Special Mention: Lasting Systemic Change

Hekmatullah Zadran, Relief International / Community Midwife Training program

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You were nominated in the category of lasting systemic change. Can you tell us more about your work in this area?


I graduated from Kabul Medical University in 2003 and started work as a medical doctor in a clinic. In 2004 I joined MRCA (a French NGO which currently has an alliance with Relief International) as a medical supervisor in Logar province in Afghanistan.


There was a shortage of midwives in the entire province, even in the provincial capital, and we had to hire midwives from Kabul, the capital of Afghanistan, to work in the remote area of Logar province. But this was not sustainable because the midwives from Kabul were working for six or eight months and then they were leaving. Finally, with the Midwifery Association based in Kabul, we decided to establish a community midwifery school in Logar province. The midwifery school started work in 2006.



What challenges have you faced? Have there been any solutions that worked particularly well?


First, families in remote areas of the province were reluctant to send their girls to midwifery school. In these conservative communities, it was difficult to encourage or even discuss girls’ education. We had several meeting with girls’ parents and community elders to describe the midwifery programme and encourage them to send their girls to the school. We also encouraged the clinic’s doctors to discuss this with communities and families.


We provided accommodation facilities for the girls and their parents in the capital of the province, as the parents were not ready for their daughters to stay in dormitory accommodation.


Second, girls did not have the right level of education. The eligibility for enrolment in midwifery school was tenth class graduate. In some districts, the level of education for girls was lower (eighth class). We enrolled these girls in midwifery school and beside midwifery training they also received their ninth and tenth class education. For those districts where there were no educated girls, we enrolled students from the neighbouring districts and got agreement from their families for them to work in the nearest district clinics.


Third, there were threats to the students or they did not have permission to go to midwifery school.

In 2010, one student’s husband was threatened by armed people and told to stop her education in midwifery school. For one week she was not able to come to school. We discussed this with the community elder, who held a meeting in the village and finally were able to get permission for her education. The girl started education again and graduated from midwifery school. She is now the expert midwife of Logar provincial hospital.



Where do you see your work going next?


After the first midwifery education programme in Logar province, we successfully completed three other batches. In the second and third batches, the number of requests for the midwifery programme increased as the community saw that graduated students were starting work in the clinic as midwives and were getting high salaries. This encouraged other families to enrol their girls in midwifery school.

After Logar province, we also graduated students in Baghlan province, Kapisa and Nimroz. These midwifery schools opened the door for the girls’ education in these communities and in most provinces private midwifery/nursing schools are now available.



Why is this work so important to you?


All these graduated students are currently working in a different part of these provinces (Logar, Paktia, Baghlan, Nimroz and Farah) and they are saving the lives of pregnant women. This is a great encouragement for me and for my work. I am proud of the changes that these midwives brought to the life of women in our society and mainly for timely access for women suffering from obstetric complications. I remember before these midwives, women in villages were suffering from difficult situations during birth and women were dying due to the unavailability of skilled birth attendance. The Ramus survey 2001 showed the maternal mortality ratio in Afghanistan was 1,600 per 100,000 live births. Now it has decreased to 327 per 100,000 live births (Afghanistan Mortality Survey 2010).



What changes to the humanitarian sector are needed in the next 10 years? What are the main obstacles to achieving this?


There is a need to focus more on transparency and accountability in the humanitarian sector, mainly in fragile states, in order that vulnerable communities have effective access to humanitarian aid.



2020 has presented multiple challenges globally. What are the key lessons for the humanitarian sector this year?


Strong coordination and collaboration with humanitarian clusters of local, national and humanitarian actors is the key to responding to these challenges.

Developing contingency plans is a key for emergency response as there will be no rapid response if these are not available.


Close partnership with the community, and involving the community in programme implementation, can increase trust and pave the way for proper implementation of humanitarian projects.


Improving staff capacity on the COVID -19 response was the key lesson learned for us. This improved staff protection from COVID-19 and relieved staff anxiety caused by rumours about COVID-19.


In these challenging situations, focusing on child protection and women’s right is key, as in these complex conditions children and women are more affected.



Why do you think that in an era when we have more access and communications, crises have increased in numbers and gravity?


This access and communication provides information based on realities on the ground, and this is the reason for this apparent increase.



Why is important to transform the sector and if there is one thing that you would encourage your fellow humanitarians to do, what would it be?


Transformation is important in all sectors because this is the process of changing the overall systems, business processes and technology to achieve measurable improvements in efficiency and effectiveness. I would encourage fellow humanitarians to implement transparency in their method of work.


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