased the opportunity for the Taliban to recruit (UNFPA, 2014). Truly the beds of poverty are fertile. They have to be in order to have some children survive to reproduce.

In Britain in the time of Thomas Malthus a significant factor in limiting fertility was late marriage (Malthus, 2015 [1798]). The UNFPA report of 2015 says that Afghan youth were then marrying later than previously. It refers to marrying later “extending their education period”, but without evidence for that link (UNFPA, 2015). For young men marrying later is often due to the time needed to earn and save the bride price. It is largely in order to gain the bride price (not mentioned in these UNFPA reports) and have one less mouth to feed that parents arrange the marriages of their daughters at young ages. So poverty can be a factor both for young men in marrying later and for girls in being married earlier. And where older men marry young girls, fertility is likely to be high. Saving or borrowing the bride price and paying for the customary enormous wedding impoverishes the already poor, and it is the poor who most lack contraception and education about family planning.

The Taliban has recruited 60,000 core fighters, a quarter of the level of the Afghan defence forces (Giustozzi, 2012). The majority of the fighters recruited by the Taliban and many by government security forces were born after the US-led invasion of 2001 and thousands of child fighters are recorded among the Taliban (Agence France-Presse, 2017). According to President Ashraf Ghani 45,000 security force personnel were killed between 2014 and 2019 (BBC, 2019).

On average in Afghanistan women with no education have two more children than women with more than a secondary education (Central Statistics Organization (CSO), et al., 2017). If the sons of women who have lacked education also receive less than average education, they may be expected to have less success in finding employment and to be more likely to join the Taliban.

  1. Discussion

Even after more than two hundred years we still can’t get away from the harsh but rather obvious forecast of Thomas Malthus that population grows until it reaches the limit of the capacity of the land to feed people, whereupon increasing mortality returns it to equilibrium: the “Malthusian trap” (Malthus, 2015 [1798]). Population studies in the present era have, however, tried to turn it on its head. The UNFPA has set out increase in child survival as the first stage of the demographic transition which, with family planning information and services and education should constitute a “window of opportunity” (UNFPA, 2014). Yes, of course. But increase in child survival without family planning, education and employment opportunities can be a window not to the second stage of the demographic transition, but to armed conflict. The dismal truth of the Malthusian trap is still with us.

The UNFPA’s Investing in Youth report aims for a “balanced perspective …. recognizing that fast population growth, under a context of constrained resources, may reproduce and expand poverty; yet, under conditions of abundant resources and relevant investments in new technologies, infrastructure, research and human development, a larger and highly qualified population would represent an important factor to increase productivity and wellbeing” (UNFPA, 2015, p.13). This theory is based on evidence from countries where the demographic transition has taken place, the now-rich countries, but how can Afghanistan achieve this aspiration? Without addressing the enormous gap between the aspiration and the present reality of Afghanistan, it would not be difficult for those in government and donor agencies alike to take from this report that stabilisation of population growth is a process which will be, contingent on a few factors, almost automatic. That could lull them into believing, in a country where many issues daily call for urgent action, that stabilisation of population requires no higher priority than any other call for additional effort or resources. Add to this that population growth is a long-term matter and that issues to which politicians give highest priority are those which require their response this week, if not today. Permanent Afghan staff in ministries and foreign delegations may better understand the import of population growth, but most expatriates are in Kabul for the short term only. Statements of balance need weighting and emphasis so that all concerned can see which way the scales tip.

We do not contest the need for UN agencies to set out the prospects for a country in diplomatic terms, but the enormous risk here is that the optimistic gloss will be taken at face value. UN reports are written and edited by people with many years of experience not only in their technical specialisms but also in diplomacy. The risk is that they may be read by those in government ministries or by representatives of foreign donor governments and international organisations such as the World Bank whose specialisms and experience are far outside the realm of population studies. Those readers will not have the background necessary to assess either the nuanced language, perhaps in a foreign tongue, or the full impact of the figures themselves.

For example, the UNFPA report says candidly “even if Afghanistan continues to make progress in meeting family planning needs and if population growth continues to decline, the country remains decades away from a possible demographic dividend” (UNFPA, 2014, p. 14). The statement “population growth continues to decline” is too comforting for the politician or diplomat whose training and skills lie in other fields. Yes, when fertility starts to decline, if adult and child mortality do not decrease, the rate of growth of population also declines, but demographic momentum means the population continues to grow for decades to come, and all the faster when child mortality if reducing. Given the restricted access to, and very low uptake of, family planning, messages such as this need to be in words which convey the urgency of the problem if decision makers are to understand fully, sit up and respond. Reports on important issues like this, in other words, need to be written with full attention to the likely priorities, workloads and time scales of the main target readers. Authors need to bear in mind that population growth is still a dismal science that few will wish to attend to.

The UNFPA’s Investing in Youth report says “The largest benefits [of the demographic bonus] are obtained when the favourable age structure combines with job opportunities for the new entrants to the labour force, as well as investments in health, education and technical skills …” (UNFPA, 2014, p. 15). If only it were so in Afghanistan! Even more liable to be misunderstood is the gloss that Afghanistan’s “population dynamics provide a unique potential for accelerated and sustainable development” (ibid. p. 4). Even the most prosperous economies would tremble before a population surge such as Afghanistan faces: witness the high barriers to immigration put up by European countries and their “offshoots” like the United States and Australia. Even China with its rapidly growing economy still has stern controls to population growth in place, even if less punitive than before.

Certainly, the UNFPA’s Afghanistan State of Youth Report 2014 does allow that the demographic dividend is not an automatic process but depends on the right kind of policy environment, but much more than policies are needed. Policies, where the means to implement them are lacking, may be little more than good intentions.

The UNFPA reports provide important analyses of the situation, but they do not take sufficiently into account the obstacles stacked against making the youth bulge a force for the good in Afghanistan. The circumstances are very different from those of Silicon Valley, where a youth culture is highly productive. There will be little investment in industry, excepting some extraction of minerals, and little job creation until the armed conflict is greatly reduced. Even then, Afghanistan will remain a landlocked country with its capital 1394 kilometres from the nearest port, Karachi. And mountains have so far confined its three short lengths of railway to the North.

Security requires that the expatriate staff of UN agencies based in Kabul can only leave their compound in a convoy of at least three vehicles. When they do get out, they will have seen able young men selling a few mobile phone scratch cards on the streets. Many expatriates will have experienced the disappointment at job interviews of the many university graduates struggling to find work.

The massive inflow of funds for aid and development, with insufficient monitoring and audit, has fostered corruption at all levels where there is power (Chayes, 2015), and that extends to corruption of data. It should be no surprise if recipient organisations aim to please their international donors by reporting high achievements. Responding to the felt need for success stories by manipulation of data can do massive harm to the work of government ministries and to wider society. A report by the Afghan government in 2016 said “fraud, falsification, fakes, and forgeries have become a routine aspect of documentation in the Public Health sector. This has had dire consequences for the integrity and reliability of each of the main elements of the health system”, including finance, health services delivery and management information systems (Independent Joint Anti-Corruption Monitoring and Evaluation Committee, 2016, p. 20).

Let us illustrate how that falsification of data harms. The USAID-funded Afghanistan Mortality Survey 2010 estimated maternal mortality ratio (MMR) of 327 deaths per 100,000 live births (Afghan Public Health Institute, et al. 2011). If this and the primary survey of 2002, which found MMR of 1,600 per 100,000 live births (Bartlett, et al., 2005) were approximately accurate, Afghanistan would have achieved Millennium Development Goal 5a, a 75% reduction in MMR from 1990 to 2015, five years early. Could it have been achieved so fast? In countries which have successfully reduced high MMR it has taken decades (Koblinsky, 2003). Some have asked if this decline in MMR was “too good to be true?” (Marcus, Pavignani and Hill, 2013; Britten, 2017). For the donors such a good outcome would spell mission accomplished, enabling withdrawal of funding. Detection of falsification in scientific fields in most of the rich nations is the fast route to the end of a career. But those funding a survey in a least developed country do not always apply such high standards and sometimes appear to turn a blind eye to falsification. Standards are not invisible; implementing agencies in a least developed country like Afghanistan see the standards required by their donor agencies. For them, as for the donors, a favourable result is success, but for the population it could spell withdrawal of funds from a programme less than half accomplished. In the year of the Afghanistan Mortality Survey 2010 two-thirds of deliveries in Afghanistan took place on the floor at home without a skilled birth attendant.

To their credit, UN agencies initially rejected the Afghanistan Mortality Survey’s figure, which resulted in a year-long discussion before agreement and publication of the Survey’s findings, bearing the logos of WHO, UNICEF, and UNFPA. The UN agencies appear to have done their diplomatic best in arbitration to reduce falsification and possibly to keep donors engaged. The truth about population, like that of maternal mortality, needs to be told as it is.

Conclusion

In many developing countries demographic transition is compressed and taking place a lot faster than it did over centuries in the now-rich countries, but it is still likely to take almost a century before the new equilibrium is reached, and in some instances of social instability fertility decline is likely to be slower than it was in Europe (Dyson, 2015). In Afghanistan the benign progression to a demographic bonus outlined by some demographers is unlikely to be achieved for a long time to come. The challenge is, by provision of countrywide and effective family planning services and employment opportunities and by continuing progress in education, to reduce the wastage of armed conflict and prevent a malign cycle growing.

No one hesitates to pick the low-hanging fruit of the first stage of population transition, reducing child deaths. In Afghan villages little input is needed to make large reductions in post-weaning under-five deaths. Provision of improved water and oral rehydration salts can reduce deaths from dehydration in summer drastically, and antibiotics can greatly reduce deaths from pneumonia in winter, though neonatal deaths remain harder to reduce. Why not pick the low-hanging fruit of the second stage of population transition by providing highly cost-effective family planning services? It should not be an after-thought.

In 2016 the government of Afghanistan introduced the Citizens Charter to improve multi-sectorial collaboration across certain key ministries, including the Ministry of Public Health and the Ministry of Education (Islamic Republic of Afghanistan, 2016). The Citizens Charter marks an important step forward, but such inter-ministerial collaboration could achieve much more if it took into account the part which family planning could play, alongside the improvement of education and employment, which the Charter addresses, in reducing armed conflict. Family planning, education and employment should be major parts of the peace effort.

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