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UNITED STates institute of peace

© USIP 2010 • All rights reserved.

“The decline of humanitarian space is likely a product 

of complex factors, starting 

with the overall increasing 

level of violence and political 

judgments by insurgent groups 

that in particular situations they 

gain more by attacking civilians 

than they lose by defying international humanitarian law. ”

October 4, 2010 

Humanitarian Space Shrinking 

for Health Program Delivery in 

Afghanistan and Pakistan

Summary

•	 In Afghanistan and Pakistan, humanitarian space has shrunk as the Taliban and other insurgent groups have stepped up attacks on civilians, especially international aid workers, contractors and local leaders. Health programs continue to operate, but the ability of nongovernmental organizations (NGOs) to recruit and retain staff and to travel outside Kabul has suffered. 

•	 The United Nations, International Committee of the Red Cross (ICRC), and other groups have 

sought to persuade the Taliban and other armed groups not to impede or interfere with 

humanitarian aid activities. These efforts have had some success where the aid is administered by Afghans, but they have not limited attacks on international staff, who along with all 

foreigners, remain at high risk of attack. 

•	 Many NGOs act as implementing partners in the government’s strategy to implement a 

comprehensive primary care system in Afghanistan under the direction of the Ministry of 

Public Health. They have managed to maintain those services with local staff despite their 

association with the government of Afghanistan, so long as they operate with impartiality and 

community engagement. The vulnerability of their staff to attack appears to be a product of 

generalized insecurity or the presence of foreign aid workers, rather than a result of collaboration with the Ministry. 

•	 NGOs report that military activities in Afghanistan and Pakistan, and military involvement in 

the medical sector, have contributed to the shrinkage of humanitarian space. The military’s 

provision of health services through Provincial Reconstruction Teams and other mechanisms, 

though well-intended, sometimes sows confusion about the allegiances of U.S. and other 

Western aid workers and creates tensions with humanitarian principles the agencies rely on 

to operate in conflict environments. The conduct of the Afghanistan National Army and Police 

and the Pakistan military in entering facilities to gain access to arrest insurgents or gather 

information also leads to greater insecurity for NGO personnel.

Introduction 

Humanitarian space—the ability of aid agencies to operate safely and securely in insecure regions 

while adhering to principles of independence, neutrality, and impartiality, and to access and 

engage in open dialogue with communities—has come under increasing assault. According to 

Leonard S. Rubenstein

E-mail: lrubenst@jhsph.edu

Phone: 443.287.8749

peaceBrieF59
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Humanitarian Space Shrinking for Health Program Delivery in 

Afghanistan and Pakistan page 2 • PB 59 • October 4, 2010

the Humanitarian Policy Group, 260 humanitarian aid workers worldwide were killed, injured or 

seriously injured in violent attacks in 2008.1 A disproportionate number of these attacks took place 

in Afghanistan, Sudan (Darfur) and Somalia. In Afghanistan, attacks on aid workers in the first half 

of 2010 declined by 35 percent from the 2009 level.2 The general level of insecurity increased, 

however, as the total number of insurgent attacks went from 630 in August 2009 to 1,353 so far 

in 2010.3 In August 2010, the Taliban and another group each claimed credit for the murder of ten 

health workers from the International Assistance Mission while traveling in northern Afghanistan 

en route to Kabul. In Pakistan, the Taliban have threatened aid workers who provide flood relief, 

which has required increased security and more restricted travel in areas of great need.

To gain insight into the question of humanitarian space in health programs at ground level, 

USIP’s Health and Peacebuilding Working Group brought Robert Lankenau and Jehangir Ali Khan, 

International Medical Corps (IMC) country directors in Afghanistan and Pakistan, respectively, to 

discuss the challenges in these environments. Steven Hansch, a fellow in Georgetown University’s 

Institute for the Study of International Migration, provided commentary. Leonard Rubenstein, 

coordinator of the Working Group, moderated the discussion.

The Work of Health NGOs in Afghanistan and Pakistan

Dozens of international and national NGOs provide health services in Afghanistan, many of them 

under contract with the Ministry of Public Health. Among other activities, these NGOs operate 

rural clinics as part of its Basic Package of Health Services (BPHS), a nationwide program of primary 

care development. The program has vastly increased access to health services and brought child 

mortality down considerably. IMC has worked in the region along the Afghanistan-Pakistan border 

for more than 25 years, and is now one of the largest of these healthcare providers, employing 

roughly 12 expatriate and 900 national staff in 160 health facilities and as community health workers. Along with other NGOs, IMC runs clinics in some of the most insecure areas of southeastern 

and eastern Afghanistan. Apart from their role in implementation of the national primary care 

program, NGOs receive funding to provide reproductive health services, train midwives, manage 

hospitals, and other key health services.

In Pakistan, NGOs also play a central role in providing health services and supporting capacity 

development of local and national Pakistani NGOs. IMC, for example, focuses on health services 

and training for Pakistanis and Afghan refugees in the former Northwest Frontier Province, now 

Khyber-Pakhtunkhwa Province (KPK) and in Federally Administered Tribal Areas. It runs reintegration programs, including those addressing gender-based violence, and provides a wide array of 

maternal and child health services including basic emergency obstetric care, health education, 

immunizations, curative care, dental care, growth monitoring and supplementary feeding, wound 

care, laboratory services, and reproductive health services. In the wake of the flood in August 2010, 

NGO health providers increased their presence, operating mobile medical teams and providing 

other services to displaced populations. 

Taliban Attacks and Health Operations

In Afghanistan, Taliban activities and at least some Taliban presence affect 80 percent of the country. In 43 percent of provinces there exists extreme operating risk for NGOs, the highest percentage 

ever. Lankenau reported that in the past, NGO health workers were generally considered off limits 

to attack by the Taliban, but this is no longer the case. Road checkpoints have become increasingly 

dangerous for staff. Even within Kabul, high profile attacks on civilians now occur every five to six 

weeks. These attacks grossly violate the provisions of international humanitarian law, which bind 
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Humanitarian Space Shrinking for Health Program Delivery in 

Afghanistan and Pakistan page 3 • PB 59 • October 4, 2010

all parties to the conflict including non-state actors. In addition, the higher intensity of the conflict 

between the warring parties affects operational safety even when clinics and staff are not directly 

attacked. In August 2009, an IMC-operated clinic was bombed and destroyed by the International 

Security Assistance Force (ISAF) in a botched Taliban arrest operation. In another case, an IMC car 

was caught in a Taliban ambush of an ISAF convoy. 

Despite the insecurity, NGOs continue to provide health services, even in many insecure 

provinces, but they now operate under severe constraints. International staff members are generally not assigned to programs outside the capital. Local staff travel outside Kabul has become 

extremely restricted. Many NGOs have grounded vehicle fleets used to reach rural districts, so staff 

members travel in unmarked vehicles without official papers or computers identifying them as 

NGOs. Staffing health programs has become increasingly difficult, especially in meeting needs for 

nurses, midwives, gynecologists, and other positions mostly filled by women. Financial incentives 

have proven insufficient to stimulate recruitment given the level of insecurity. 

In Pakistan, though violence against humanitarian workers is not as pervasive as in Afghanistan, 

humanitarian workers have been shot, taken hostage, threatened and kidnapped. In 2009, a militant group seized a health unit operated by the International Medical Corps in the Buner district. 

Staff members were kept hostage for over an hour and clinic inventories stolen. 

The International Committee of the Red Cross (ICRC) and U.N. agencies have sought to secure 

the Taliban’s compliance with international humanitarian law and respect for humanitarian and 

health programs. These efforts have had some success in allowing some humanitarian activities to 

go forward, such as vaccination campaigns. Moreover, health clinics themselves are not generally 

attacked by the Taliban, though the Taliban have interfered with programs at the clinics addressing 

gender-based violence. Even when the Taliban refrain from such attacks, splinter groups in the 

region may not follow agreements made by the national leadership and may perceive advantages 

in attacks on aid activities.

Contributing Factors?

In determining the sources of insecurity, a question has arisen whether the conduct of military 

forces or the NGOs themselves contributes to the vulnerability of aid agency staff to attacks, 

unjustified as the attacks are. In the experiences of NGOs and the Afghanistan Ministry of 

Public Health, the conduct of conventional fighting forces—the Army in Pakistan and national 

and international military forces in Afghanistan—adds to the insecurity of NGOs operating 

health programs. The participation of military units, such as Provincial Reconstruction Teams, in 

conducting or supporting health and other programs, such as by supplying drugs and supplies 

to clinics, has sometimes sown confusion about whether and to what degree aid organizations 

are affiliated with the military. According to NGOs, such confusion in turn appears to increase 

the likelihood of attack. Guidelines developed to govern U.S. military-NGO relationships in 

hostile environments4

 only tangentially address the security consequences of military-operated 

humanitarian relief programs on civilian NGOs, e.g., by stating that military personnel engaged 

in such activities remain in uniform and not visit NGO facilities except by prior arrangement and 

respect NGO impartiality. 

Current guidelines do not address the implications for NGO security of military-operated health 

programs in conflict regions to comply with obligations of an occupying power, or to support 

development programs. Guidelines should take account of the activities of civilian health programs, including those of the Ministry of Public Health, as well of the potential impacts of military 

participation on humanitarian space in health development activities. They should set out ground 
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Humanitarian Space Shrinking for Health Program Delivery in 

Afghanistan and Pakistan page 4 • PB 59 • October 4, 2010

rules and limits for the military’s health activities so as to allow for the independence and community orientation of health-related NGOs.

The practices of the Afghanistan National Army (ANA) and the Afghanistan National Police bring 

even greater threats to NGO programs. U.S. military forces generally do not seek to gather intelligence at civilian-operated health facilities, but ANA troops and Afghan police – which often operate like a paramilitary force—have entered health facilities in search of suspects and intelligence.

Another potential source of vulnerability is the NGOs’ role in administering primary healthcare 

services under contract from the Afghanistan Ministry of Public Health. Some commentators have 

suggested that when NGOs engage in development activities on behalf of the Afghan government 

(and indirectly in support of the U.S. counterinsurgency strategy), they violate principles of strict 

neutrality and open themselves to attack.5 Health programs operated by IMC and other NGOs on 

behalf of the Ministry with local staff do not, however, appear to be specific targets. Rather, the 

danger experienced by staff in these programs appears to stem from the increasingly high levels 

of general insecurity and violence rather than from work on behalf of the Ministry of Public Health 

to expand primary care services. The infrequency of attacks on clinics, despite their affiliations 

with the Ministry of Health, may be a product of the impartiality of NGO operations, which serve 

insurgents and members of their families, and their ongoing connections to communities. 

Conclusions 

The decline of humanitarian space is likely a product of complex factors, starting with the overall 

increasing level of violence and political judgments by insurgent groups that in particular situations they gain more by attacking civilians than they lose by defying international humanitarian 

law. Although ICRC and others have made efforts to persuade the Taliban to adhere to the law, 

political calculations and lack of centralized control makes the situation volatile. The vulnerability 

of aid groups may well be exacerbated by the conduct of the opposing military forces. Nevertheless, health programs have been established and continue to operate, even in many insecure areas, 

often under auspices of the Afghanistan Ministry of Public Health. These programs generally can 

only be safely conducted, however, without foreign workers, when they engage with local communities and act impartially in serving all segments of the population. 

In the current environment of heightened levels of violence, expanding humanitarian space will 

be difficult. Some steps, however, could lead to improvements. These include:

•	 Continuing effort by the U.N. and ICRC to persuade the Taliban to respect humanitarian 

principles.

•	 Increasing separation between humanitarian and development assistance programs 

and military operations, and guidelines to govern that separation. The guidelines should 

provide for respect for the need for health NGOs to gain support of local communities and 

to operate according to principles of neutrality, independence and impartiality. Military 

organizations can also take steps to avoid confusion between military and civilian humanitarian programs.

•	 Commitment by Pakistani, Afghan and allied military and police forces to cease intrusions into the operations of aid organizations or seeking intelligence information from or 

through them. 
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Humanitarian Space Shrinking for Health Program Delivery in 

Afghanistan and Pakistan page 5 • PB 59 • October 4, 2010

Endnotes

1. Abby Stoddard, Adele Harmer and Victoria DiDomenico. “Providing aid in insecure environments. 2009 update: Trends in violence and the operational response.” Humanitarian Policy Group 

HPG Policy Brief 34. http://www.odi.org.uk/resources/download/3250.pdf

2. U.N. Office of Coordination of Humanitarian Assistance. “Humanitarian Space Easing in 

Afghanistan?” Integrated Regional Information Network (IRIN), July 8, 2010. http://www.reliefweb.

int/rw/rwb.nsf/db900SID/CJUE-876GKD?OpenDocument&RSS20=18-P 

3. Rod Norland. “Security in Afghanistan is Deteriorating, Aid Groups Say.” The New York Times, 

September 11, 2010.

4. “United States Institute of Peace and InterAction Guidelines for Relations between U.S. Armed 

Forces and Non-Governmental Humanitarian Organizations in Hostile or Potentially Hostile 

Environments.” http://www.usip.org/files/resources/guidelines_handout.pdf

5. Antonio Donini. Afghanistan: Humanitarianism under Threat. Einstein international Center 

briefing paper. 2009. https://wikis.uit.tufts.edu/confluence/download/attachments/22520580/

Donini-Afghanistan.pdf?version=1

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About This Brief

The ability of humanitarian health 

organizations to operate safely 

in Afghanistan and Pakistan is 

becoming increasingly difficult. 

This Peace Brief uses the work 

of one NGO, the International 

Medical Corps, as a case study 

to understand the factors that are 

contributing to the diminution of 

humanitarian space and actions 

that could possibly expand it.