Five years before the 2015 deadline for achieving the United Nations' Millennium Development Goals (MDGs), the picture on progress is mixed. Persisting challenges include dysfunctional health systems, gaps in reliable morbidity and mortality data, uneven progress between goals and growing inequity between subpopulations. (1-3)
Jan Vandemoortele, one of the architects of the MDGs, emphasizes that the MDGs are globally aggregated and "not meant as a uniform yardstick for measuring performance across countries". (4) Progress across regions and in individual countries varies with social and political structures, geography and local history. The impact of conflict cannot be underestimated: countries suffering conflict are also performing poorly in meeting their MDGs. One-third of countries with low human development are in conflict, with the impact spilling across borders into neighbouring regions. (5) Sub-Saharan Africa, the site of 40% of the world's major conflicts, suffered the highest direct death toll in the decade before 2000. The indirect health implications compound the situation with deaths from consequent disease and malnutrition. In 2008, there were an estimated 41.2 million internally displaced people and refugees globally. (3)
In these situations, more than any other, the context of MDG progress is critical: conflict disrupts health systems and other government institutions, compromises capacity and renders governance and the legitimacy of authorities uncertain. While securing peace is the main goal, building local ownership of the MDG process and mapping out locally effective programmes are important priorities within that process. (4)
Afghanistan provides an intriguing and, in certain ways, encouraging example: in 2000, the declaration of the MDGs was irrelevant to the (then) Taliban government and its patchwork of warlord allies. At 0.345, its development index--a composite of life expectancy, education and economic performance--ranked it 174th of 178 countries. Neonatal and infant mortality rates were high. Its maternal mortality ratio, with estimates ranging from 1600 to 2200 per 100 000 live births (6500 reported in Badakshan province), compared poorly with its neighbours. (6) Development assistance was minimal. Women were prohibited access to education. The health system was fractured and dysfunctional.
Then, in 2001, the "war on terrorism" brought Afghanistan to the centre of international attention. In the immediate aftermath of the defeat of the Taliban, the health systems vacuum was rapidly filled by international development assistance. Health services, provided by international civil and military agencies, developed without effective integration, sustained by project support in major population centres and lacking a coordinating policy framework or effective governance structures. There were early attempts to secure a strategic approach for development. In 2002, the National development framework (7) focused on the acute rehabilitation needs of the country. The 2004 document Securing Afghanistan's future: accomplishments and the strategic path forward, (8) while adopting a longer-term perspective, and arguing for more sustainable development of sectors including health, lacked Afghan engagement and a sense of local ownership. …