Livelihoods and Integrated Health Strengthening in Afghanistan and Pakistan

The project was implemented by CARE Afghanistan & Pakistan, and the Afghan Women’s Resource Center (AWRC) in Afghanistan and Pakistan. It began in June 2022 and ended in December 2024.

This project supported displacement-affected communities along the Pakistan-Afghanistan border through partnerships with local women-led organizations. Healthcare services, delivered by trained community health workers and midwives, focused on women and children's needs. The project provided entrepreneurship support through the Afghan Women's Resource Center, while in Pakistan, activities included agricultural training, livestock distribution, and vocational skills development for refugee and IDP communities.

The aim of this good practice was to provide holistic assistance to increase community access to services and support income generation among displacement-affected persons in Pakistan and Afghanistan. The objectives included boosting household income, addressing food insecurity, and bolstering local supply chains and economies, thereby creating further job opportunities. The goal was also to increase displacement-affected persons' access to health, nutrition, and WASH services. On the Pakistan side, activities were developed in light of skills and assistance that would be most impactful to support Afghan refugees in Pakistan should they decide to return to Afghanistan.

Main activities of the Good Practice

On both sides of the border, livelihood assistance provided vulnerable households with poultry, livestock, fodder, and kitchen garden supplies. The project actively supported small businesses, offered agricultural management training, and strengthened market linkages to boost local economies. Vocational training, conducted in collaboration with local training centres, addressed labour shortages identified through rigorous market assessments. The skills taught were diverse and practical, including food processing, kitchen gardening, livestock management, tailoring, mobile phone and motorbike repair, solar power maintenance, and carpentry. In Pakistan, support was designed with returns to Afghanistan in mind, offering adaptable resources like Khurasani goats, which are well-suited to Afghanistan, and seeds that could thrive in both countries. In Afghanistan, livelihood support was provided by women for women – an approach that had to adapt to the challenges of diminishing space for women-led initiatives following the takeover of the country by the Taliban.

Health activities focused on training community health workers and midwives as frontline healthcare providers. In total, 98 local women were trained, committing to providing ongoing support to their communities, either free of charge or at affordable rates. Collaboration with private sector partners ensured the reliable delivery of low-cost medicines, contraception, first aid supplies, and essential sanitation items. The project significantly improved access to health services by providing vital medical and non-medical supplies to local health centres, and offering sexual and reproductive health services.

WASH initiatives involved the rehabilitation and installation of sustainable (often solar powered) water, sanitation, and hygiene facilities in healthcare centres and communities across Pakistan.

Elements which helped facilitate the implementation of the good practice

Key aspects of the implementation included:

1. Context-specific and culturally appropriate skills were provided, expected to be effectively utilized by Afghan refugee communities. These skills add value to economic empowerment in both short-term and long-term scenarios in Pakistan, as well as upon return to Afghanistan.
2. Projects were adapted to local contexts, ensuring cultural and social acceptability, especially in regions like Nangarhar. Focus areas such as poultry, pickle, and jam production align with traditional skills, enhancing their relevance and effectiveness.

Partners involved

• EU-funded and UNOPS-managed Lives in Dignity Grant Facility
• Sarhad Rural Support Program (SRSP)
• United Nations
• Ministry of Ministry of States and Frontier Regions (SAFRON)
• Commissionerate of the Afghan Refugees (CAR)
• Home and Tribal Affairs Department (Baluchistan and Khyber Pakhtunkhwa)
• Deputy Commissioner Office (Pishin and Kohat)

What challenges were encountered in delivering the project and how were they overcome?

Challenges

1. The regime change in Afghanistan in 2021 led to the authorities banning all humanitarian and development initiatives, banning women-led NGOs, and restricting the use of public-private partnerships. Health initiatives were unaffected: leading to the rejection by authorities and removal of all non-health related activities from the project in Afghanistan. The restrictions have limited the scope of women's economic empowerment, as many remain dependent on male family members to manage livestock or income.
2. Insecurity and political instability led to changes to project locations and adjustments to activities in Pakistan In addition, LiD's needs-based approach to forced displacement differed from the Pakistan government's more status-based approach.
3. Tracing project participants to ensure support and sustainable results after their return and deportation to Afghanistan proved challenging.

How they were overcome

1. The project demonstrated exceptional adaptability in an uncertain and volatile context. Despite challenges, it successfully pivoted by adjusting its focus on HDP nexus components and other LiD Grant Facility-related themes. The project expanded health sector activities, including strengthening health systems, providing medical supplies, and conducting community-based screening of vulnerable populations, ensuring their nutritional and health needs were met. While to a much smaller degree than planned, the project succeeded in training women in various skills and strengthened their income generation capacity, despite many restrictions placed on women in Afghanistan.
2. Following a needs-based approach, project partners advocated for the inclusion of undocumented refugees, internally displaced people, and Afghanistan Citizen Card holders in Pakistan. They advocated among government departments for greater assistance to highly vulnerable persons not included in status-based targeting in Pakistan. A written letter was sent to authorities as part of the advocacy approach.
3. A project participant tracing and tracking mechanism for returnees to their home country after deportation was put in place to ensure continuity of support and sustainable results. Additionally, learning workshops among project partners were conducted to ensure the exchange of good practices and enhance adaptation and timely revisions in programming.

Results of the Good Practice

Thousands of mothers and children received treatment for common sexual and reproductive health (SRH) problems and immunizations, including dozens of safe institutional deliveries in urgent cases. More than 40,000 pregnant and lactating women and children received health services along with improved access to Water, Sanitation, and Hygiene (WASH) facilities at health centers. Public awareness and demand for services have been created and improved in target communities.

More than 30,000 refugees/individuals in Pakistan, now have improved access to clean drinking water through the rehabilitation of water supply systems.

Around 2,000 households received income generation assistance. Results reveal a significant increase in the incomes of those assisted by the project. A total of 150 women in Nangarhar, Afghanistan, who participated in vocational training programmes have successfully launched their own small businesses from home. As a result of the skills they acquired, these women are now generating income ranging from approximately 2,000 to 4,000 AFN monthly.

In what way does the good practice meet one or more of the four objectives of the Global Compact on Refugees?

Objective 1: Ease the pressures on host countries

It eases pressure on the host country by supporting Afghan refugee and host communities' livelihoods in Pakistan and reinforcing Water, Sanitation, and Hygiene (WASH) services there.

Objective 2: Enhance refugee self-reliance

The good practice activities in Pakistan also enhance Afghan refugee self-reliance.

Objective 4: Support conditions in countries of origin for return in safety and dignity

The work carried out in Afghanistan by the project supports conditions in the country of origin for return in safety and dignity.

Next steps

The livelihood intervention project participants, who received poultry, goat, and kitchen gardening packages, have successfully achieved self-sufficiency. They have expressed their intention to continue these initiatives in the long term, ensuring the sustained impact of these interventions. Both the Village Savings and Loan Associations (VSLA) and One-Stop Shops have been structured to ensure their long-term sustainability. WASH interventions have been handed over to the community, ensuring their continued implementation. The project has informed all relevant government departments, including the Deputy Commissioner's office (DC), Public Health Engineering Department (PHED), and District Health Office (DHO), about the project's closure in both districts. Assistance in ensuring a smooth transition and continued support for the project participants has also been requested.

Are there areas in which support would be required to continue and/or scale up your good practice?

There is a need to establish standard institutional delivery services in Community Midwife (CMW) health posts and some remote Community Health Worker (CHW) health posts, particularly in Khost province, Afghanistan. Additionally, nutrition and psychosocial counselling services are recommended to be included in future programming, based on the unavoidable need and burden of malnutrition and mental health problems in the country.