VZCZCXRO8845
OO RUEHDBU RUEHPW RUEHSL
DE RUEHBUL #3907/01 3401527
ZNR UUUUU ZZH
O 061527Z DEC 09
FM AMEMBASSY KABUL
TO RUEHC/SECSTATE WASHDC IMMEDIATE 3793
RUCNAFG/AFGHANISTAN COLLECTIVE

UNCLAS SECTION 01 OF 03 KABUL 003907 
 
SIPDIS 
 
DEPT FOR GWI, S/SRAP, SCA/FO, SCA/RA, SCA/A 
DEPT PASS AID/ANE 
CENTCOM FOR USFOR-A AND CSTC-A 
NSC FOR JJONES 
DASD FOR DSEDNEY 
 
E.O. 12958 N/A 
TAGS: ESTH SOCI AF
SUBJECT: ENABLING THE GOVERNMENT OF AFGHANISTAN TO GIVE ITS CITIZENS 
WHAT THEY WANT: HEALTH AND EDUCATION 
 
¶1. (U) Summary:  With one of the lowest literacy rates and some of 
the worst health statistics in the world, the lack of an educated 
and healthy population is a severe impediment to social and economic 
progress and stability in Afghanistan.  Enabling the Government of 
the Islamic Republic of Afghanistan (GIRoA) to deliver critical, 
high demand services in health and education is one of the most 
simple and effective methods for increasing citizen's active and 
continued support of their government.  Citizen support increases 
with further expansion of GIRoA service delivery as reflected in 
President Obama's recent messages on Afghanistan and our COIN 
strategy.  Health and Education are two of Afghan citizens' most 
demanded and appreciated services from the GIRoA.  USG commitment to 
strengthening the GIRoA's ability to expand and deliver health and 
education services into more districts needs greater support - 
especially since other donors are either unwilling or unable to 
help.  The gains we have made in education and health and the 
increased support of the citizens for the GIRoA because of these 
gains are not reflected in current USG funding levels.  We have 
requested separately additional funding for these two important 
sectors.  End Summary. 
 
 
Progress in Health but a Long Road to a Healthy Afghanistan 
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 
 
¶2. (U) The Ministry of Public Health (MoPH) has vastly improved its 
health service provision in the last six years with USG assistance. 
Afghanistan's under-five mortality rate has dropped 25%, infant 
mortality 22%, and access to health care rose by 76%.  The number of 
midwives has quadrupled and health facilities with a female health 
worker have more than doubled.  A model for good governance, the 
MoPH is also the first ministry in Afghanistan eligible to receive 
large amounts of direct funding from the USG due to its high level 
of transparency and accountability.  The funds travel through a Host 
Country Contracting (HCC) mechanism that allows USG assistance to 
flow directly to the GIRoA for the provision of basic health 
services.  Currently, USAID has agreed to channel $236 million 
through the MoPH in the next five years.  Already managing $40 
million a year in USG funding the MoPH could easily manage three 
times the resources due to their proven management and capability. 
 
 
¶3. (U) Despite these gains, Afghanistan continues to struggle with 
one of the poorest public health situations in the world.  According 
to the United Nations Children's Fund (UNICEF), Afghanistan is the 
worst place in the world for children to be born as it has the 
highest infant mortality in the world, and the World Health 
Organization (WHO) lists Afghanistan as the second highest maternal 
mortality rate in the world.  To put this into perspective, in 2008, 
four times as many women died in pregnancy and childbirth than 
anyone did from insurgent/battle related causes in Afghanistan. 
Women and girls suffer more by these statistics, and Afghanistan is 
one of few countries in which women have a lower life expectancy 
than men.  Fifty-seven percent of Afghan women marry before the 
legal age of 16, and the average Afghan woman has 6.75 children in 
her lifetime before dying at age 44. Afghanistan continues to have 
extremely poor access to clean water and adequate sanitation and a 
high burden of infectious diseases such as tuberculosis (TB), 
malaria, and polio.  Equally alarming, the population will likely 
double in the next 15 years, posing a real threat to the 
Afghanistan's stability. 
 
 
Education - Major Success Could Lead to Major Problems 
- - - - - - - - - - - - - - - - - - - - - - - - - - - - 
 
¶4. (U) The USG and the GIRoA are continuing their successful 
partnership extending access to and quality of education.  The 
Ministry of Education (MoE) and the Ministry of Higher Education 
(MoHE) vastly improved education service delivery and management 
capacity with USG assistance.  Key achievements include a seven-fold 
increased student enrollment in primary and secondary education, 
especially for females; increased quality of the teaching force at 
primary, secondary and university levels; increased quality of key 
university-level degree programs; increased numbers of adults 
enrolling in literacy programs; improved MoE management of the 
education system; increased availability of teaching and learning 
materials, especially textbooks and teacher guides; a new primary 
school curriculum; and improved school infrastructure. 
 
¶5. (U) These successes will create an estimated 100,000 high school 
graduates by 2010 and 600,000 by 2014.  These impressive gains 
create a high demand for university education, where places are 
extremely limited.  With 56,000 students enrolled in higher 
education institutions in 2008, the rapidly increasing demand easily 
outstrips the available places - adding to the instability caused by 
 
KABUL 00003907  002 OF 003 
 
 
large numbers of out-of-school children and youth and the lack of 
workforce skills training opportunities.  Women are severely 
disadvantaged due to their limited access to secondary schools with 
female teachers.  In fact, the MoE states that 214 of 400 districts 
in the country do not have any female teachers.  The MoE estimates 
that Afghanistan needs 160,000 new teachers by 2014 to keep pace 
with current demand for education as Afghanistan's school-age 
population grew by more than 3 percent or 250,000 children last 
year.  Even if the insurgents stopped destroying schools and 
obstructing attendance, the government would face a momentous 
challenge in furnishing enough classrooms and teachers for this 
burgeoning generation. 
 
 
Can Other Donors Step Up? 
- - - - - - - - - - - - - 
 
¶6. (U)  Thanks to excellent donor coordination by the MoPH, the 
overall amount needed by the USG is rather small compared to the 
amount of funding needed for measurable success in other USG funded 
sectors such as rule of law, democracy, and agriculture.  The MoPH 
has coordinated donor financing by assigning provinces to the three 
main donors: USAID has thirteen; the World Bank has eleven; and the 
European Commission has ten.  Unfortunately, despite the division of 
labor, the World Bank (the second largest funder after the USG) is 
decreasing their funding from $20 million to $12 million a year for 
the next four years to the health sector, while there are no new 
donors stepping up to fill the gap.  USAID/Afghanistan has engaged 
other donors working in health - the German Embassy, the French, the 
Lithuanians, the Asian Development Bank, the British, the Canadians 
and Norwegians with discouraging results.  Due to smaller budgets 
and a focus on provinces in which their troops are stationed, other 
donors are unwilling or unable to contribute anything meaningful 
enough to make a difference in USG strategy. 
 
¶7. (U) Due to most donors' desire to only work in primary education, 
USAID remains one a few that will fund secondary and higher 
education - the two most underfunded parts of the education system. 
Additive funding would enable USAID to expand much needed 
programming in secondary education to allow girls the opportunity to 
continue with their education.  Moreover, assistance to improve the 
quality and accessibility of secondary education is critical to 
counterinsurgency objectives as it engages youth in productive 
activities at an age when they are most susceptible to recruitment 
by the insurgency.  USAID could also build on its successes in 
higher education by supporting expanded access to females and by 
improving quality in fields of study relevant to economic growth. 
 
 
So Now What? 
- - - - - - 
 
¶8. (U) In a country with the some of the lowest literacy rates and 
some of the worst health status statistics in the world, the USG has 
had phenomenal success in only a six-year time frame with a 
relatively small budget.  But, as fruitful as USG investments have 
been, much more is needed to build an Afghanistan that can manage 
its own future.  USAID's health and education budgets have decreased 
since FY 08.  The USG should be expanding on its success by 
increasing support with an increased budget in health and education 
to support the GIRoA in these critical areas.  Previous budgets have 
only been a fraction of the $650 million necessary to support fully 
the MoPH and the MoE as they extend their services to the furthest 
districts in the USG supported provinces as well as other targeted 
districts in other donor supported provinces.  Such an amount of 
funding could also create a workforce development program and 
respond to GIRoA's need to create basic skills training and advanced 
university degrees. 
 
¶9. (U) The health budget could quickly be expanded and expended in 
one of the most high-impact, visible and Afghanized means possible, 
if we had additional resources into the direct-funding to HCC with 
the MoPH.  The structure is in place, and it is now a matter of 
expanding its reach to further provinces and districts in the South 
and East.  Filled with both Afghans and expatriates, USAID believes 
the MoPH Grants and Contracts Management Unit (GCMU) can triple the 
amount it manages while continuing its strong oversight and 
accountability.  With increased funding, the USG can scale up 
successful health programs to meet Afghan citizens' needs and 
achieve USG COIN objectives.  More specifically, the USG can enable 
the GIRoA to offer critical health services to more than 13 million 
Afghans through the HCC mechanism with the Public Health Ministry. 
Health and education services are often the only face of GIRoA in 
remote or non-permissive regions recognized by communities as an 
essential service - something the Taliban definitely cannot provide. 
 It remains critical that the number of local NGOs contracted by 
 
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GIRoA to deliver health services will continue to increase. 
 
¶10. (U) Much like the HCC with the MoPH, an increase in funding 
would enable the USG to support the Education Ministry's goal of 
achieving universal primary education by 2020.  As Afghanistan's 
largest donor to basic education since 2002, USAID is 
well-positioned to solidify its gains in the education sector. 
These include a quadrupling (from 70,000 children to nearly 300,000) 
of the reach of community-based primary and secondary education. 
Further funding could also provide assistance to the long-overlooked 
madrassas which provide education in areas with high insurgent 
activity.  As the only formal education accepted by conservative 
communities, USG support would promote less radical agendas and 
reduce the numbers of youth susceptible to insurgent recruitment. 
Madrassa engagement includes support for the implementation of the 
GIRoA's secular curriculum with a focus on providing practical 
skills to help students transition from school to work. 
 
 
Requested Levels 
- - - - - - - - 
 
¶11. (U) With a $212 million FY 10 initial request ($95 for education 
and $112 for health) both portfolios will remain severely 
underfunded.  Post hopes the USG will be able to triple both 
portfolios in order to meet the needs of the GIRoA as it further 
expands its services into additional districts.  An overall USG 
commitment to an increased budget is critical for expanding these 
services - especially in light of the new US Military commitment. 
Expanding access and coverage of high-impact quality health and 
education services to currently underserved populations, especially 
in insecure areas, through ways that are highly visible and provide 
immediate benefit to target communities, will increase legitimacy 
and support for the government.  Not only do these activities help 
improve health and education status in Afghanistan, they support job 
creation and employment.  Support for building functional and 
efficient health and education systems in Afghanistan is a 
high-impact, necessary investment for Afghanistan's vulnerable rural 
population that will reap benefits for generations to come. 
 
¶12. (U) COMMENT:  Post has requested separately a large plus up in 
developmental assistance portfolios to support the emergence of a 
legitimate Afghan state that meets the needs and has the support of 
its citizens.  Despite their importance to COIN, high Afghan citizen 
demand, and success in combating some of the worst conditions in 
health and education in the world, the portfolios have received low 
funding.  Therefore, commensurate with the requested increases 
slated for the USG economic growth, agriculture, and democracy 
portfolios, post believes the health and education portfolios 
require an increase and sustained additional support.  END COMMENT. 
 
 
RICCIARDONE