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Development efforts in Afghanistan: is there a will and a way ?

De
286 pages
This collective work addresses key issues surrounding the provision of international assistance. It is based on fieldwork and research undertaken in Afghanistan, and evaluates a number of development programmes. By identifying the gap between the needs of people and the delivery of aid, and examining the decision making processes of donnor agencies in determining which programmes to fund, this book questions the underlying values and assumptions that motivate interventions.
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DEVELOPMENTEFFORTSINAFGHANISTAN:
ISTHEREAWILLANDAWAY?
The case of disability and vulnerabilityEthiqueEconomique
Collection dirigée par François Régis Mahieu
L’éthique rejoint l’économie dans la recherche du bonheur pour soi et pour
les autres. L’individu n’est pas totalement opportuniste, il concilie égoïsme
et altruisme. Reconnaître les formes de l’éthique est une priorité en
économie: vertu, responsabilité, discussion, justice. Une attention
particulière est accordée à l’éthique du développement, en particulier à la
considération accordée à la justice intra et intergénérationnelle dans le cadre
du développement durable. L’éthique se traduit par des évaluations et des
sanctionsvis-à-visdeceuxquiontlaresponsabilitédelavie bonne.
Cette collection concilie recherche et pédagogie, réflexion et action, dans
l’optiquelapluslargepossible.
Déjàparus
ArnaudMAIGRE, De l’éthique en économie,2010.
AliTOUSSI, Le taux d'intérêt dans un système financier islamique,2010.
Ali La banque dans un système financier islamique,2010.
Jean CARTIER-BRESSON, Economie politique de la corruption et de la
gouvernance,2008.
Réseau IMPACT, Repenser l’action collective. Une approche par les
capabilités,2008.
Laurent PARROT (coord.), Agricultures et développement urbain en Afrique
subsaharienne. Gouvernance et approvisionnement des villes,2008.
Laurent PARROT (coord.), Agricultures et développement urbain en Afrique
subsaharienne. Environnement et enjeux sanitaires,2008.
SamirZEMMOUR, Vers une certification de qualité halal ?,2007.
Samir Le marché de la viande Halal : évolutions, enjeux et
perspectives,2006.
JérômeBALLET,KatiaRADJA,Le capital social en action,2005.
J.BALLET,J.-L.DUBOIS,F.-R.MAHIEU,L’autre développement,2005.Jean-FrancoisTrani(Ed.)
DEVELOPMENTEFFORTSINAFGHANISTAN:
ISTHEREAWILLANDAWAY?
The case of disability and vulnerability
L’HARMATTAN©L'HARMATTAN,2011
5-7,ruedel'École-Polytechnique;75005Paris
http://www.librairieharmattan.com
diffusion.harmattan@wanadoo.fr
harmattan1@wanadoo.fr
ISBN:978-2-296-54522-9
EAN:9782296545229Foreword
Jean-LucDuboisand Francois-RegisMahieu
Afghanistan is still in a situation of conflict. This is a sad but undeniable
reality. The said conflict continues to generate thousands of wounded and
distressed Afghans thus increasing the number of people with disabilities
and mental problems. War survivors are not the only victims of the on going
conflict. Many others vulnerable groups are facing some form of disability
that leads to their exclusion from society. These are poor, uneducated or
unemployed people,isolated women withchildrenandtheelderly. Moreover
people with other forms of impairment such as congenital diseases, chronic
conditions, victimsof accidentsalsoface difficult circumstances.
This book shows that war alongside poverty or social disadvantage leads to
problems such as low self-esteem, loss of meaning of life and deterioration
of social networks and sometimes even marginalisation. Disability and
vulnerability are therefore intertwined and the present book explores
concepts and instruments for identifying and assessing such conditions and
their human and social consequences. This would provide policy makers the
inputs needed to implement policies and programmes in order to improve
conditionsandpromoteinclusion.
The international community tends to believe that whatever is done is good
enough as it at least brings something to the people. And they inevitably
refer to absence of infrastructure, poverty, natural disasters as the major
problems to be addressed. The development effort of the last decade in
Afghanistan, where the international community has contributed too little to
improve circumstances of Afghans, and certainly less than what was
expected and announced, shows that such a belief is deemed to always bring
discontentment and disappointment. Lackof knowledge of whatthe Afghans
reallyneedandwantis primarilythecauseforthecurrentsituation.
Therefore evidence –based knowledge is necessary to try to disentangle the
complexity of what disability and vulnerability are in a context of war and
turmoil. This is undoubtedly a growing, ongoing and salient issue.
Understanding the interaction between disability and vulnerability in such a
context requires analysing how people cope in everyday life: Their capacity
to survive in the midst of war, deprivation and sometime, what is worse,
socialexclusion.
Resilience with social support is in the Afghan psyche fundamental to
survival. We also need to understand what disabled people, as well as other
vulnerable groups, would choose to be and to do if the barriers they face
-5-wereremoved.Development,intheperspectiveofthecapabilityapproach of
Nobel Prize in Economic Sciences Amartya Sen and philosopher Martha
Nussbaum, is about improving well-being by providingmore opportunities
to individuals and groups, and addressing constraints that prevent them from
beinganddoingwhattheyvalue.
This work is driven by concerns for justice and equity. It stresses on
attention to justice by recognizing the specificity of those who are excluded
due to impairment, or another condition, and by providing the means to
restore dignity and self-esteem, and bears a concern for equity expressed in
the denunciationofinequality.
Part of the present book is inspired by the results of a nationally
representative household survey that looked at the circumstances of people
with disability in Afghanistan. Other chapters are based on the field
experience of the authors who draw useful reflexions fromtheir professional
practice. All learned a lot from the years they spent in the country and try to
share this amazing experience with the reader. The latter might find it
edifyingandreproducibleelsewhere.
The various contributions also demonstrate that policies set-up in recent
yearsthat havebeen mainlyrights-based,focusontheindividualina context
where coping strategies are also built at the family and community levels.
Such policies place people who are isolated, at a disadvantage. Increased
participation of vulnerable persons also require involvement of families and
communitiesinstead ofholdingadiscourseattheindividuallevel,whichcan
be seen as irrelevant by Afghans because too far removed from their own
world view. This shows the need to adapt development frameworks to local
realities, including taking ethnic and regional differences into consideration,
an important idea in development studies that the authors of the present
book, through the example of disability and vulnerability in Afghanistan,
demonstratetobestillundervalued.
-6-Acknowledgements
The editor is grateful to Nora Groce, Ray Lang, Maria Kett, Anu Bakhshi
Nicki Bailey and Ellie Cole for comments on early drafts of this book, to
participantsofthe NDSA for their commitment tothisstudyas wellastothe
respondents of the survey and their family for their warm welcoming, their
patienceandtheirtrust.
Thestudywas supported bythe European Commission, UNOPS/UNDP, UN
Mine Action Center for Afghanistan (Voluntary Trust Fund), Handicap
International, French Embassy, Swiss Agency for Development and
CooperationandLeonard Cheshire International.
Jenny Wickford (chapter 7) is grateful to Fiona Gall, Zemarai Saqeb, Anne
Hertzberg and Ian Edwards for their constructive feedback, comments and
discussions about this chapter. Special thanks go to the Afghan
physiotherapists in RAD who have put up with my incessant observations,
note-takingandquestionswhich ultimatelyenabledthischaptertoevolve.
-7-Tableof Contents
Foreword _______________________________________________5
Acknowledgements_____________________________________________7
TableofContents______________________________________________8
ListofTables _______________________________________________9
Listof Figures ______________________________________________10
ListofAbbreviations __________________________________________11
Introduction: Disability and vulnerability in a conflict affected
fragilestate;learningfromtheAfghanexperience____________________13
Chapter One: Capability and disability: Approaches for a better
understandingofdisabilityissues_________________________________23
Chapter Two: The historical and cultural context of disability in
Afghanistan ______________________________________________47
ChapterThree:Profilingandunderstandingpeoplewithdisabilities
inAfghanistan ______________________________________________75
Chapter Four: Deconstructingmyths; facing reality. Understanding
socialrepresentationsof disabilityinAfghanistan. __________________103
Chapter Five: A gender analysis of disability, vulnerability and
empowermentinAfghanistan___________________________________123
Chapter Six: CBR in Afghanistan: Foreign import or home-grown
development? _____________________________________________161
Chapter Seven: Considerations for enhanced community based
physiotherapyservicesin Afghanistan. ___________________________193
Chapter Eight: Mental health and primary care: Fighting against
the marginalisation of people with mental health problems in
Nangarharprovince,Afghanistan________________________________215
Chapter Nine: ‘TodayIfeel that I’m a person….’: Impact of
communityeducationondisabilityissuesinAfghanistan _____________243
Conclusion _____________________________________________269
Glossary _____________________________________________273
Notesoncontributors_________________________________________281
-8-ListofTables
Table2.1. LiteracyRates:Comparinghouseholdsurveys 64
Table3.1. Set of questions in the screening tool of the NDSA:
PrevalenceandTypology _______________________________________80
Table3.2. Set of questions in the health module according to
the9 dimensions of well-being: Severity or ‘Depth’ of a given
Difficulty ______________________________________________82
Table3.3. Prevalence rates and distribution of the population
bytypesofdisability___________________________________________87
Table3.4. Profileof disabilities______________________________88
Table3.5. Accessto public and privatehealthfacilities ___________90
Table3.6. TransportationtoHealthFacilities___________________91
Table3.7. Healthexpenses_________________________________91
Table3.8. BarrierstoSeekingHealthCareServices______________92
Table3.9. School AttendanceaccordingtoGenderandAge _______93
Table3.10. Function or Activity Difficulty and School
Exclusion,PrimaryEducationCompletionand LiteracyRate___________94
Table3.11. Main Reasons for Lack of Access to Education
accordingtoAgeCategoriesandGender___________________________95
Table3.12. AccesstoWork(15-64 yearsold) ___________________97
Table3.13. Child Labour(6-14yearsold) ______________________98
Table3.14. Perceptionsofthecauseofdisability_________________99
Table5.1. EducationforChildrenbetweenAgesof7and14______135
Table5.2. LiteracyRates__________________________________136
Table5.3. VariablesusedintheMCA________________________152
Table6.1. CBRframework ________________________________165
Table7.1. Differencesin physical therapyroles________________206
Table7.2. Whichorganisationdoessomethingusefulfor you? ____207
Table8.1. TrainingofTrainersfordoctors____________________226
Table8.2. TrainingofTrainersforPsychosocialworkers_________226
Table8.3. Trainingofdoctors:anexample____________________229
Table8.4. Anexampleofasupportgroup ____________________232
-9-ListofFigures
Figure5.1 Access to education according to age of disability
andgender _____________________________________________137
Figure5.2 Access to education according to age of disability,
genderandagecategories______________________________________138
Figure5.3 Gap in access to school according to gender and
typeof disabilityforpersonsaged7to14 _________________________139
Figure5.4 Literacyrates __________________________________141
Figure5.5 Literacy rates according to age of disability and
genderforpersonswhoaccessedpublicschool_____________________142
Figure5.6 Literacy rates according to type of disability and
gender allagesabove9________________________________________143
Figure5.7 Axes 1 and 2 of the multinomial correspondence
analysis on vulnerability potential factors and literacy for persons
agedabove12 _____________________________________________145
Figure5.8 Attendance rates by sex for persons with disability
andnon-disabledaged7-18 ____________________________________147
Figure5.9 Attendance rates by sex and age groups for
personswithdisabilityandnon-disabled __________________________148
Figure5.10 Axes 1 and 2 of the Multinomial Correspondence
Analysis onfactors of vulnerabilityforpersonsagedabove10. ________154
Figure5.11 Classification in 7 clusters on all Dimensions of
Vulnerabilityforpersonsagedabove10.__________________________155
-10 -ListofAbbreviations
AABRAR Afghan Amputees for Bicycle Rehabilitation And
Recreation
AFAs AfghansAfghanis(currency)
ANAB AfghanistanNational Associationofthe Blind
ANAD AfghanistanNational Associationofthe Deaf
APTA AfghanPhysio-Therapists’Association
ASC AfghanSwedishCommittee
CAFS ConflictAffected FragileState
CAHD CommunityApproachesofHandicapinDevelopment
CBR CommunitybasedRehabilitation
CDAP ComprehensiveDisabled Afghans’Programme
CDCs CommunityDevelopmentCommittees
CEDAW Convention on the Elimination of all forms of
DiscriminationagainstWomen
CHA CoordinationofHumanitarianAssistance
CP CerebralPalsy
CRDC CommunityRehabilitationandDevelopmentCentres
CRDP Conventionthe Rightsof PersonswithDisabilities
CRDW CommunityRehabilitationandDevelopment Workers
CTA ChiefTechnicalAdviser
DAO DevelopmentandAbilityOrganisation
DPO Disabledpeople/persons Organisation
HI Handicap International
HIFA HearingImpairedFoundationofAfghanistan
IAM InternationalAssistanceMission
IDPs InternallyDisplaced Persons
IDUs InjectingDrugUsers
IEC Information,EducationandCommunication
ILO InternationalLabourOffice
IMR InfantMortalityRate
INGO InternationalNonGovernmentalOrganisation
IRC InternationalRescueCommittee
MCA MultinomialCorrespondenceAnalysis
MMD Ministryof MartyrsandDisabled
MMR MaternalMortalityRate
MoE MinistryofEducation
MoLSAMD MinistryofLabourandSocial Affairs,MartyrsandDisabled
MoPH MinistryofPublicHealth
MoWA Ministryof Women’sAffairs
NDSA National DisabilitySurveyinAfghanistan
-11 -NER NetEnrolmentRatio
NGO NonGovernmentalOrganisation
NPAD National PlanofActionforDisability
PWD People/PersonswithDisability
RAD Rehabilitationof AfghanswithDisabilitiesProgramme
SCA SwedishCommitteefor Afghanistan
SERVE ServingEmergencyReliefandVocationalEnterprises
TB Tuberculosis
TSU TechnicalSupportUnit
UNDP UnitedNations DevelopmentProgramme
UNICEF UnitedNationsChildren'sFund
UNIFEM UnitedNations DevelopmentFundforWomen
UNMACA UnitedNationsMineActionsforAfghanistan
UNOPS UnitedNations Officefor Project Services
USD UnitedStatesdollars
WB WorldBank
WHO WorldHealthOrganisation
-12 -Introduction:Disability and vulnerability
inaconflictaffectedfragilestate;learning
fromtheAfghanexperience
Jean-FrancoisTrani,CatherinePanter-BrickandAshrafMashkoor
Decades of turmoil and conflict have made Afghanistan one of the poorest
nations in the world, a ‘fragile state’ (DFID 2005) and a ‘complex
emergency’ (IASC, 1994) faced with serious, ongoing challenges having no
simple solutions. Several indicators show the extent of the challenge ahead.
On the global Human Development Index (HDI), Afghanistan ranks 155 and
iitsHDIisevaluatedat0.349. Zimbabwe,currentlythelastcountryinthelist
has a HDI of 0.181 following Niger at 0.321. On the Transparency
iiInternational' s corruption perception index, Afghanistan is ranked 176 out
of178countriesin2010.
The route to development is paved with good intentions: equity, justice,
rights, ownership and participation. These principles are emphasised in the
PovertyReductionStrategyPaper(PRSP)frameworkproposedbytheWorld
Bank and the IMF (IMF and IDA, 1999). In principle, approval of the PRSP
is conditional on acceptable participatory processes (McGee, Levene, and
Hughes, 2002). In addition, human rights and sustainable development are
considered as linked and complementary (UNDP, 1998). Programmes and
policy guidelines are inspired by such values and principles, and largely
adopted by the international community (Demirel-Pegg and Moskowitz,
2009). Unfortunately, on the field, challenging situations and extreme
poverty soon become reasons for compromise, and sometimes, even
justifications for inefficiency, leading to these principles being discarded
(Kamruzzaman,2009).
Since the fall of the Taliban, in 2001, Afghanistan has effectively received
only $15 billion in aid andit is estimated that 40percent has been returned to
donors countries in corporate profit and international workers’ wages
(Waldman, 2008). The financial effort focuses mainly on security: USA
alone spent $ 127 billion for the war and $ 25 billion for security related
expenses such as strengthening Afghan forces (Waldman, 2008). In June
2008, international donors pledged another $ 21 billion to development
assistance. The 2010 London (January) and Kabul (July) conferences
committed to good governance, a fair judicialsystem and fundamental
human rights (reiterating the centrality of women's rights) at all levels of
government and to deliver increased economic development. Yet the process
of reconstruction is slow to yield tangible results: there is mismanagement,
-13 -lack of coordination leading to duplication of actions, and widespread
corruption. Many Afghans are now questioning the outcome of such aid, as
is public opinion within donor countries. Many experts underline the fact
that aid has not met the needs of the people but is driven by the international
communityagendaandpriorities.
Issuesandchallengesahead?
Understanding the dynamics of the development process in a given social,
cultural, economic and global context is a challenge in itself. The range of
different stakeholders, as well as the complexity of power relations between
them, has led to a growing need to re-think the objectives, practice and
assessment of the development process through research and policy
definition. Many programs aiming at reducing poverty and inequality have
fallen short of their ambitions. Experts offer two explanations for this: a
disconnection from reality and the absence of real stakeholder participation
in policy implementation. This book builds upon academic research, policy
design and programme implementation to examine development in practice
in the context of a conflict-affected fragile state From an academic
perspective, based on data from the national disability survey (NDSA)
carriedoutin2005,severalcontributors attempttodisentangletheintricacies
of this difficult context to better understand the needs of the people of
Afghanistan. Policy makers and funding agencies describe the processes
behind their decisions. Development practitioners and experts in the
rehabilitation field provide insight into their recent projects. Adopting
different perspectives, the authors try to answer the following questions:
How have needs of people with disabilities been identified? What has been
achieved so far in terms of development programmes for people with
disabilities? Who takes on the responsibility for translating research
information to action? Does it fall on researchers or on the policy developers
andimplementers?
Contributors to this book present an analysis of the programmes that they
have implemented in one of the most challenging conflict-affected countries
in the world today. They explain how weaknesses in programme
implementation and public policy definition are to be found in a lack of
comprehensive action, which in turn reflected a lack of understanding of the
situation on the ground.They suggest sustainable and practical solutions
based on research findings as well as field practice, together with
recommendations on how to overcome problems inherent to the recovery
process in the context of violent conflict and ongoing political instability.
Oftensimilarconclusionsarereached:atop-down,benefactorto beneficiary,
-14 -patron-clientrelationship, uni-dimensional approach has become irrelevant
from a sustainable development perspective (Uphoff, 1996; Hickey and
Mohan, 2005). Our contributors support strengtheningeffective participation
of the most vulnerable groups in society; with respect to disability, they
advocate a more comprehensive and multidimensional approach that looks
beyond disability but consider globally all dimensions of vulnerability.
Processes defined by users and beneficiaries determine the impact:
ownership of programmes by those supposed to benefit fromthemis key for
meeting objectives (Datta, 2003). They insist on the necessity for long term
funding and sustainable programmes. Finally, they require better monitoring
and evaluation of programmes, as has been already suggested by other
authorsfor Afghanistan(Donini,2007).
Contributionsinthisbook
This book tries to shed new light on old challenges of development!
proposing fresh perspectives in the context of a conflict-affected fragile
state. We feature examples showing that, in certain cases, decision makers
were unable to redefine and adapt programs and policies to match the needs
of given contexts, due to lack of understanding and the rigidity of a
traditional top-down approach to policy implementation. In order to see
impact inthelongterm, programmes and policies need to becomprehensive,
structured and ‘participatory’. The question of participation is about who
will be deciding in a programme. In order to ensure a truly participatory
process of development a number of conditions have to be met. Firstly, the
necessity to work on the various aspects of empowerment or ‘agency’ as
defined in chapter one. This constitutes the basis ofaparticipatory approach
applying the capabilities approach. Secondly, inclusion of all actors of the
development process at all levels does not imply a confusion of roles and
mandates. The responsibilities of each partner are well-defined as each
partner is held accountable by the others for fulfilling their given role.
Thirdly, the inclusion of various expertises is a pre-requisite to defining any
programs.Variouspartnershave verydifferentexpertiseandallcontributeto
a comprehensive understanding of the situation and to the defining and
implementing of a focused policy or programme. The book illustrates these
points through the example of programmes for Afghans with disabilities set
upinrecent years.
In chapterone,TraniandDuboisexplorethetheoreticalbackgroundusedfor
the NDSA. The methodology operationalises the ‘capability approach’
proposed by A. Sen (1985, 1999), M. Nussbaum (2000) and followers
(Alkire, 2003), implementing an innovative approach to collect information
-15 -in thefield of disability. The Capability approach conceptualises people’s
well-being in terms of ‘functionings’, ‘agency’ and ‘freedom’. The focus is
put on equality of choices, available to an individual. The Capability
approach highlights not only what a person actually does ! his/her
‘functionings’! but also a ‘capability set,’ the range of possibilities that
he/she chooses that specific functionings from (Sen, 1999). ‘Agency’ looks
at to what extent the person considers him/herself as the main decision-
maker in his/her own life and defines a positive outcome for his/her future.
‘Agency’ is a person’s ability to form goals, commitments, values, etc. The
individual’s relationship with his/her environment has to be included in this
perspective, considering that most choices are made with (and often by) the
family and the community under the constraint of actual socially available
opportunities (Sen, 1999: 39). Human ‘freedom’ determines quality of life,
as itenables each person topursuethe capabilities thatshe/he values and has
reason to value (Sen, 1999, 53-56). Focusing on enlarging the choices an
individual has in a given environment contributes to a general objective of
sustainability: programmes and policies are defined for the long term in this
perspective and therefore need long term investment. The key issue regards
what people are able to achieve through the use of available commodities.
With respect to disability, Sen wrote: ‘We must take note that a disabled
person may not be able to do the many things thatan able-bodied individual
can,withthesamebundleofcommodities’(1985:7).
Trani and Dubois argue that this approach offers another perspective for
analysing, in economic terms, the situation of people with disabilities. The
‘capability set’ open to a disabled person is governed by the larger context,
namely the social, economic and political environment relevant to a person’s
impairment. The issue remains the same: how should limitations and
improvement of capabilities be tackled in order to allow people with
disabilitytoconductalifethattheyvalue?
The authors investigate various ways of conceptualising ‘disability’, with
reference to competing theoretical models. In the NDSA, they used a
specific and comprehensive definition of disability and developed a survey
instrument based on both the international classification of functioning,
health and disability (ICF, WHO, 2001a) and the capability approach. The
methodology was designed to detect disability in the Afghan context and to
gather reliable information about the perceptions of people with disabilities
regarding their situation:where they facing discrimination in access to
school or health facilities for instance? These tools consisted of specific
sections for assessing livelihoods, health conditions, education levels, and
other relevant dimensions, as well as the means of assessing a person’s
capabilityset,specifyingdifferenttypesof disability.
-16 -The authors then address the limitations of the ‘capability approach’ and
propose to extend the paradigm to look at collective capabilities. Each
individual is situated within a web of relationships which produce
capabilities common to the social group. The specificity of experiences of
disability requires enlarging the conceptual framework to the
phenomenological paradigm. It provides a systemic view of human
behaviourincludinginteractionswith others.
Measuring specific capabilities, especially along the freedom dimension, is
more complex and requires identifying and assessing people’s potential
choices in an ever-changing environment. Achieved functionings (Sen,
1999) can be measured by using cross-sectional surveys, through
comparison of the situations of disabled and non-disabled persons, as done
in the NDSA. The authors discuss various methods currently used to
measure capabilities.These methodstryto identifyallpossible choices made
available to individuals in a given context fromwhich they choose their own
capabilityset.
In chapter two, Nancy Dupree provides a subtle overview of Afghanistan, in
all its complexity. She revisits history,geography, culture and current
political issues, reminding us that Afghan history is ‘filled with the fury of
battle, the discord of fratricidal and tribal rivalries and harsh retributions in
thenameofhonour’(p.30).Yetthedramaofintensestrugglesforpowerand
honour is only one aspectof the country’s history. Nancy Dupree describes
both traditional and recent challenges experienced by the country. Ecology,
access to health care, education, transportation, and stigma and exclusion
attached to disability are traditional hurdles. Three contemporary challenges
arealsoconsidered:theconflictbetweentraditionalrole ofwomen insociety
and new rights-based approach to gender issues, the place of human rights
andtheexperience ofdemocracy.
In chapter three, Trani and Bakhshi review the situation of persons with
disabilities in Afghanistan. They present results regarding prevalence, access
to services, social participation, and challenges faced by persons with
disabilities. They demonstrate the extent to which children with disabilities
have limited access to school, adults with disabilities have limited access to
the labour market or to land, and households with a disabled family member
have reduced access to shelter. The authors show how people with
disabilities systematically face difficulties to access basic social and welfare
services. Finally, the authors investigate the link between discriminatory
beliefs attachedto disabilityinAfghanistanandthesituation ofexclusion.
In chapter four, Teresa Cerveau further explores the beliefs, drivers and
barriers related to disability. She identifies perceptions attached to different
-17 -types of disabilities, some considered less acceptable than others by the
community. In particular, she explores the concept of disability in Afghan
culture, and the different meanings attached to the notions of malul and
mayub, the two main categories of disabilities in Dari and Pashto languages:
the former refers to being disabled after an accident, the latter to being
disabled from birth. Often, a supernatural cause is responsible for mayubiat
(the state of being mayub). The worse situation is attached to Jadu, black
magic, that can turn someone dewana (crazy). This label, which covers both
mental illness and intellectual disabilities, leads to deep and age-old stigma.
The persistence of prejudice explains that children with disabilities are
protected from the outside and sometimes isolated, that women with
disabilities have enormous difficulties to get married, and that an
individual’s disability has an impact on the whole family’s status in society.
Until recently, disability programmes were built without understanding of
attitudesand practicesrelatedto disability.
In chapter five, Bakhshi and Trani present a gender-specific analysis of the
NDSA data. In 2008, 35 percent of the 5.7 million children at school were
girls (MoE, 2008). Women hold 68 seats in the 249-member National
Assembly. A record number of women runned in Afghanistan's contested
parliamentary elections in September 2010. But these news-worthy statistics
do not reflect a change towards more equitable living circumstances. Forced
marriage is common practice and often at a very early age. Amnesty
International (2005) has highlighted reports of the pervasive abuse of
women, including the use of severe physical violence. In traditional Afghan
culture, the mistreatment of women by male family members is exacerbated
by the absence of legal penalties associated with such behaviour. Social
attitudes related to gender roles, especially in the case of disability, are key
to potential changes in role-distribution within the family, the community
and society. The NDSA data show that the situation of women with
disabilities is disturbing, as prejudice and discrimination resulting from their
condition compounds barriers to basic capabilities such as access to health,
education,qualityfoodor assets.
Conflict, poverty and vulnerability, have given, in some cases, a higher
decision-making power to women, even to women with disabilities. This is
particularly true in the case of female heads of household who acquire
decision-making power regarding the welfare of the household. Following
Nussbaum (2006), women, including those with disabilities, can adjust their
‘capabilities structure’ according to the circumstances and strengthen their
‘agency’ to take on larger responsibilities in the society: participation to the
labour market, management of the house or land, in the absence of a male in
the household. The NDSA survey specifically features different sections on
-18 -psychosocial perception and social participation for women and men.
Gathering relevant information about social roles is particularly challenging
in the Afghan context. Although essential for any efficient programming,
manydevelopmentactors neglecttotacklethisissue.
This brings us to the gap between research and development policy. The
NDSA analysis of livelihoods and economic activity, for men and women
with and without disability, provides essential information to shape both
policies and field programmes. It is often emphasised that women suffer a
higher burden of disadvantage relative to men in Afghanistan, especially in
terms of income and livelihoods. Therefore, it is relevant to assess the major
differences in the livelihood situation between households according to the
gender of the head of the household in order to determine if women with
disabilities are more vulnerable to multidimensional poverty than any other
vulnerable group. Regarding employment, women are often limited to
household tasks and looking after the children and elders. In line with other
authors who argue that mainstreaming women in development programmes
and policies might be an efficient wayto change gender perception and roles
(Larson, 2008), the chapter discusses the consequences of enhancing gender
equityinAfghanistan.
In chapter six, Coleridge and Hertzberg review the development of the
community based rehabilitation (CBR) in Afghanistan, from being primarily
a method of providing essential rehabilitation services at the community
level(ie. villageand neighbourhood)topeople with disabilities,tolookingat
acomprehensiveapproachaimingprimarilyatempowerment.Thischangeis
traced in three distinctphases: 1989 - 1995, 1995- 2001, 2002 - present. The
first two phases were marked by the absence of a functional and effective
government, from the Soviet withdrawal in 1989 to the fall of the Taliban at
the end of 2001. At the time, UN agencies and NGOs were the only
organisations delivering services in health, education and rehabilitation. The
United Nations Development Programme (UNDP), the World Health
Programme (WHO) and the International Labour Office (ILO), in
partnership with the Swedish Committee for Afghanistan (SCA) and
SERVE, promoted CBR as the bestmethod of reachingpeople with
disabilities in both urban and rural areas. The third phase, marked by the
establishment of the Karzai government and a huge influx of foreign aid,
saw efforts by the UN to encourage the government to assume its
responsibility for providing basic services, including those for people with
disabilities. However, with so many needs unmet for non-disabled people,
the government has not been able to see rehabilitation as a priority and the
onus for its delivery has continued to rest primarily on NGOs, while the UN
hastriedtoplaytheroleofcoordination and advocacytothe government. At
-19 -the same time general community development efforts in Afghanistan have
focused on the creation of a genuine civil society through the formation of
village- and neighbourhood-level committees (shuras) to manage local
affairs. CBR programmes have joined this effort and worked to ensure that
disabilityisontheagendaoftheselocalcommittees.
In chapter seven, Wickford discusses the role of physiotherapy in CBR
programmes within Afghanistan. This discussion is based on a field study
conducted in 2004 to assess needs and challenges for developing
physiotherapyinAfghanistan,andonanactionresearchprojectconductedin
2006-2007 to investigate issues related to professional development of
physiotherapy in Afghanistan. The author presents international perspectives
of physiotherapy in CBR, along with thecontext within which Afghan
physiotherapists work. Based on the example of the physiotherapists
workingin the largestCBRprogramme in Afghanistan(the Rehabilitation of
Afghans with Disabilities, RAD), models of disabilityare examined. Finally,
recommendations for more focused physiotherapy services provision are
given. The author suggeststhat the patient with disabilityand his/her careris
associated to the decision taken during the consultation. Furthermore,
evaluation by patients of the service provided should be promoted through
regular consultations. This requires a progressive change in the relationship
between patients and practitioners. A long way to go as attitude towards
disability will have to change. Finally, the author argues that better outcome
for physiotherapyrequiresastrongreferralsystemwithallhealthservices.
In chapter eight, Ventevogel, Faiz and Van Mierlo depict the first attempt
made at implementing a development programme aiming to alleviate mental
illness and intellectual disability as well as various forms of mental disorder,
including epilepsy. The authors explain that after decades of violence and
poverty, the prevalence of mental disorders is very important. In 2005, the
Afghan government has included mental health and disability as first tier
priority in the Basic Package of Health Services (BPHS) launched in 2002
(MoPH, 2003, 2005a). The BPHS is composed of health posts, basic health
centres, comprehensive health centres and district hospitals. It covers seven
health categories: maternal and newborn health; child health and
immunisation; public nutrition; communicable diseases with concentration
on tuberculosis and malaria; mental health; disability; and finally the supply
of essentialdrugs.The MoPH contracted 27 NGOscovering 31 of the 34
provinces of Afghanistan partly through performance-based partnership
agreements to deliver the BPHS. Basic health services are delivered by the
MoPH itself in the remaining 3 provinces. The MoPH has kept the
stewardship of the health sector, defining the priorities for the health policy,
monitoring, coordinating and evaluating implementation of the BPHS by
-20 -serviceproviders. The project, launched in 2002 by the international NGO
Healthnet TPO to include mental health in the basic health care system of
Nangarhar province in Eastern Afghanistan, is the first of its kind. The
methodologyusedbytheprojectandtheactivitiescarriedoutareinnovative,
relatively inexpensive and rely largely upon community support and
participation in the process. The authors argue that such a combination is the
key for ‘success’. In a last section, the authors evoke the limitations and
pitfalls of their approach,and review the feasibility of scaling-up mental
health community-based services in the primary health care system of
Afghanistan, an example of a conflict-affected fragile state with low-
resources.
Finally, in chapter nine, Rolland describes a programme of Handicap
International in Herat, west Afghanistan. Byengagingcommunityleaders on
disability issues, it became possible to involve these key actors in the
recognition of the needs of people with disabilities, and implement or
encourage changes at services and community level. Based on the analysis
of the organisation of the community as well as recognising the weaknesses
of existing programmes and services, the author explains how leaders’
committee in order to have its members decide, co-build and co-implement
awareness campaigns in schools, health services and the media. The author
argues that the committee involvement in the process of monitoring and
evaluation of the campaign funded by UNDP and the European Commission
in 2005 and again in 2006 are the main keys of success. She further argues
that engagement of communityleaders, DPOs,isnecessarybut not sufficient
to scale up from this pilot action into the design and implementation of
various actions aiming at identifying the needs of all people with disabilities
and at developing supportive solution. The main difficulty is to ensure
accessibility and secure enough resources for an issue often considered not
tobeapriority.
This book brings together academics, programme implementers, and policy
makers, to examine multifaceted issues of disability and vulnerability in
Afghanistan.Basedondifferentprofessionalexperienceandbackground,the
authors nonetheless come to similar recommendations. They underline the
need for more participation of stakeholders, coordination of action,
monitoring and evaluation of programmes and policies, long term strategy
and vision. To the best of our knowledge, thisis an original/unique example
of collaboration in the field of disability and vulnerability in a conflict
affected fragile state. We provide a strong evidence base for the need to
betteraddress well-beingofpeople with disabilities and useful guidelines for
stakeholders in Afghanistan committed to do so, as well as a model for
-21 -analysis with globalrelevance, given that similar constraints operate in other
conflict-affected,poverty, naturaldisasterandcomplexemergencysettings.
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-23 -Doubleamputeefromsteppingonalandmine,
Jalalabad(F.Oberson,2005)ChapterOne:Capabilityanddisability:
Approachesforabetterunderstandingof
disabilityissues
Jean-FrançoisTraniandJean-LucDubois
Introduction
Thenumber of people with disabilitiesworldwide, i.e. theprevalenceof
disability,isnotaccuratelyknown.Thisisrecognisedasamajorissuebythe
2007 UnitedNationsConventiononthe Rights of Persons with Disabilities.
In fact, theconventionincludesaspecialarticle,article 31, which stipulates
thatStatesParties’ design and implementation of disability policies should
include the collection of information, particularlystatistical and research
data.
Appropriatemethodological tools forthe collectionand the analysis of
disabilitydata aretherefore required to obtainabetterestimation of the
incidenceofdisability,and promotethe principles of theconvention.
However, collectingappropriate information is stillquite acomplex
endeavour duetothe variety of conceptualparadigms used to define
disability. Agreeingaconceptualframework,used by both researchers and
practitionersonone hand, and adapting it forvarious culturaland social
contextsonthe other, remainsamajor challenge(Baylies,2002; Groce,
2006).
Assessing disabilityisthereforeaperilous exercisethatrequiresovercoming
the difficulty of choosing amongalternativeparadigms,and operationalising
the chosenparadigminto appropriate survey instruments (Altman, 2001;Me
and Mbogoni, 2006;Mitra, 2006). Thevarious models, theories and
definitions, whichare currently available fora conceptualframework,
proposediverse (sometimes competing)views of thedisabilityphenomenon,
ranging from themostmedicalview toavery socialone (Mont,2007). In
the last decade, however, majorsteps have been made to reconcilethese
positions by looking at differentdisabling conditions. They consider the
relationshipbetweentheindividualsituationandthecollectiveopportunities,
or limitations, whichmay transformanindividualimpairment intoasocial
disability. This hasled to thetwo majorframeworksconsidered in this
chapter:the InternationalClassification of Functioning,Disability and
Health(ICF), defined by theWorld Health Organization (2001), andthe
CapabilityApproachdevelopedbyAmartyaSen(1995,1999).
-25-Therehavealready been considerableefforts to improveand standardise the
measurement of disability by referring to theICF (Loeb et al.,2008;Van
Leit, 2008). TheCapabilityApproach, shifts thefocus onto thedisabled
individualembedded inaspecific context, community and society,which
permanently interacts withhim/her. This innovativeapproach was tested for
the firsttimeinAfghanistan(Trani and Bakhshi, 2008), butdespite this
improvement, there is stilla need for furtherresearchtounderstand what
disabilityencompasses, andhow it influences theliving conditionsand
aspirationsofdisabledpeople,especiallythoseindevelopingcountries.Such
research impacts on thedesignand implementation of policiesintendedto
improvethecapabilityof peoplewithdisabilitiestoconducttheirownlives.
In this chapter, which is groundedinfieldexperienceinAfghanistan, the
various models of disabilitywill be reviewed in ordertoselect the
conceptualframeworkbestabletoadequately express themultidimensional
reality of disability.The chosen framework is based on thecapability
approach, and focusesonthe extensionofpeoples’ capability sets,aswellas
on the agency of those whosuffer from disabilities. Appropriate assessment
methodologiesaresuggestedwithinthisframework.
Ananalyticalframeworktodealwith disability
To ensure thatthe relevantdata on disabilityiscollected, an appropriate
conceptualframework is required. This frameworkmustprovide a
theoretical definitionofdisability asacomplex phenomenon with various
facets inagiven socio-cultural context,consistent with the objectives of the
assessment. It shapesthe waythe assessment is carriedout by definingthe
various types of impairment, the difficulties affecting function, the
characteristicsofthe socialenvironment, and theinteraction between people
with disabilities and theirfamilies, communitiesand society.Measurement
toolsnormally refer to this framework in order to collect the information
requiredfor theimplementationofrelevantpolicy measures,programmes
andprojects(AltmanandBarnartt,2000).
Approachesaddressing disability: The medical, social and
ICFmodels
Theconceptualframeworkhasimplicationsforthewaydisabilityprevalence
is estimated and thesub-populations of disabled peopledefined inagiven
context. Over the past four decades, threemajor approaches havebeen
developedtoaddressthisissueof measurement.
Thefirst approachcan be describedasthe ‘individualormedicalmodel’.It
is based on theviewthatdisabilityisadeviationfromaphysical norm.
-26-According to this concept, disability is viewed as aphysicalcondition
intrinsic to theindividual. Her/his quality of life and participationinsociety
is lowerthanitwould be fora‘normallyfunctioning’ person(Pfeiffer, 2001;
Amundson, 2000;Marks,1999). In this model, the measurement of
disabilityprevalenceisbased on thenumberofpersons affected byaseries
of different impairments, which areconsidered to reducethe functioning and
structures of the body.Individuals with disabilitiesare allocatedtoa few
distinct categorieswithclear boundaries such as the deaf, blind, paraplegic,
mentally ill, and so on. According to this model, disability is only
experienced byalimited number of persons, and thephenomenon is not
viewedaspartofthe generalhumanexperience.
This medical model hasconsequencesonthe waydata is collected as it
focuses solely on theindividual andonhis/her impairment. Lowrates of
prevalence areusuallyfound by disability surveysthat usethisapproach,
which only ask questions about these particular health conditions.They do
not take intoaccountfactors thatmay influence the disablingsituation,such
as theavailability of appropriate equipment and medicalservices,cultural
normsand beliefs, and thelevel of economic development. Yet, this
environment hasa majorimpact on each person'sspecific health condition,
andmore generally on thewell-being of any individual. Asaresult, the
questionsmay be perceived by the respondents as stigmatising,leading to a
reluctance to answer honestly and therefore to systematic under-reporting.
Themedical model generatesnegativeimplications by seeingdisabilityasa
deviancefromwhatissupposedtobenormalhealth(Amundson,2000).
Thesecondmodel is called the ‘socialmodel’.The socialmodel is basedon
adistinct paradigm, hasseveral versions anddoesnot put the centralfocus
on anygiven healthcondition (Pfeiffer, 2001); it rejectsthe idea of
impairment asadeparturefromaveragehuman functioning,defined as
"normal",but rather considers theperson with impairment as being disabled
due toaspecificsocialand economic environment. This view, whichhas
been putforward byanumberofacademics and organisations dealing with
disability, tends to examinethe barriersthatexist within thesocialcontext,
andwhich preventa disabled person from achievingthe same levelof
functioningasanon-disabledperson. From this perspective, it is thesociety
that needs to be redesigned in ordertotakeinto account theneeds of people
with disabilities (Olivier, 1996). Mainstreaming disability,within a
particularsocial context, can be achieved by redesigning society in a
progressive and sustainableway in ordertoinclude people with disabilities.
Advocates of this model consider that thephysicallimitationsofa person
only becomeadisability because society fails to accommodate their
differences. Inotherwords,itisthesocietythatisnotadequatelystructured.
-27-This model also hasimplications formeasuring theprevalence of disability.
It eliminates from the 'disabled' categoryindividuals whose impairment is
already adequately cateredfor, andwho havefullaccess to thesociety and
equal participation. Theinvestigation willtherefore have to combine
questionsaboutthe physicallimitations or differences of thedisabled
persons with questions identifying thesocial barrierstheyface. For instance,
in the case of Australiawhere short-sightednessisconsideredtobe
disability, thecurrentdisability rate of 19.3%would probably drop to less
than 10%ifweweretoallow for thegood level of inclusionofpeople
‘impaired’byshort-sightorothermildhealthcondition.
However, in both models, disability is related to theexistence of an
impairment understood asahealthcondition that differsfromthe health
statusperceived as beingthe benchmark of ‘normal’.The distinction
betweenthese twomodels lies in their different approaches to disability.Itis
relatedtoa lack of adaptation of the environment in thesocial model or to a
restriction of activity causedbyimpairment in themedicalmodel. However,
this average ‘normal’ health is probably an idealthatmostpeopledonot
actuallyexperience.
Forthisreason, anotherapproachproposes viewinghealth asacontinuum:
everyindividualmay havesomelimitation in some aspect of his/her
functioning. Seen in this way, disability is an integral part of thegeneral
human experience. It is on thebasis on sucha view, that theWorld Health
Organization (WHO) hasdefined the InternationalClassificationof
Functioning,Disability andHealth, more commonly known as ICF(WHO,
2001).ICFprovidesaspecifictoolthataddressesdisabilityinthisthirdway.
TheICF model wasformed by merging themedicaland socialmodels. It
viewsdisability asacombinationofvarious individual, institutionaland
societalfactors that define theenvironment within whichaperson with
impairment exists. Themodel covers variousareasofactivities and levels of
participationthatcorrespondtowhatthe body,the person him/herself, and
the person-in-society can do. This extendsthe dimensions andlevels of
disability: “In the ICF, theterm functioning refers to all the body functions,
activities and participation, whiledisability is similarlyanumbrellaterm for
impairments,activitylimitationsand participationrestrictions”(WHO,2001:
3). This definition encompassestwo majorconcepts: body functions and
structures, on theone hand, and activitiesand participation, on the other. It
therefore leads to theassessment of twofactors:firstly,environmental
factors,which includethe physical, social, legaland culturalenvironment
(and so includes the impact of attitudes), and secondly,personal factors,
which correspond to thepersonality and distinguishing attributes of the
individual.
-28-