List of Acronyms

AI	Amnesty International
ACBAR	Agency Coordinating Body for Afghan Relief
AIHRC	Afghan Independent Human Rights Commission
ANDS	Afghanistan National Development Strategy
ANSO	Afghanistan NGO Safety Office
AREU	Afghanistan Research and Evaluation Unit
ARV	Antiretroviral Treatment
BPHS	Basic Packages of Health Services
CAC	Children and Armed Conflict
CAAC	Children affected by Armed Conflict
CEDAW	UN Committee on the Elimination of Discrimination Against Women
CIVIC	Campaign for Innocent Victims in Conflict
CPA	Child Protection Advisor
CPAN	Child Protection Action Network
CTFMRM	Country Task Force on the Monitoring and Reporting Mechanism
DIAG	Disbandment of Illegal Armed Group
ERW	Explosive Remnants of War
FATA	Federally Administered Tribal Areas
FRU	Family Response Unit
GBV	Gender-Based Violence
GOA	Government of Afghanistan
HAP	Humanitarian Action Plan for Afghanistan
HRW	Human Rights Watch
ICG	International Crisis Group
ICRC	International Committee of the Red Cross
IDMC	Internal Displacement Monitoring Centre
IDPs	Internally Displaced Persons
IEC	Independent Election Commission
IED	Improvised Explosive Device
ILO	International Labour Organization
INGO	International Nongovernmental Organization
ISAF	International Security Assistance Force
MACCA	Mine Action Coordination Centre of Afghanistan
MoU	Memorandum of Understanding
MRE	Mine Risk Education
MRM	Monitoring and Reporting Mechanism
MSF	Médecins Sans Frontières
NATO	North Atlantic Treaty Organization
NDS	National Directorate for Security
NGO	Nongovernmental Organization
NLD	National League for Democracy
NSAG	Non-State Armed Groups
NWFP	North West Frontier Province
OCHA	UN Office for the Coordination of Humanitarian Affairs
OEF	Operation Enduring Freedom
OHCHR	Office of the High Commissioner for Human Rights
PRT	Provincial Reconstruction Teams
RI	Refugees International
SCR	UN Security Council Resolution
SCWG-CAC	UN Security Council Working Group on Children and Armed Conflict
SOP	Standard Operating Procedure
SRSG	Special Representative of the Secretary-General
SRSG-CAC	Special Representative on Children and Armed Conflict
UN	United Nations
UNAMA	UN Assistance Mission in Afghanistan
UNDP	UN Development Programme
UNDSS	UN Department of Safety and Security
UNHCR	UN High Commissioner for Refugees
UNICEF	UN Children’s Fund
UNIFEM	UN Development Fund for Women
UNODC	UN Office on Drugs and Crime
UNSC	UN Security Council
USDA	Union Solidarity and Development Association
USFOR-A	U.S. Forces Afghanistan
USDOS	U.S. Department of State
UXO	Unexploded Ordnance
WHO	World Health Organization

Indicators

INDICATORS	Afghanistan
Population	23.8 million people in 2005;[i] as of 2008, 46.5% were younger than 14[ii]
Gross National Income (GNI) per Capita	US$466 in 2008 (UN Statistics Division)
Refugees and Internally Displaced Persons (IDPs)	As of the end of December 2009, an estimated 297,000 IDPs in Afghanistan, including 161,000 children As of January 2010, approximately 1.6 million registered refugees in Pakistan, including about 1.18 million children, and approximately 1 million registered refugees in Iran, including 345,000 children[iii]
Infant Mortality	165/1,000 in 2008[iv]
HIV/AIDS	Afghanistan’s National AIDS Control Program registered 559 cases as of November 2009; UNAIDS and WHO put the number of reported cases much higher at 1,000 to 2,000.[v]
Education	Estimated 74% national net enrollment rate for boys and 46% for girls[vi]; only 11% of boys and 5% of girls enrolled in primary school continue on to grade 12.[vii]
Gender-Based Violence (GBV)	Rape is a “widespread phenomenon” that affects women, boys and girls. Acts of sexual violence are committed by armed groups or criminal gangs as well as family members, guardians or caretakers. As a result of the taboo surrounding the issue, there are few publicly reported cases and no comprehensive or official data available on rape and gender-based violence.[viii] Child marriage is also common, with nearly half of all marriages involving boys and girls under the age of 18.[ix]
Trafficking	Trafficking of children within the country and into Pakistan and Iran is a serious concern; some children are exploited by armed groups or criminal gangs to carry out illegal activities such as smuggling.[x]
Landmines and Explosive Remnants of War (ERW)	As of December 2009, there were 630 km² of mine-affected land; 734 recorded instances of children injured or killed by landmines and other explosives in 2008 and 2009; 626 were males and 105 females.[xi]
Small Arms	Estimates for numbers of small arms range from 1.5 million to 10 million;[xii] no statistical data is available on children injured or killed by small arms.
Child Soldiers	Afghan Security Forces and armed opposition groups have recruited an unknown number of children throughout the country. Most of the reported cases of child recruitment in national security forces were due to poor birth registration systems, weak age verification, and the rising demand for police and soldiers. Armed groups have recruited children to be used as fighters, camp guards or suicide bombers, particularly along the Afghanistan-Pakistan border.[xiii]
Abductions and Disappearances	Most cases of abduction and disappearance are related to trafficking by criminal networks; there is some confirmed information of children abducted or transferred to Pakistan where they have received military training. [xiv]
Attacks on Humanitarian and Human Rights Workers	Afghanistan represents one of the most violent environments for aid workers, especially national staff, worldwide.[xv] A reported 19 NGO staff and at least 11 UN staff were killed in 2009.[xvi]

Please note: Due to extremely limited access to certain areas of Afghanistan, especially where active fighting is taking place, there is a severe gap in reliable nationwide data. The general lack of socio-economic and demographic data is further compounded by weak institutional and technical capacities to produce information.

International Standards[xvii]

International Treaties Signed (S)/ Ratified (R)/ Acceded (A) (Year)	International Treaties Not Signed
Convention on the Rights of the Child (R, 1994) Optional Protocol to the Convention on the Rights of the Child on the involvement of children in armed conflict (A, 2003) Optional Protocol to the Convention on the Rights of the Child on the sale of children, child prostitution and child pornography (A, 2002) The Geneva Conventions I, II, III and IV of 1949 (R, 1956) Protocol I of the Geneva Conventions, Relating to the Protection of Victims of International Conflicts (A, 2009) Protocol II of the Geneva Conventions, relating to the Protection of Victims of Non-International Armed Conflicts (A, 2009). Convention on the Prevention and Punishment of the Crime of Genocide (A, 1956) Convention on the Elimination of All Forms of Discrimination against Women (R, 2003) International Covenant on Economic, Social and Cultural Rights (A, 1983) Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (R, 1987) International Covenant on Civil and Political Rights (A, 1983) Convention Relating to the Status of Refugees (A, 2005) Protocol Relating to the Status of Refugees (A, 2005) Convention on the Prohibition of the Use, Stockpiling, Production and Transfer of Anti-Personnel Mines and on their Destruction (A 2002) Convention on Cluster Munitions (S, 2008) Rome Statute of the International Criminal Court (A, 2003)	Protocol III of the Geneva Conventions, relating to the Adoption of an Additional Distinctive Emblem ILO Convention 182 on the Worst Forms of Child Labor Protocol against the Illicit Manufacturing of and Trafficking in Firearms, Their Parts and Components and Ammunition, supplementing the United Nations Convention against Transnational Organized Crime Optional Protocol to the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment International Labour Organization (ILO) Convention 29 on Forced Labor ILO Convention 87 on Freedom of Association and Right to Organize Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, supplementing the United Nations Convention against Transnational Organized Crime
UN Security Council Actions Relating to Children and Armed Conflict in Afghanistan
UN Security Council Resolutions on Afghanistan	The UN Security Council passed 27 resolutions on Afghanistan between 2001 and March 1, 2010 of which six specifically referred to children. These are 1419 (2002), 1833 (2008), 1806 (2008), 1868 (2009), 1890 (2009)
UN Security Council Resolutions on Children and Armed Conflict (CAC)	1882 (August 2009); 1612 (July 2005), 1539 (April 2004), 1460 (January 2003), 1379 (November 2001), 1314 (August 2000), 1261 (August 1999)
UN Security Council Working Group Conclusions on CAC in Afghanistan	S/AC.51/2009/1 (July 2009)

Executive Summary

Children bear the brunt of the ongoing armed conflict in Afghanistan. In 2009, at least 346 children were killed in aerial strikes and search-and-raid operations by international special forces as well as by assassinations and suicide bombings by anti-government elements. In addition, landmines, explosive remnants of war and other explosives have killed or severely injured hundreds of children, particularly boys who play outside, tend animals, or collect food, water or wood. Armed groups have also damaged and destroyed schools, targeting students (especially girls), teachers and others who are seen as supportive of Afghanistan’s education system.

Thousands of Afghan families have been forced to flee their homes due to armed conflict and economic hardships. More than half of the country’s internally displaced – approximately 161,000 people – are children; an additional 1.5 million children are refugees in Pakistan and Iran.

Despite some progress in expanding basic health services to a wide population, infant and maternal mortality is alarmingly high. Afghanistan remains the worst place in the world for a newborn child, according to child protection agencies.

Current strategies of the Afghan government and its international supporters – though aimed at protecting civilians - have largely neglected the specific needs of children affected by armed conflict. This reluctance to commit to the protection of children is reflected in policy and funding decisions. The London Conference[xviii] communiqué of January 2010 which served as the “roadmap” to address security, governance and economic concerns in Afghanistan over the next five years, did not refer to children’s needs despite the severe impact that its decisions, such as planned offers of amnesty to Taliban soldiers, will have on their security. Only one child protection advisor has been stationed at the United Nations Assistance Mission in Afghanistan (UNAMA), despite repeated calls by the UN Security Council to allocate more resources to bolster UNAMA’s child protection capacity.

Key decision makers have also neglected the advice of child protection agencies. During the 2009 presidential election for instance, Afghanistan’s Independent Election Commission ignored repeated warnings of UN agencies, nongovernmental organizations and some governmental agencies not to use health facilities and school buildings as polling stations. This disregard ultimately resulted in multiple attacks on schools and hospitals.

The protection of children’s rights should not be limited to “safe“ areas, or stop at Afghanistan’s borders. In 2009, approximately 43 percent of the country was cut off from humanitarian assistance, particularly in the conflict-affected south, southeast and parts of the west. Limited access resulted in thousands of children missing out on urgently required services offered via national health and education campaigns.

The lack of access due to insecurity has also severely hampered the work of the UN-led Monitoring and Reporting Mechanism (MRM) in Afghanistan which was set up to address the six grave violations against Children and Armed Conflict (CAC) in accordance with UN Security Council Resolutions 1612 and 1882, which include killing or maiming of children, abductions, recruitment or use of child soldiers, attacks against schools and hospitals, rape or other grave sexual violence against children, and the denial of humanitarian access to children.

In addition, there is insufficient information available on the extent of violations that are cross-border in nature, including child recruitment or trafficking and the exploitation of children to smuggle drugs or illegal goods. In order to hold perpetrators of these violations accountable and to provide more systematic responses to children, protection actors should make a concerted effort to engage with all parties to conflict, concerned governments and local communities.

The protection of war-affected children merits special attention and must be made a strategic priority as the Afghan government, with support from the international community, lays out plans to bring lasting peace and stability to the country.

The following are key recommendations from Watchlist’s report:

1. Ensure that the protection of children from conflict-related violence becomes a top priority in policy and funding decisions on Afghanistan

The Government of Afghanistan (GoA) and its international supporters should set specific benchmarks on child protection against which progress can be measured. This could include developing an “Agenda for Children Affected by Armed Conflict” along the lines of the Afghanistan Compact, which sets out specific goals for the next five years and establishes a coordination mechanism to ensure implementation and monitoring of this plan.

The UN Security Council Working Group on Children and Armed Conflict (SCWG-CAC) should ensure that core concerns relating to children affected by armed conflict are reflected in the terms of reference of the upcoming Security Council field visit planned for mid-2010. This includes following up on the commitments made by the GoA and international military forces to the Special Representative on Children and Armed Conflict (SRSG-CAC) during her recent visit.

The UN Secretary-General should ensure the immediate deployment of additional child protection advisers throughout the country in an effort to strengthen the child protection component of UNAMA, as recommended by the UN Security Council.

The SCWG-CAC and relevant donors should request an informational briefing with child protection actors and civil society representatives in order to better understand the role of community-based mechanisms in Afghanistan to prevent attacks against schools, and how to better support these initiatives.

The SCWG-CAC should request an independent assessment of the impact of projects that are funded or operated by Provincial Reconstruction Teams (PRTs) on the security and well-being of children in Afghanistan. The assessment should explore alternative ways to assist children living in areas that are not accessible by UN agencies or NGOs.

Donors should follow the Good Humanitarian Donorship Principles so that funding is allocated in proportion to the needs of the most vulnerable populations, including children, and not to further political goals.

2. Take effective measures to prevent violations against children in armed conflict and end impunity for perpetrators

Non-state armed groups should immediately halt all violations perpetrated against the security and rights of Afghan children.

· Halt all suicide and improvised explosive device (IED) attacks on civilian targets.

· Refrain from attacks and threats of attacks against schools, teachers, education staff, students and parents at the local and national level.

· Stop operating out of schools and other civilian facilities, and end the use of humans as shields.

The GoA and international military forces should ensure that systems for investigating alleged violations against civilians are transparent, timely and independently monitored. The results of these investigations should be publicly shared and include data disaggregated by age on combatant and civilian casualties.

All parties to the conflict should fully cooperate with the Country Task Force on the Monitoring and Reporting Mechanism (CTFMRM) to prepare and implement action plans to end the recruitment and use of child soldiers, rape and other grave acts of sexual violence and killing and maiming of children in line with UN Security Council Resolutions 1540, 1612 and 1882. Commanders should equally work towards halting all violations against children.

The GoA should repeal the reconciliation and general amnesty law and hold all perpetrators of violations against civilians, including children, accountable in accordance with national and international law.

The GoA should under all circumstances avoid the use of education and health facilities in the upcoming elections and for other political purposes.

The GoA should adapt the Elimination of Violence against Women Act to include a definition of rape that complies with international standards and brings perpetrators to justice in accordance with UN Security Council Resolutions 1820 and 1888.

The GoA should criminalize child recruitment and the use of child soldiers, and actively prosecute those who exploit children as soldiers. The GoA should work closely with UN agencies to refine age determination procedures and grant full access to all training and detention facilities, including those of the National Directorate of Security (NDS), for monitoring purposes.

3. Strengthen monitoring, reporting and response on all violations committed against children, including those committed in Afghanistan’s conflict zones and across its borders

The UN Country Team in Afghanistan, under the dedicated leadership of the Special Representative of the Secretary-General for Afghanistan (SRSG), should commit staff and resources to prioritize child protection within their respective agencies, including the full implementation of Security Council Resolutions 1612 and 1882 throughout the country.

The Country Task Force on the Monitoring and Reporting Mechanism (CTFMRM) should work with all parties to the conflict to capture critical information that could prevent violations against children and more effectively assist survivors, including monitoring early warning signs as well as the circumstances surrounding the attacks and their impact. Quarterly reports from their evaluations should be used to track trends and inform evidence-based advocacy.

Donors should support strengthening the capacity of Child Protection Action Networks (CPAN), which consist of governmental and nongovernmental organizations in Afghanistan, to respond more effectively to violations against children.

The SCWG-CAC should request the UN High Commissioner for Refugees (UNHCR) and/or the Representative of the Secretary-General on the human rights of internally displaced persons (IDPs) to lead a study to determine vulnerabilities and risks for displaced and refugee children from Afghanistan. The study’s findings would be the first step towards enacting a comprehensive action plan to find durable solutions for displaced children from Afghanistan.

The Government of Pakistan should invite the Special Representative on Children and Armed Conflict (SRSG-CAC) to conduct a mission in Pakistan to identify potential ways to improve coordination in ending “cross-border violations” that impact children affected by armed conflict such as the drug trade, trafficking and small arms trade.

The Secretary-General should request the UN Country Teams in Afghanistan and Pakistan, under the leadership of the SRSG-CAC, to establish a UN regional strategy to contribute actively to the protection of children affected by cross-border violations.

The UN Country Team in Pakistan should establish a Working Group on Children affected by Armed Conflict to more effectively address the concerns of Afghan refugee children, and cooperate with the CTFMRM and other child protection agencies in Afghanistan to address issues of common concern, including cross-border recruitment of child soldiers and trafficking.

The Afghan Independent Human Rights Commission (AIHRC) should coordinate closely with the independent Human Rights Commission of Pakistan (HRCP) to conduct joint monitoring and reporting along their common border areas.

Context

Major Armed Conflicts

In 1979 at the height of the Cold War, Soviet forces invaded Afghanistan to fight a proxy war. After the withdrawal of the Soviet forces in 1989, factional fighting among various armed groups continued until 1996, when the capital, Kabul, was taken by the Taliban, a fundamentalist Islamic group. By 2001, the Taliban controlled 90 percent of the country and imposed a new regime based on the strictest version of Sharia, or Islamic law, denying basic rights to women and children, including access to education, and subjecting them to cruel punishments.

Following the terrorist attacks of September 11, 2001, a U.S.-led coalition intervened in Afghanistan and with the Northern Alliance, an Afghan opposition armed group, soon removed the Taliban, which had harbored Al Qaeda, a terrorist network, from power. This intervention initiated a process of political, security and social reforms aimed at establishing a democratically elected Afghan government and rebuilding peace in the society after nearly three decades of war.

International Efforts for Peace and Security

The Bonn Agreement of December 2001 laid the foundation for Afghanistan’s future government, which led to the establishment of a transitional authority in 2001, the adoption of a new constitution in 2004, and presidential and parliamentary elections in 2005. In order to support the Afghan Security Forces to maintain security, the UN Security Council authorized member states to form the International Security Assistance Force (ISAF), which operates under Chapter VII of the UN Charter. Since 2003, ISAF has been led by NATO and as of March 5, 2010, is comprised of approximately 89,480 troops from 44 different countries. More troops are anticipated to arrive in the first half of 2010, bringing the total number of ISAF troops to about 100,000. In addition to ISAF, at least 12,000 mostly U.S. forces are deployed along the Afghanistan-Pakistan border under the mandate of Operation Enduring Freedom (OEF), a joint U.S., UK and Afghan operation. All international military forces operating in Afghanistan – whether under ISAF or OEF – are placed under the operational control of the U.S. Forces Afghanistan (USFOR-A). Linked to these military efforts, ISAF member states have also deployed 26 Provincial Reconstruction Teams (PRTs) in Afghanistan, which include military and civilian components to facilitate development, reconstruction and governance efforts in various parts of Afghanistan.

Since 2002, the UN Assistance Mission in Afghanistan (UNAMA) has been mandated by the Security Council to support the government to build peace through the promotion of human rights, reconstruction and development. UNAMA works as an “integrated” mission, meaning that it aims to address development and humanitarian issues, as well as political affairs. UNAMA has also assisted the government in implementing key frameworks for cooperation with the United Nations and the international community, including the Afghanistan Compact of 2006 and the Afghanistan National Development Strategy (ANDS). With a staff of 1,500 military and civilian employees, most of which are national staff, UNAMA is one of the smaller UN operations worldwide. In the beginning of 2009, UNAMA added a child protection advisor, who works closely with the mission’s various sections, particularly the Human Rights Unit.

The Return to Violence

The new government and international support for the peace-building process sparked hope among many Afghans, instigating the voluntary repatriation of millions of refugees from Iran and Pakistan to Afghanistan immediately after the defeat of the Taliban. However, the security situation deteriorated significantly after 2004.[xix] From 2004 to 2010, the areas experiencing ongoing attacks have extended from the south and southeast to the areas that were earlier deemed secure, including the northern and eastern regions. Violence against civilians has not only spread throughout the country but has also intensified in the last few years, as demonstrated by the rise in civilian casualties from about 1,500 civilians killed in 2007, to over 2,100 killed in 2008 and more than 2,400 civilians killed in 2009, according to UNAMA’s annual reports on the protection of civilians in armed conflict.[xx]

Many Taliban forces and other armed groups never left their strongholds in Afghanistan. Others regrouped into areas along the Afghanistan-Pakistan border and gained strength, largely operating from the semi-autonomous tribal-dominated area of western Pakistan, including the Federally Administered Tribal Areas (FATA), Baluchistan and the North West Frontier Province (NWFP). Given the Taliban’s frequent cross-border attacks, Afghan authorities and the international community have increased pressure on the Pakistani government to take stronger action against the insurgents in northwest Pakistan, including through military operations.[xxi]

These armed opposition groups have used insurgency tactics to undermine the government and push out international forces. They have also specifically targeted those seen as supporting government efforts such as teachers, health professionals and students. Common tactics include attacks on schools and hospitals, the use of indiscriminate improvised explosive devices (IEDs) and employing suicide attacks in highly populated areas. The authority of the central government is further limited by the existence of shadow governments established by the Taliban in many provinces, warlords claiming ownership of certain areas and the expansion of criminal networks. In some areas, local militias – allegedly with clandestine support from the Afghan and American governments– also conduct military operations against insurgents which risk undermining the rule of law due to their lack of formal training and accountability structures. [xxii]

Intensified aerial attacks by international military forces have also killed civilians. In several instances, the Afghan government and international and national human rights organizations have questioned whether aerial bombardments were proportional and necessary.[xxiii] In response, the commander of U.S. and NATO forces in Afghanistan, General Stanley McChrystal, revised the strategy of international military operations and issued tactical directives to troops under his command with the specific goal of avoiding civilian casualties and increasing transparency and accountability of military operations.[xxiv] This strategy has resulted in a reduction of recorded civilian casualties by international forces in 2009 and in the first few months of 2010.[xxv] Yet, the continuing deterioration of the security situation and the lack of basic health and social services in many areas have made it difficult for international military forces to gain the Afghan people’s support for counterinsurgency and reconstruction efforts.

Rebuilding the Country

After decades of conflict and corrupt governance, Afghanistan currently depends almost entirely on international support for maintaining safety, rebuilding its economic, political and legal structures and paying for such basic services as policing, health care and education. Despite progress achieved in the health and education sector in recent years, Afghanistan has been consistently ranked near the bottom of the Human Development Index with the majority of Afghans living in extreme poverty.[xxvi] In contrast, economic activity in the black market – often coupled with criminal activity – has been growing, partly due to the government’s inability to enforce the rule of law, particularly in the border areas. For instance, a significant share of the estimated US$4 billion net profit of drug trafficking goes to armed groups through direct involvement, bribery and taxation, according to the UN Office for Drugs and Crime (UNODC).[xxvii] Extortion and misbehavior as well as impunity by the police and senior government officials have left local people in some parts of the country resentful towards their own government.[xxviii]

Moreover, institutionalized corruption prevents the government from establishing the rule of law and instilling trust among citizens in their state institutions. Local powerbrokers have been accused of bribing government officials and law enforcement agencies, or using patronage linkages to evade prosecution, according to the 2009 report of the UN Office of the High Commissioner for Human Rights on the situation of human rights in Afghanistan.[xxix] In the 2009 elections, Hamid Karzai was affirmed as President of Afghanistan after the first round was declared fraudulent by a UN-backed commission and the subsequent second round withdrawal of Karzai’s main rival who cited a lack of transparency in the proceedings. Such reports of corruption by high-level state officials risk undermining not only the credibility of the Afghan government but also of the UN and the wider international community backing it.

At the London Conference in January 2010, the Afghan leadership and its international partners agreed to a “roadmap” setting out a five-year military and civilian strategy to address the security, governance and economic concerns of the country. Conference participants agreed that international military forces would gradually transfer responsibility for Afghan security to the national government and by the end of 2011, the Afghan army would expand troop levels from 97,000 to 171,600, and the national police forces from 94,000 to 134,000. [xxx] Further, donor nations promised to support the government’s plans for an Afghan-led National Peace and Reintegration Programme to lure low- and mid-level insurgents away from violence by offering economic incentives. They also welcomed the government’s plans to hold a loya jirga that would bring government officials, tribal leaders and some moderate Taliban leaders together to discuss steps towards resolving the current conflict. The London Conference participants announced US$1.6 billion in debt relief, and appealed to donors for US$870 million in humanitarian aid. The specifics of the five-year plan are expected to be determined at a conference in Kabul in mid-2010.

Humanitarian Access

Deterioration of Humanitarian Access

There were approximately 1,300 national NGOs, 300 international NGOs and 16 UN organizations engaged in humanitarian and development assistance in Afghanistan as of January 2010, according to the Agency Coordinating Body for Afghan Relief (ACBAR). Intense fighting, landmines and targeted attacks or threats against staff members often prevent these aid organizations from assisting children and their communities in the areas most affected by the conflict.[xxxi] Afghanistan represents one of the most violent environments for aid workers worldwide, according to the Humanitarian Policy Group, an independent think tank.[xxxii] In 2009, approximately 43 percent of the country was considered “high-risk” by the UN Department of Safety and Security (UNDSS) and was cut off from humanitarian assistance, particularly the conflict-affected south, southeast and parts of the west.[xxxiii] As a result of limited access, national health and education campaigns miss thousands of children in need, and the campaign’s effectiveness is undermined. For example, 130,000 children did not benefit from the UN-led vaccination campaign against polio in 2009 (see below: Health).

Despite large-scale internal displacement, ongoing conflict and natural disasters, most donor states have largely neglected growing humanitarian needs.[xxxiv] The 2010 UN Humanitarian Action Plan for Afghanistan (HAP), the main mechanism for coordinating humanitarian response, requests a total of US$870 million from international donors, a 30 percent increase in requested funding compared to the 2009 HAP. However, the desire of troop-contributing nations to reinforce development in the provinces where they are active means that aid is not necessarily channeled to the areas with the highest needs for humanitarian or development aid.

In addition to depriving children of their basic rights, the lack of access to some of the areas most affected by the conflict makes it difficult for aid organizations to define the needs of children and other vulnerable groups.For example, the campaign of the Afghan government, with support from the United Nations Children’s Fund (UNICEF), to register all newborn children by 2009 had to leave out all children living in remote or insecure areas.[xxxv] With only 1 percent of Afghans holding a birth certificate as of 2008, information from this registration exercise would have allowed the government to obtain accurate and comprehensive numbers of children to inform its planning for building schools and health facilities, as well as vaccination initiatives. Moreover, the possession of a birth certificate endows children with the right to benefit from the special legal protection framework, including the specific laws on juvenile justice, and on the recruitment and use of children by armed groups or forces.

Violating Humanitarian Principles

The military involvement in development activities has endangered Afghan civilians and aid workers as these projects often become the targets of armed opposition groups, leading to the blurring of lines between the military and humanitarian mission.[xxxvi] The UN Office for the Coordination of Humanitarian Assistance (OCHA) re-established its presence in Afghanistan in October 2008 to advocate for more principled humanitarian action and to strengthen independent humanitarian coordination by the UN.[xxxvii] Despite this positive development, on a structural level OCHA remains connected to UNAMA – and thereby its political mandate – as it is led by the Humanitarian Coordinator who also functions as Deputy Special Representative of the Secretary-General and Resident Coordinator.

The deterioration of aid delivery in Afghanistan is to a significant extent due to the nature of PRTs and the way they have been implemented. PRTs, which usually consist of a military and a substantially smaller civilian contingent, carry out relief work but are directly managed by ISAF member states. PRTs tend to operate in some of the most insecure areas that are off limits to the UN, the Afghan government and many NGOs. However, their underlying political agenda – to gain support for the government and the international presence – undercuts humanitarian principles of neutrality and impartiality and makes it even harder for aid agencies to retain their space in other areas, according to a study by Tufts University’s Feinstein Institute.[xxxviii] Moreover, NGOs have criticized PRTs for their lack of technical expertise and the absence of a coherent nationwide strategy among the various PRTs, which are currently only accountable to their home governments.[xxxix] Instances where PRT-led projects have proven unsustainable tend to negatively affect how communities view and accept international aid workers.

In order to clarify the specific roles and responsibilities of civil and military actors, UN agencies, ISAF and NGOs agreed to non-binding Civil-Military Guidelines in May 2008.[xl] The Guidelines affirm that in principle, government and humanitarian actors are responsible for providing humanitarian assistance. In contrast, the role of the military is only to assist civilian actors to provide basic infrastructure and urgent reconstruction assistance in exceptional cases and as a “provider of last resort.” This usually refers to cases where the protection of the person’s physical security requires a military presence. In addition, the Guidelines call for the clearly visible distinction between humanitarian and other actors. However, some military actors have violated the Guidelines and international humanitarian principles by engaging in relief activities for force protection purposes.[xli] Humanitarian actors have also noted a lack of awareness of the Guidelines among PRT staff or lack of commitment among troop-contributing countries to implement them due to their voluntary nature. In addition, the impact of the Guidelines is limited as the US-led OEF has not agreed to its provisions and the Taliban and other armed opposition groups remain largely unaware of it.[xlii]

In the recent presidential elections, Afghanistan’s Independent Election Commission (IEC) used health facilities and school buildings as polling stations, citing the lack of alternative public buildings for this use. UNICEF, the World Health Organization (WHO), OCHA, the UN Educational, Scientific and Cultural Organization (UNESCO), NGOs and several government officials repeatedly warned of the severe risks to the security of students and patients given the Taliban’s opposition to the elections.[xliii] In August 2009, the month of the elections, there were 249 reported incidents against education compared to 48 reported incidents in the month of July, according to the UN-led Country Task force on the Monitoring and Reporting Mechanism (CTFMRM). In many of these cases, insurgents had attacked polling stations located in schools.

Recommendations on Humanitarian Access

UN agencies, ISAF and NGOs should integrate child protection best practices and relevant provisions of Security Council Resolutions 1612 and 1882 into the Civil-Military Guidelines, including prohibitions against the use of schools and students for political purposes. Adherence to the Guidelines should be reported to the Expert Committee on Protection of Civilians to inform its recommendations regarding UNAMA’s mandate renewal.

International military forces should ensure that their standard operating procedures (SOPs) are in line with the Civil-Military Guidelines. This includes providing regular trainings on the Guidelines for all staff, including civilians and PRTs and highlighting the relevant provisions related to the protection of children.

The GoA should under all circumstances avoid the use of education and health facilities in the upcoming elections and for other political purposes.

Humanitarian organizations should involve local community members in the planning, execution and evaluation of development assistance projects to increase their applicability and long-term impact.

Killing and Maiming

Military and Other Attacks

The number of civilians killed and injured since 2006 as a result of the armed conflict has risen at an unprecedented rate. Nearly 6,000 civilians were injured or killed due to conflict-related violence in 2009, and of this number 2,412 were killed, according to UNAMA’s annual report, Protection of Civilians in Armed Conflict in Afghanistan, 2009.[xliv] This marks a 14 percent increase in civilian deaths as compared to the same time period the previous year. Most of the incidents were recorded in the south, southeast and eastern regions where aid organizations have limited access and hostilities have escalated. In 2009, 346 children were reportedly killed due to conflict-related violence, including 131 through air strikes and 22 in night raids by Special Forces, and 128 were killed through assassinations, suicide bombings and other attacks by armed opposition groups, according to UNAMA.[xlv] This number does not include incidences where children were killed by landmines and explosive remnants of war (ERW), and might only be a fraction of the actual cases as human rights monitors have limited access to conflict zones due to insecurity. The Afghan Independent Human Rights Commission (AIHRC) reported 520 children killed by warring parties between March 2009 and March 2010, which also includes mine-related victims. The Afghanistan Rights Monitor (ARM), a local human rights group, reported at least 1,050 children killed by suicide attacks, air strikes, improvised explosive devices (IEDs), ERWs and in cross-fire between warring parties in 2009.[xlvi]

While the Taliban’s Code of Conduct instructs “every member of the Mujahideen [to] do their best to avoid civilian deaths, civilian injuries and damage to civilian property,” armed opposition groups have at times directed their violence at civilians to intimidate them and undermine the government, staging suicide bombings in highly populated areas, detonating IEDs on busy civilian roads, and attacking schools and hospitals (see below: Education and Health). Children have also been targeted by these armed groups and executed on allegations of spying for government or international military forces, according to UN sources. There are also reports of armed groups deliberately using children as human shields.[xlvii]

Most of the civilian deaths attributed to pro-government forces were as a result of airstrikes and, to a lesser extent, night raids often involving excessive use of force. For example, in May 2009, the U.S. claimed that it responded to calls by Afghan Armed Forces for protection against insurgent attack by using aerial bombardments, which killed at least 65 children and 21 women in a village in the Bala Bulok district of Farah Province, southwestern Afghanistan, according to AIHRC. Independent human rights organizations have struggled to verify such claims due to the lack of transparency in investigations conducted by international military forces.[xlviii] In many of these cases, the use of unreliable sources or faulty intelligence have contributed to increased civilian casualties.[xlix]

One of the most problematic aspects for child protection actors is that contrary to the Convention on the Rights of the Child’s definition, ISAF’s Civilian Casualties Tracking Cell defines a child as a person under the age of 15. This makes it extremely difficult to accurately assess the impact of military attacks on children and may lead to underestimates of the number of children associated with armed groups.

Children have also been caught in the cross-fire as fighting between the Afghan forces and international military forces against armed opposition groups continues. Similarly, landmines, ERW and other explosives placed by armed forces and other groups have killed hundreds of children and inflicted permanent injuries on others throughout the conflict (see below: Landmines and ERW).

Assistance to Survivors and Impunity for Perpetrators

Following an attack, children and their families usually do not even receive basic information as to who has committed the crime, the circumstances of the incident or the status and follow-up of investigations, including potential prosecutions.[l] To date, there has never been an indictment or conviction of Taliban combatants for crimes against humanity or war crimes, which can be punished under international and domestic criminal law. Moreover, in February 2010, the Afghan government put into force the reconciliation and general amnesty law which gives immunity to prosecution for those engaged in the current hostilities if they agree to engage with the government on reconciliation. Human Rights Watch (HRW), the Transitional Justice Coordination Group, which consists of 24 Afghan civil society organizations and other human rights organizations have raised serious concerns regarding the amnesty law, arguing that it would ultimately undermine the reconciliation and peace process and violate international law.[li]

The responses of international military forces to attacks involving the injury or death of civilians has varied depending on the troops involved. However, the lack of public acknowledgement, prosecution and compensation have increasingly caused Afghan civilians to lose faith in international troops, according to AIHRC.[lii] In August 2009, General Stanley McChrystal, the commander of NATO ISAF and U.S. Forces, put the protection of civilians from attacks, the reduction of civilian casualties and transparency and accountability for military operations at the center of his counter-insurgency strategy.[liii] As part of this strategy, General McChrystal issued a series of Tactical Directives to ISAF and U.S. Forces in Afghanistan that provide specific instructions to troops regarding “force protection,” air strikes and night-time raids.[liv] ISAF’s Civilian Casualties Tracking Cells and a parallel unit within USFOR-A, the command and control headquarters for U.S. forces operating in Afghanistan, were established to ensure a more systematic monitoring and response to reported incidents, including investigations and compensation.

As a result of these initiatives, fewer civilians were reportedly killed in airstrikes in 2009 than in 2008, according to UNAMA’s figures. The focus on civilians is also reflected in some of the drastic responses that some troops have taken in instances where civilians have become the victims of military operations: The order of German NATO forces to carry out an air strike in Kunduz on September 3, 2009, which appeared to contravene McChrystal’s directives and ISAF standard operating procedures, led to the resignation of three German senior officials. A NATO investigation confirmed that the military had withheld information that civilians had been killed in the incident.[lv]

However, there is still no transparent, comprehensive and independently monitored system to investigate violations committed by military forces and to hold perpetrators accountable or a uniform strategy for compensating civilians. Compensation also largely depends on the troops perpetrating the attack and is provided on a case-by-case basis, according to the Campaign for Innocent Victims in Conflict (CIVIC).[lvi] While most troops offer an ex gratia payment to civilians suffering losses in combat operations, survivors face serious obstacles in obtaining this assistance in a timely manner due to the difficulty in identifying the military unit responsible, the lengthy bureaucratic process involved and the lack of access to offices receiving complaints. [lvii]

A number of NGOs have thus called for a more pro-active and systematic approach in contacting victims and their families to offer official apologies, inform them about the circumstances of the incident and to explain to them how they can raise complaints and have them heard by ISAF. They also urged all troop-contributing countries to develop a systematic, transparent way of compensating families and victims that is standardized by all troop-contributing countries. [lviii]

Children Living with Disabilities

More than 200,000 children in Afghanistan live with permanent injuries and disabilities suffered during hostilities or as a result of inadequate medical support, according to the most recent survey by Handicap International in 2005. The government pays a monthly pension of US$6 to US$10 to persons with disabilities, which barely covers the cost of medical treatment, according to Handicap International.[lix] School facilities and teachers are not equipped to address the special needs of students with disabilities, which further casts the children into disadvantage and isolation, according to officials at the Ministry of Education.[lx] Only 22.4 percent of the 196,000 children with disabilities in Afghanistan who would have qualified for school were able to attend school, according to the International Organization of Persons with Disabilities.[lxi]

Afghanistan has not signed the UN Convention on the Rights of Persons with Disabilities, which asks signatory states to ensure that “children with disabilities are not excluded from free and compulsory primary education, or from secondary education.” National legislation related to persons with disabilities is currently in the process of being approved. In order to facilitate integration of children with disabilities, the Ministry of Education has introduced awareness-raising components in the school curriculum and is working on strategies to provide specialized and inclusive education.[lxii]

Recommendations on Killing and Maiming

All parties to the conflict must take all possible measures to avoid civilian casualties. All alleged perpetrators should be held accountable in accordance with national and international law.

The GoA and international military forces should ensure that their investigations into alleged violations against civilians are transparent, timely and independently monitored. The results of these investigations should be publicly shared and include data disaggregated by age on combatant and civilian casualties.

The GoA should repeal the reconciliation and general amnesty law and hold perpetrators of violations against civilians, including children, accountable in accordance with national and international law.

International military forces, in coordination with the related national mechanism (Presidential Fund and the Ministry of Labor, Social Affairs, Martyrs & Disabled compensation mechanism), should devise a uniform strategy for compensating civilian survivors of attacks and ensure that these compensation systems are made easily accessible to victims, including children.

The GoA should immediately sign and implement the UN Convention on the Rights of Persons with Disabilities and, with international support, more effectively assist children with disabilities.

Refugees and IDPs

Internally Displaced Persons

Thousands of Afghan children and their families have been forced to flee their homes due to armed conflict and economic hardship. In addition, more and more Afghan refugees are returning from other countries only to fall again into displacement in their own country due to insecurity in their places of origin or lack of access to their previously owned land. Large and mounting numbers of the internally displaced remain “invisible” to the government and international organizations due to ongoing hostilities and serious access constraints.

As of the end of 2009, an estimated 297,000 internally displaced persons (IDPs) were living in makeshift camps, informal settlements, or being hosted by Afghan families to which they have close ties, according to the UN High Commissioner for Refugees (UNHCR), which co-chairs the National IDP Task Force together with the Afghan Ministry of Refugees and Repatriation Affairs. More than half of these IDPs – approximately 161,000 – are children, according to UNHCR estimates. Despite their large number and special needs, humanitarian agencies on the ground confirmed that there was a dearth of comprehensive, disaggregated data on their situation to inform policy and programmatic responses.

Assistance to IDPs – whether residing in camps, settlements or outside the camps, including in urban areas of major Afghan cities – remains minimal, uncoordinated and partially ad-hoc. Health workers frequently describe children suffering from preventable diseases like measles, dysentery and diarrhea as a result of the lack of vaccinations, unhygienic conditions in IDP settlements and the lack of access to safe drinking water.[lxiii] Many of these children are deprived of access to educational opportunities in the settlements as one-third of all sites lack education facilities and virtually none offer access to higher education.[lxiv] Displaced parents residing in Kabul’s makeshift camps have reportedly even sold their children to criminal and trafficking circles to survive or provide for their other children.[lxv]

Moreover, the state of displacement often deprives children of protective community or family structures and exposes them to a greater risk of recruitment into armed forces or groups. While more evidence is needed, available data seems to indicate a correlation between child recruitment and high levels of displacement, according to the 2008 Secretary-General report on CAC in Afghanistan (see below: Child Soldiers). In fact, the threat of child recruitment has caused some families to flee their homes, according to the same report.

In particular, finding durable solutions for children at risk, including unaccompanied and orphaned children, remains a challenge, according to UNHCR. While the Government of Afghanistan’s 2006 National Strategy for Children at Risk focused on developing community and family based support for vulnerable children and reducing the emphasis on institutional care, the orphanages run by the government and the Afghan Red Crescent Society provide mostly temporary shelter and do not always admit boys of 15 years and older.[lxvi] Child protection agencies have also warned of the poor living conditions in some orphanages. For example, a survey conducted by AIHRC with 43 children in Alahuddin Orphanage in Kabul found most children to be dissatisfied with the facilities, citing poor food quality, lack of sanitation facilities and physical and verbal violence.

Refugees

In the mid-1990s, at the peak of the displacement crisis, an estimated 8 million Afghan refugees lived in neighboring countries, mainly in Pakistan and Iran, representing one of the largest refugee populations worldwide.[lxvii] With the arrival of a new government, international forces and funding, more than 5.6 million people decided to return to their home country between 2002 and 2009.[lxviii] Of the 4.4 million assisted returnees from Pakistan and Iran, over 2 million were under the age of 18, according to UNHCR; the agency further reports approximately 1.6 million registered refugees living in Pakistan and about 1 million in Iran as of January 2010.[lxix] While updated data on Afghan refugee children in Pakistan and Iran is not available, UNHCR estimates about 1.18 million children among Afghan refugees in Pakistan and 345,000 children among Afghan refugees in Iran based on statistics from registration exercises conducted in 2007.[lxx]

Pakistan is not a signatory to the 1951 Refugee Convention and its 1967 Protocol, which establish the international legal standards for refugee protection. While Iran is a signatory to both the Convention and the Protocol, regimes after 1979 have refused to abide by the provisions of the 1951 Convention. The prolonged refugee presence and security issues due to cross-border migration and crime have led to concerns that the countries would close their borders and put pressure on Afghan refugees to return home, according to the International Crisis Group.[lxxi] Since 2004/2005, both Pakistan and Iran have tightened their asylum policies and increased pressure on Afghans to leave the country by closing refugee camps, cutting off assistance and in some instances arresting and deporting refugees.

Most of the registered refugees in Pakistan (around 85 percent) are living in the two provinces adjacent to Afghanistan – North West Frontier and Baluchistan – two of the most destitute provinces. There are serious protection concerns for refugees living in these areas as some armed groups have reportedly used the camps as bases for their military operations in Afghanistan.[lxxii]

Citing security concerns, the Government of Pakistan has limited the access of aid organizations and only allows aid to be provided to refugees through its own programs despite its limited expertise on protection issues and its direct political involvement in the conflict.[lxxiii]

In March 2010, a new Tripartite Agreement between the governments of Pakistan and Afghanistan, and UNHCR on voluntary repatriation was signed, which extends the stay of registered refugees through December 31, 2012. Between 2005 and the beginning of 2010, about 25 Afghan unaccompanied minors – largely undocumented labor migrants – were deported from Pakistan, according UNHCR’s statistics from border monitoring.

The situation for refugees in Iran also remains precarious. Since 2002, about 5,818 Afghan unaccompanied minors have been deported from Iran, according to UNHCR. While the majority of these child deportees are undocumented labor migrants, human rights organizations warn that child deportees may be at a heightened risk of sexual exploitation, physical abuse, human trafficking and various exploitations and abuses upon their return, according to AIHRC.[lxxiv] Some deportees have accused the Iranian police of beatings, illegal and arbitrary detention, and the Iranian security forces of insults before their expulsion.[lxxv] The Iranian government has also made it more difficult for Afghan refugees to stay in the country by banning them from 22 provinces as part of its “no-go area” policy and gradually cutting off their access to subsidized education, health care and food.[lxxvi] In 2009, the government took some steps to ease these restrictive policies by beginning to give work permits to registered Afghan refugees and allowing all school-age children, including registered and unregistered refugees, to enroll in grades 1 -12 in the same manner.[lxxvii] However, gaps in the implementation of these policies remain, according to UNHCR.

Most registered Afghan refugees do not want to return to their home country due to the deteriorating security situation, the limited absorption capacity of communities in Afghanistan and the lack of socio-economic opportunities. Without land, jobs, access to basic services and with ongoing security risks, returnees are at a high risk of renewed displacement within Afghanistan or forced re-migration to neighboring countries.[lxxviii] UNHCR alluded to the specific protection concerns of returnee children, including child labor, smuggling and human trafficking, and early or forced marriage.[lxxix] Moreover, about half of all refugees grew up in another country and 80 percent have lived there for more than two decades, making it difficult for them to reintegrate upon their return to Afghanistan.[lxxx]

Recommendations on Refugees and IDP Children

The UN Security Council Working Group on Children and Armed Conflict (SCWG-CAC) should request UNHCR and/or the Representative of the Secretary-General on the human rights of IDPs to lead a study to determine vulnerabilities and risks for displaced and refugee children from Afghanistan. The study’s findings would be the first step towards enacting a comprehensive action plan to find durable solutions for displaced children from Afghanistan.

The GoA should ensure that unaccompanied and separated children receive adequate interim care until they are reunited with their families, placed with foster parents or other long-term arrangements for care are made, in accordance with the Inter-agency Guiding Principles on Unaccompanied and Separated Children. The government should monitor that the standards of protection and care provided by private and public orphanages are met.

The Government of Iran should comply with the 1951 Refugee Convention and its 1967 Protocol; the Government of Pakistan should sign and comply with the 1951 Refugee Convention and its 1967 Protocol. In particular, they should provide refugee children from Afghanistan with access to education, health and documentation to facilitate opportunities for local integration or repatriation and ensure that their protection against harassment or deportation is in line with international standards.

The Governments of Afghanistan, Pakistan and Iran should work with UNHCR to ensure that children can continue their education or vocational training upon their return.

AIHRC should coordinate closely with the independent Human Rights Commission of Pakistan (HRCP) to conduct joint monitoring and reporting on human rights and child rights violations along their common border areas and to take specific measures to prevent them.

Health

Access to Services

The destruction from the war and ensuing political and economic instability have left Afghanistan’s health care system in shambles, and nearly fully dependent on external funding and assistance. Since 2002 the government has taken some important steps in improving health care, which have resulted in the increase of health facilities from 400 in 2002 to 1,788 in 2009 and a substantial increase in trained health personnel, according to the Ministry of Public Health.[lxxxi] With the expansion of basic health services, preventable fatalities among infants and young mothers have marginally decreased. However, intensified conflict, attacks and intimidation against health workers, and low quality services, have continued to keep infant and maternal mortality rates alarmingly high.

Afghanistan is still the worst place for a newborn in terms of access to health care and survival opportunities, according to UNICEF and Save the Children.[lxxxii] One in four Afghan children do not reach their fifth birthday, partly due to lack of access to adequate health care.[lxxxiii] Save the Children reports that 15 percent of vulnerable people, including children, in urban settings and 30 percent of those in rural areas do not have access to any government, nongovernmental organization or privately run health facilities in Afghanistan.[lxxxiv] Newly developed national health care policies to provide people with basic health services (Basic Packages of Health Services – BPHS) generally do not reach people living in the southern and western parts of the country, partly due to insecurity.[lxxxv] As a result, children have contracted or died of diseases that are easily preventable or controlled in most countries around the world, including respiratory infections, diarrhea and vaccine preventable deaths, especially measles, according to WHO.[lxxxvi]

At least 1 million Afghans (15 percent of the population) were deprived of basic health care services due to attacks on health care facilities and health workers in 2008, and insufficient coverage by the BPHS system. This number has doubled since 2007, according to the Ministry of Public Health and WHO (see above: Humanitarian Access).[lxxxvii] The situation in the conflict-affected southern region (Helmand, Kandahar, Zabul and Nimroz) is particularly severe and continues to degrade. Some health facilities have been closed, damaged or destroyed by the armed opposition and the deliberate targeting of health facilities and workers limits access to health services for much of the population living in insecure areas. Many security incidents involving the harassment, intimidation and kidnapping of health workers remain unreported because of fear of retaliation. As of November 2008, 13 southern districts had no functional public health facilities, potentially affecting hundreds of thousands of people, including children, according to the UN.

Armed groups have largely been responsible for attacking health facilities, staff members and patients. For example, armed opposition groups destroyed several NGO-run clinics in the east and abducted staff between July 1^st and September 30, 2009.[lxxxviii] Afghan Security Forces and international military forces have also not always respected the special protection afforded to medical personnel and facilities under international law. For example, in August 2009, Afghan military forces reportedly occupied two Basic Health Centers in Helmand province.[lxxxix] The Swedish Committee for Afghanistan also accused ISAF of invading its hospital on September 6, 2009.[xc] In order to prevent further incidents involving the occupation of health facilities by military forces, the Health Cluster members, who coordinate the health response among UN, government, NGO, academic and private actors, have developed a code of conduct for all military actors regarding entry into health facilities (see above: Humanitarian Access). In addition, the Health Cluster – in coordination with the UN-led Country Task Force on the Monitoring and Reporting Mechanism (CTFMRM) – established a mechanism for members to report attacks against health staff and facilities (see below: UN Security Council Actions).

There is also a critical shortage of health care workers in conflict-affected or remote areas.[xci] On average, one doctor is responsible for treating more than 5,500 patients, and 80 percent of health clinics lack adequate equipment.[xcii] In particular, the lack of female medical staff poses a serious obstacle to providing essential services to women and children. In Paktika province, for example, there is not a single female doctor and only a few female nurses and midwives in the entire province, where more than 180,000 women live, according to Afghanistan’s Central Statistics Office.[xciii]

Without access to medical supplies and professional staff, some Afghans have relied on informal medical advice from family elders or bought medicine from local drug sellers such as opium, with harmful consequences.[xciv] In particular, the small number of female health workers discourages girls and women from seeking medical assistance, especially for reproductive health concerns, according to the same report. Currently, less than one-third of health facilities have at least one female health worker, according to the Secretary-General’s report on Women, Peace and Security, September 16, 2009 (S/2009/465, para. 16).

Maternal Death and Reproductive Health

In spite of improvements, Afghanistan continues to have one of the highest maternal mortality rates worldwide with 1,800/100,000 live births.[xcv] One mother dies every half hour in Afghanistan because of birth-related problems, according to UNICEF.[xcvi] The infant mortality rate stands at 165 for every 1,000 live births.[xcvii] The prevalence of early marriage has resulted in girls giving birth at a young age when they are not yet physically mature, which carries serious health risks for the mother and infant. For example, an adolescent girl is two to five times more likely to die from pregnancy-related complications than a 20-year-old woman, according to Save the Children.[xcviii]

In addition, traditional gender norms prevent women and girls from learning about reproductive health, visiting male doctors or accessing health facilities without a male person accompanying them, according to UNICEF. The agency further reports that the high maternal mortality rate is due to very limited access to comprehensive emergency obstetric care for women living in rural areas, poor awareness about safe delivery practices and the scarcity of professional health workers, particularly females.[xcix] More than 70 percent of births take place at home without any medical support and any “emergency plan” in place.[c] While the number of midwives has increased substantially from 400 in 2001 to approximately 2,500 in 2008, more than 4,500 more midwives are required to meet current needs.[ci]

The enrollment of students for community midwifery schools is hampered by the low literacy rates among females in the rural and remote areas and even more by the threats and intimidation of their families by the armed opposition groups, according to WHO. Some of its implementing partners operating in “security challenging districts” reported dropout rates of between 30 – 40 percent. Progress in improving the access to skilled birth attendants is likely to be slow, especially in areas where this would be most needed, namely in rural, remote and insecure locations.

Infectious Diseases

Untreated communicable diseases threaten individuals and communities in Afghanistan. Of the cases reported to the Disease Early Warning System administered by the Ministry of Public Health, more than 60 percent posed the threat of developing into a major epidemic, according to WHO. This situation is especially dire in insecure areas where government and humanitarian agency operations are restricted due to conflict. Sources at WHO report that 50 percent of outbreaks are taking place in insecure areas, where even access to emergency health care is impossible. For example, during the cholera outbreak of 2009, a fatality rate of 13 percent was recorded in unstable parts of the southern region. These untreated, often serious diseases contribute to Afghanistan’s under-five mortality rate of 25 percent, which is one of the highest in the world.[cii]

Nationwide campaigns by the Afghan government with UN support to eradicate polio have resulted in the near-eradication of the pandemic in the last two to three years within the country, according to WHO. However, insecurity has prevented agencies from accessing 110,000 children in the conflict-affected southern provinces, where 20 of the 23 cases were registered in 2009, according to a WHO 2009 report on the polio eradication campaign. Health agencies consider the Afghanistan-Pakistan region as a primary risk area for polio as it involves two of the four remaining countries where polio still remains endemic due to insecurity and displacement, according to WHO. [ciii] While insecurity has prevented access to certain areas, parties to conflict have not directly obstructed vaccination efforts in areas under their influence or control, and the Taliban publicly declared that it would not oppose immunization campaigns.[civ] The successful engagement of humanitarian agencies with non-state armed groups in negotiating access for immunization campaigns has allowed WHO and its partners to include 30,000 children from difficult-to-reach areas, and to establish additional Diseases Early Warning Systems for the identification and response to outbreaks.[cv]

Malnutrition

The Humanitarian Action Appeal warned of severe malnutrition among under-five children, and in pregnant and lactating women in 2008 due to drought, rising food prices and insecurity. In fact, 40 percent of children under five in Afghanistan are underweight and 54 percent display severe signs of stunting according to UNICEF, State of the World’s Children 2008. According to the same survey, 24 percent of lactating women are malnourished and over 19 percent of pregnant women have poor nutritional status. There are strong indications that young mothers and children regularly die of malnutrition-related diseases, according to UNICEF and the Afghan Ministry of Public Health.[cvi] UN initiatives focus on feeding children under five and pregnant and breastfeeding women through feeding centers and offer daily lunches to students to encourage parents to send their children to school.[cvii]

Water and Sanitation

Inadequate access to clean water and sanitation further exacerbates the health situation for children in Afghanistan. Less than one-quarter of all Afghans currently have access to safe water sources, and less than one-third of the population is able to use adequate sanitation facilities.[cviii] Three out of four public schools do not have safe sanitation facilities for students and approximately 2 million students attending these schools do not have access to safe drinking water, according to UNICEF.[cix]

Basic hygienic measures such as washing hands with soap after visiting the toilet or before eating can reduce the risk of a child dying of diarrheal diseases by half, according to UNICEF. UNICEF further affirms that especially older girls are extremely unlikely to attend schools that lack gender-separated latrines. Improving access to water and sanitation at schools can thus contribute to both increasing school attendance and reducing child mortality in Afghanistan.

Drug Addiction

The large supply of opium together with poverty, unemployment, mental illness, lack of awareness and widespread despair has created an increasing demand for drugs in Afghanistan’s war-torn society. The most recent UN Office on Drugs and Crime Drug Use Survey 2005 estimated that nearly 1 million Afghans, including 60,000 children under the age of 15, were addicted to drugs. Children were mostly reported as using inhalant tranquilizers. Figures on drug abuse among youth are believed to be much higher today and encompass a wider range of substances due to availability and continuing stresses, according to UNODC. Most of the women using opium are of reproductive age, making babies they may have more susceptible to withdrawal syndromes, prematurity, accidental poisoning and other health issues.[cx]

More recently, a few health agencies have reported entire families in Afghanistan becoming addicted to drugs.[cxi] An AIHRC study found that 15 percent of drug users surveyed gave their children drugs to keep them quiet while they work.[cxii] The use of drugs has particularly harmful consequences for children because they are more easily addicted and suffer permanent mental and physical damage.[cxiii] In their drive to acquire more drugs, some children join criminal networks or armed groups, according to UNAMA’s 2007 report. Health experts also warn of the impending risks relating to diseases that can be transmitted by sharing needles such as HIV/AIDS and hepatitis C (see below: HIV/AIDS).

Only one out of four reported drug addicts in Afghanistan receives the necessary treatment and rehabilitation services, according to UNODC. Patients expecting treatment often have to wait months for one of the 100 beds reserved for treatment.[cxiv] The fear of being stigmatized also keeps many women and children from seeking information and services.

Psycho-Social Disorders

Traumatic events experienced or witnessed during the conflict continue to haunt many children, making it difficult for them to readjust to normal life. A recent survey found that 22 percent of 1,011 children between the ages of 11 and 16 years attending government-operated schools in Kabul, Bamiyan and Mazar-i-Sharif exhibited signs of psychiatric disorder; girls were two-and-a-half times more likely to have disorders than boys.[cxv]

However, there is limited psycho-social trauma support provided in the country, according to Handicap International. Standard health responses for victims of violence – even rape victims – focus on physical care with little attention paid to the patient’s mental well-being. The profession of counseling does not even exist in public health services. Some child protection initiatives engage conflict-affected children in activities to promote creativity and play as an alternative to more traditional psycho-social interventions, including skateboarding and staging a children’s circus. While such programs may benefit a few, more systematic interventions are needed for children to help them deal with their war experiences.

Recommendations on Health

(compare, Recommendations on Humanitarian Access)

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