Social Work in Public Health

ISSN: 1937-1918 (Print) 1937-190X (Online) Journal homepage: https://www.tandfonline.com/loi/whsp20

Armed Conflict in the Federally Administered

Tribal Areas of Pakistan and the Role of NGOs in
Restoring Health Services

Muhammad Ammad Khan, Jian Xiaoying & Nazish Kanwal

To cite this article: Muhammad Ammad Khan, Jian Xiaoying & Nazish Kanwal (2016)
Armed Conflict in the Federally Administered Tribal Areas of Pakistan and the Role of
NGOs in Restoring Health Services, Social Work in Public Health, 31:4, 215-230, DOI:
10.1080/19371918.2015.1099495

To link to this article: https://doi.org/10.1080/19371918.2015.1099495

Published online: 30 Mar 2016.

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SOCIAL WORK IN PUBLIC HEALTH
2016, VOL. 31, NO. 4, 215–230
http://dx.doi.org/10.1080/19371918.2015.1099495

Armed Conflict in the Federally Administered Tribal Areas of

Pakistan and the Role of NGOs in Restoring Health Services
Muhammad Ammad Khan,a Jian Xiaoying,a and Nazish Kanwalb
a
Department of Development Studies, China Agricultural University, Beijing, China; bDepartment of Agricultural
Economics and Management, China Agricultural University, Beijing, China

ABSTRACT KEYWORDS
The Federally Administered Tribal Areas (FATA) of Pakistan have been a Armed conflict; militancy;
hotbed of terrorists’ violence since 9/11. The unremitted armed conflict in the NGOs; health services; FATA
region and limited role of the government in delivering fundamental health
services has left the people at the disposal of nongovernmental organizations
(NGOs). This research aims at empirically substantiating the successful
strategies adopted by the NGOs to run their projects under threats and to
know the perceptions of the community toward NGOs and their services.
Triangulation methodology was adopted in collecting data. Based on results,
the research found that health care is a highly demanded service in the study
area, and the government does not have the capacity nor the resources to
ensure decent health coverage for all the people of the region. NGOs indeed
have a crucial role not only in building the capacity of the government and
the community but also in restoring and providing health services in the
region, but still many efforts are required to overcome the challenges they are
facing. By implication, the research places forward some recommendations.

Introduction
Armed conflict is a major public health hazard that cannot be ignored. It adversely affects civilians
directly, and indirectly, through the resulting complex emergencies1 (Branczik, 2004). Complex
emergencies are usually associated with widespread destruction of property, massive displacement
of populations, increasing morbidity, mortality, and high disease outbreaks. Consequently complex
emergencies require rapid and coordinated response to deliver essential services to the affected
population and reduce the likelihood of high morbidity, mortality, and disease outbreaks (Muriuki,
2005). In terms of providing health services in complex emergencies, nongovernmental organizations
(NGOs) play a very significant role. This role is short term, in the emergency phase of the conflict, and
long term, during the reconstruction phase. Waters, Garrett, and Burnham (2007) explained that in
conflict zones, usually in the health sector, humanitarian assistance focuses on three targets of
intervention that are broadly sequential: (a) meeting the immediate health needs of conflict-affected
populations, (b) restoring essential health services, and (c) rehabilitating the health system.
Meeting immediate health needs falls at the core of humanitarian and complex emergency crisis
response, and NGOs are at the forefront around the world, in some cases providing services while
conflict is still underway, not simply following cessation of violence. As experience in Liberia,
Mozambique, Sierra Leone, and Timor Leste demonstrates, interventions call for rapid ramp-up, urgent
infusion of resources and capacity, and concrete results, as the provision of health (along with other
services) is one of the critical demonstrations of the transition to peace (Organization for Economic
Co-operation and Development [OECD], 2008; Pavignani & Colombo, 2001; Vaux & Visman, 2005).
CONTACT Jian Xiaoying jianxy@cau.edu.cn Department of Development Studies, College of Humanities and Development,
China Agricultural University, No. 2 Yuanmingyuan Xi Lu, Haidian District, Beijing, 100193, P.R. China.
Color versions of one or more of the figures in the article can be found online at www.tandf.com/whsp.
q 2016 Taylor & Francis Group, LLC
216 M. A. KHAN ET AL.

After the urgent crisis for conflict-affected populations has been addressed, the next phase of
assistance shifts to designing a cost-effective package of basic services, setting priorities (e.g., getting
services to marginalize and/or underserved groups, targeting at-risk populations) and establishing
delivery mechanisms. NGOs also play a role here, and an increasingly popular approach is for donors
and country health ministries to contract jointly with NGOs for provision of a basic package of health
services. The governments of Afghanistan, Southern Sudan, and more recently the Democratic
Republic of Congo and its donor partners have applied the Basic Package of Health Services contracting
approach driven largely by the World Bank (Roberts, Guy, Sondorp, & Lee-Jones, 2008; Sondorp,
Palmer, Strong, & Wall, 2009).
In many countries, good health governance—which includes evidence-based policy making,
transparency and accountability, and citizen participation in influencing service priorities and delivery
—was weak prior to the emergence of conflict (Brinkerhoff & Bossert, 2008). Thus rehabilitation often
means creating new elements of the health system, not restoring something that existed previously but
was damaged during conflict. The public health system, as a component of the state, needs to develop
legitimacy in the eyes of citizens and be seen as effective, responsive, and accountable. This
rehabilitation phase puts a premium on capacity building of the health system to enable public health
actors to prepare budgets and plans, administer grants and contracts, manage human resources and
facilities, handle medicine and equipment logistics, and so on. For example, in postwar Ethiopia, donor
willingness to channel rehabilitation resources for essential drugs through the health ministry helped
the new government establish its legitimacy, as well as facilitating a quick return to basic services
provision through local health facilities (Macrae, 1997).
In general, NGOs participate in humanitarian intervention as moderate actors and specialized
groups of experts (Rucht, 2006). Their important contribution is widely recognized and acknowledged
at the 2010 UN General Assembly that “Without the work of NGOs around the world, much progress
on the Millennium Development Goals (MDGs) would have been impossible” (Worthington, 2013).

Background of the study

Since 9/11,2 the continued armed conflict between Pakistan Armed Forces and Al-Qaida and Taliban
militants has completely destroyed the socioeconomic life in Federally Administered Tribal Areas
(FATA). The insurgency has caused enormous death tolls and disabilities. According to South Asia
Terrorism Portal (SATP; 2014), more than 2,551 civilians have died in FATA from 2009 to 2014. The
armed conflict has resulted in the huge destruction of public properties, houses, health facilities,
educational institutions, and infrastructure of the region. So far, 458 educational institutions have been
destroyed including 317 for boys and 141 for girls (Ahmad, Naveed, Ullah, & Rashid, 2011). The
destruction of health centers and killing and kidnaping of doctors by the terrorists have made it more
complicated for the locals to access basic health facilities (International Crises Group [ICG], 2009). In a
study, Wazir and Din (2014) found that the destruction of hospitals had a negative impact on public
health particularly women who died while giving birth due to lack of access to basic health facilities.
Moreover, the intense armed conflict between the state and terrorist groups since 2004 has adversely
affected FATA causing a massive displacement of civilians. The displacement of people is a major social
and economic cost of serious conflict in the short as well as long term. So far, thousands and millions have
been displaced from FATA living in the Internally Displaced Persons (IDPs) Camps and with
host communities under critical circumstances (FATA Research Centre [FRC], 2013a; Internal
Displacement Monitoring Center [IDCM], 2014). Displacement usually precipitates physical illness
among affected populations during preflight, flight, and postflight periods. Wazir and Din (2014) explored
that in the IDP camps many children and pregnant women died and others suffered from serious illness.
Meanwhile, armed conflict profoundly affects the mental health of humans in the area. In the
majority of cases, conflict breeds violence which in turn increases psychological despondencies
among the masses (Murthy & Lakshminarayana, 2006). Scholars and doctors believe that military
operations, suicide attacks by the militants, bomb explosions, drone strikes, and internal
 SOCIAL WORK IN PUBLIC HEALTH 217

displacements have severe psychological impacts on the people of FATA (Khan, 2012). From
adults to the children and male to the female, everybody has been affected by the insurgency.
Even safety precautions such as long curfew hours have caused serious psychological harm and
health issues among the people in the area. Among the populations affected with psychological
disorders are children, particularly school-age boys and girls, and women having the highest ratio
in this respect. Analysts believe that children and women are more vulnerable to psychological
impacts. According to the mental health program of the Federal Ministry of Health, the majority
of children displaced in the wake of the military operations in FATA were the ages of 3 months
to 11 years, and they complained of problems including depression, phobias, acute stress disorder,
posttraumatic stress disorder, and insomnia (Din, 2010). According to a study conducted by the
Institute of Psychiatry London, depression and hypertensive disorders directly affects pregnant
women that triggers maternal mortality worldwide (Keane, 2007). Similarly, the maternal mortality
rate has been increased in the war-ravaged region of FATA as psychological illness become
prevalent due to armed conflict. More than 50% of pregnant women suffer from stress, depression,
and trauma (Yusufzai, 2012). In 2009, the Sarhad Hospital for Psychiatric Diseases (SHPD)
recorded about 97,000 psychiatric cases from the violence-hit areas of FATA. It has been
estimated that one in six people exhibit symptoms of psychological illness. Of approximately
90,000 patients examined at a local hospital in 2011, about 50,000 had been exposed to militant-
related violence or to the military operation (FRC, 2013b).
Hence, the unending decade-old armed conflict has further deteriorated the already abysmal state
of health care in FATA. According to Pinar, Ross, and Peters (2008) hundreds of health facilities
have been damaged, and about 450 health facilities are underequipped and are not regularly
functional due to fear and staff absence. Likewise, extreme poverty has further added to the miseries
of tribal inhabitants. Socioeconomic development of society is the prime duty of the state, but the
limited capabilities of the government have made it difficult to effectively respond to the growing
needs of affected people at a grass roots level. NGOs, at all levels, are now involved in emergency
relief and rehabilitation, peace and arms control, human rights, disaster management, health,
education and environmental protection in FATA. Regardless of their character, nature, and
primary intentions, NGOs’ ultimate objective is to make substantial contributions toward the
creation of a better and more stable community. Holding the hands of the government, NGOs are
directly and indirectly involved in humanitarian assistance and socioeconomic development of the
region (Huma, 2012).
This article is organized into five sections. In the first section, we describe how NGOs provide
health services in conflict zones by taking steps from emergency to rehabilitation process. The
section also explains the impact of armed conflict in FATA with a particular focus on the health
of affected people. In the second section, we present a brief overview of FATA and highlight the
situation of heath and health-care facilities before the armed conflict in the region. The third
section explains the methodology used in this research. Results and subsequent findings, based on
field experience are discussed in the fourth section. Finally, conclusion and some
recommendations close the article.

Overview of FATA before the armed conflict

Demography
Throughout history, FATA has always been an important region due to its strategic location. As an
important link between Pakistan and Afghanistan, it has been an important trade route between
Central Asia and South Asia. It is a mountainous region and shares an approximately 2,500-kilometer
border with Afghanistan known as the Durand Line.3 FATA comprises seven agencies and six frontier
regions,4 consisting of approximately 3,000 rural villages with an estimated population of 4.285 million
(FATA Development Statistics [FDS], 2010; ICG, 2006; Figure 1).
218 M. A. KHAN ET AL.

Figure 1. Map of Federally Administered Tribal Areas, Pakistan.

Socioeconomic profile
FATA is the most impoverished region with 60% of its population living below the national poverty line.
It contributes only 1.5% to the country’s economy. Residents in FATA have a per capita income that is
one half of the already-low national per capita income of $250 per year whereas the mean per capita
public development expenditure is reportedly one third of the national average (FDS, 2005). With a small
industrial and service sector base, more than 90% of the population derives its livelihood from
agriculture. Poverty and illiteracy are the biggest curses that have affected the social and economic growth
of the region. FATA has consistently been ranked as the most deprived area in the country against the key
sets of human development indicators including health, education, water and sanitation, housing, and so
on. (FATA Disaster Management Authority [FDMA], 2012). The overall estimated literacy rate is 24.05
percent compared to the 60 percent nationally. The male literacy level is 36.6% whereas the female
literacy level is a mere 10.5% compared to the national 48% for females (Bureau of Statistics [BOS], 2012).

Inadequate health facilities

Since independence, FATA has consistently been a low priority of the central government in Pakistan
(Orakzi, 2009). The people of this region face enormous difficulties in their daily lives as there are
negligible fund allocations for the socioeconomic uplift of the region. Sadly, there is only one health
facility on every 50 square kilometers serving a large clientele in the porous border regions. The total
number of hospitals in FATA is reported to be 33 with 302 dispensaries and 56 mother-and-child
health care center (Khyber Pakhtunkhwa Bureau of Statistics [KPKBS], 2011). According to a recent
study, there are about 577 doctors available for a population of 4.285 million people and 280 Lady
 SOCIAL WORK IN PUBLIC HEALTH 219

Health Visitors (LHV)5 for 1.8 million women in FATA (Burki, 2014). Although there are no private
hospitals, services are offered by private practitioners including unregistered doctors, local prayer
leaders, and faith healers (FATA Directorate of Health and Population Welfare, 2006). Counterfeit and
substandard pharmaceutical drugs are also widely available.

Disappointing health indicators

Similarly, health indicators for FATA are extremely disappointing. Communicable diseases are
prevalent, with the added risk of widespread HIV infection and a growing problem of drug addiction.
Access to reproductive health care is curtailed by cultural norms that restrict the movement of women in
the public sphere and prevent them from consulting male health care providers. These limitations are
compounded by the fact that modern health care practices (institutional delivery, neonatal care) are not
widely accepted. As a result, infant mortality is estimated to be high at 87 deaths per 1,000 live births,
whereas maternal mortality is estimated to be greater than 600 deaths per 100,000 live births (FATA,
Directorate of Health and Population Welfare, 2006). The rate of malnutrition for children and women is
also above the threshold of 11% to 14% (United Nations Children’s Emergency Fund [UNICEF], 2011).
Official records from the FATA Development Statistics (2005) show that 56% of the population is
supplied with drinking water, but less than one third of this supply is in the form of individual
connections to households. Sanitation facilities are even less available and more difficult to assess.
Overall, it appears that only 10% of the population has access to adequate sanitation in the form of toilets,
sewerage, drainage, and disposal of solid waste. Other development indicators paint a similarly dismal
picture of basic services (Government of Pakistan [GOP], 1998).

Increasing polio cases

FATA continues to grapple with polio outbreaks and holds the majority of the global cases every year
making Pakistan the major contributor of polio cases in 2014 as compared to Nigeria and Afghanistan
—the only three remaining endemic countries. With the total reaching 306 in Pakistan, at least 179
infected children belong to FATA (End Polio Pakistan, 2015). Maqbool (2012) explored that thousands
of families in different parts of the country refuse polio vaccination because of illiteracy and religious
rumors against the polio vaccine. Moreover, the failure of vaccination campaigns are also from the
lack of accurate polio vaccination coverage by the estimates and unaccountability of responsible
government officials. It has been reported that about 40,000 families refused antipolio drops during the
recently held polio campaign; of these, 19,000 families were from FATA and Khyber Pakhtunkhwa
Province (formerly known as North West Frontier Province).
In the present complex environment, NGOs have made visible contributions in providing health
services to the conflict-affected people of FATA. Therefore, this research aims to learn how NGOs
contact potential community stakeholders and audience, and what strategies NGOs develop to restore
and improve the health services on a sustainable basis in the ongoing armed conflict in FATA. In this
regard, the main objective of this research is empirically substantiating the combating role of NGOs in
providing health services to the affected people of FATA, whereas the specific objectives are to:
1. Describe the strategies adopted by the NGOs to successfully operate in the study area
2. Explore the health services provided by the NGOs in the study area
3. Pinpoint the perceptions of the community about NGOs in the study area
4. Identify the issues and challenges faced by NGOs in the study area.

Research methodology
This study is unique in its nature as FATA is the most sensitive region of Pakistan, and the continued
armed conflict in the region posed a challenge for conducting research in the field. By adopting careful
220 M. A. KHAN ET AL.

strategies, as a first step, the researchers officially obtained permission from the relevant government
authorities and security agencies for field visits and respondents’ interviews. Among the seven tribal
agencies of FATA, Bajaur and Kurram agencies were selected as the research sites for two main reasons;
first, they are the operating areas of selected NGOs, and secondly for security issues, financial, human,
and time resources available to the researchers.
Bajaur Agency is the smallest agency among all the seven tribal agencies, in FATA with a total
area of 1,290 square kilometers. Geographically, it holds strategic importance for Pakistan because it
borders Afghanistan’s Kunar Province with a 52-km-long border on the northwest. The terrain of
the agency is hilly, rugged, barren, and mostly arid. According to the BOS (2012), there are a total
of 447 state-owned health facilities6 for the population of about 803,000 in Bajaur Agency of which
13 health facilities were damaged during the armed conflict (fully damaged: five, partially damaged:
eight) in the agency.
Kurram Agency is the most scenic valley in the entire tribal belt of the Durand Line. The Agency
is bounded on the north and west by Afghanistan’s Ningarhar and Pukthia provinces. The total area
of the agency is 3,380 square kilometers that is mostly hilly and mountainous. According to the
BOS (2012), there are a total of 384 health facilities for 605,000 people in Kurram Agency, 27 of
which were damaged (fully damaged: seven, partially damaged: 20) during armed conflict in the
agency.
Lists of 138 registered NGOs (including international, national, and local) were obtained from the
pertinent government department, that is, Social Welfare Department, FATA Secretariat, Peshawar –
Pakistan. In the selection process, NGOs were identified on the basis of their completed and ongoing
projects from the lists. Then, a comparative analysis approach was used by comparing the common and
uncommon features and operating areas of the NGOs. Total 15 NGOs (five international, five national,
and five FATA-based local NGOs) were selected purposively that were involved in restoring the
damaged health facilities as well as providing health services to the affected people of Bajaur and
Kurram Agencies.
Triangulation methodology was adopted in this research because a single method can never
adequately shed light on a phenomenon. Using multiple methods can help facilitate deeper
understanding. Guion (2002) stated that triangulation methodology involves the use of multiple
qualitative and/or quantitative methods to study the program. If the conclusions from each of the
methods are the same, then validity is established. Figure 2 provides diagrammatic description of
triangulation and how it combines key informants, surveys, and secondary research to validate research
data.
For field data, all the damaged health facilities in both agencies were targeted to cross-check the
functioning of NGOs and to build a composite picture of role-playing by them in providing health
services for the affected communities. The respondents were selected by using purposive and simple
random sampling techniques from those areas where health facilities were damaged during the armed
conflict. The following Table 1 shows a proportional distribution of targeted respondents of each
agency.
Research was carried out over the course of 3 months, and interviews were held by adopting the
following approaches:

. In-depth interviews: Policies and strategies are usually derived by the top executives of
organizations. In this regard, mid- and high-level NGOs’ officials were interviewed in their
offices. The purpose of the interviews was to understand the basic operating strategies of the
NGOs in successfully running their projects in the study area.
. Key informant interviews: To understand the point of views of different stakeholders,
government officials were interviewed in their offices whereas the community elders, religious
scholars, and doctors and medical staff were interviewed in the study area.
. Structured interview: To know the views and perceptions of people who were affected toward
NGOs, the heads of household were interviewed in the villages.
 SOCIAL WORK IN PUBLIC HEALTH 221

Historical research
(qualitative & quantitative)
secondary data

Triangulation

Key information Surveys

(qualitative) (qualitative & quantitative)
primary data primary data

Figure 2. Triangulation method for cross-checking data.

Table 1. Distribution of Population and Sample Size.

Doctors (in
NGOs the government Head of Community Religious Scholars
Agency Representatives health intuitions) Households Elders (in the mosques)
Bajaur 15 25 100 10 10
Kurram 15 25 100 10 10
Note. NGO ¼ Nongovernmental organization.

. Individual and focused group discussions: Individual and group discussions were also
conducted with different groups of villagers to understand the facts and situations more clearly.
This technique is acknowledged as a good tool for gauging a community’s perception about a
particular issue or program.
. Personal observations: Personal observations helped the researchers to not only reflect upon
the responses during the interviews but also document analysis. It helped them to understand
the structure and role of NGOs in the study area.
. Research ethics: Ethical consideration was very important for this research; as FATA is a
sensitive region in terms of its unique culture and strict Islamic followings; therefore, the
research upheld all possible ethical principles during the study. Information provided during
interviews was treated with high privacy and confidentiality. Respondents were not required to
state their names on the questionnaire. The respondents were informed of all data collecting
devices before the interviews started.
. Deception: Deception occurs when researchers present their research as something other than
what it is (Bryman, 2004). In most of the cases the researchers felt that the local people would
perceive this research as something that it was not, but the researchers always tried to explain
that they were not representing an NGO that would start a program to end their suffering. The
researchers also ensured the NGOs that the research is commissioned with respect to their
academic study only.
222 M. A. KHAN ET AL.

Secondary sources of data, in the form of NGO reports, government statistics, published academic
papers, news reports, and other written material were applied to form part of the analysis. The primary
data were analyzed through Statistical Package for Social Sciences (SPSS-20) and MS Excel programs
for compilation and calculation of descriptive statistics.

Results and discussion

3Cs strategy of NGOs

During interviews, the NGOs’ representatives explained that, as per government instructions, all the
NGOs (international, national, and FATA-based local) are required to employ 50% FATA-based local
staff for field operations. NGOs are bound to create culturally compatible and locally driven projects by
adopting all the humanitarian principles.7 They described that in FATA, strategies are carried out via
different implementational mechanisms, encompassing the three major processes of cooperation,
collaboration, and coordination. Figure 3 shows the 3Cs strategy of NGOs.
The representatives explained that these mechanisms are extremely important part of relief and
rehabilitation activities and operational efficiency. By communicating and sharing information about
various regions, hotspots, or dangers that exist in the tribal region, NGOs understand more where
they can deliver humanitarian assistance. In sum, before launching their projects in FATA, NGOs use
top-down and bottom-up approaches by cooperating with security forces, coordinating with the
local government, donor agencies, and other NGOs and collaborating with targeted communities.
Involving local communities and hiring local experts is more effective because through their local
knowledge, contacts, and grassroots links, they help the community by enabling them to better deal
with their own problems and give them the strength to address those problems in a coherent way,
without having to put all of their energy into simply maintaining themselves, commonly called local
capacity building. Their structure allows for decision making at the grassroots level and enhances
their ability to provide basic public services. By encouraging local participation and involvement, the
democratic system strengthens overall, which leads to build trust for better provisions of health
services at the local level by paying attention to the needs and demands of the local population. In a
study, Farooq, Hedieh, and Waleed (2009) also explored that in FATA’s tribal society it is important
to achieve consensus and support from all members of the community before beginning a project.
Understanding and working within local cultural norms, tribal customs, and local social structures is
very important. Microlevel projects yield quick, tangible results and are effective in building initial

Cooperation

Coordination Collaboration

Figure 3. 3C’s strategy of nongovernmental organizations.

 SOCIAL WORK IN PUBLIC HEALTH 223

trust that can be leveraged for further long-term projects. International donor agencies and NGOs
establish local community-development liaison teams to help plan and implement development
schemes.
Therefore, all these interventions of cooperation, collaboration, and coordination during conflict,
whether led by NGOs, state government, or by the security forces, are very important steps in the right
direction, which help, to a major extent, in the smooth functioning of the relief and rehabilitation
services in FATA. However, the precise strategy of each NGO varies considerably in terms of their
relationships with the state, donor, and political organizations and also existing situations in the
implementation areas.

Transition strategy of NGOs

NGOs also support a transition strategy to rebuild the health system destructed during the armed
conflict in Bajaur and Kurram Agencies. Figure 4 provides a diagrammatic example of a transition
strategy that moves from bypass to partnership with an increasing emphasis on systems issues. This
illustrates how international and local NGOs, donor agencies, and government work together to restore
the health system after the breakdown in public institutions and services.
The representative of NGOs explained that this strategy is very important into restoring health
services in the region. They explored that most of the NGOs are targeting people who are displaced
and in the IDP camps and providing them basic medical facilities on an emergency basis. Upon the
announcement of Pakistan Armed Forces, the people who were displaced are now returning to their
homelands, and there is a dire need to restore the damaged health facilities on priority basis.
Therefore, NGOs are currently involved in restoring the health facilities and alleviating the suffering
of the population traumatized by the conflict. The representatives further described that the
government with collaboration of NGOs has also launched a foreign-funded “Basic Health Program”
to improve the basic health care services for the people of the Agencies. Under this partnership,
NGOs are responsible for implementing and executing the program on their own set of aims and
responsibilities. These NGOs have signed a Memorandum of Understanding (MoU) with the
government and will gradually withdraw from the region as per the agreement, and finally the
government will take the management control of all health facilities in the future that will lead to
sustainable development of health services.

Figure 4. Transition of sustainable health system development.

224 M. A. KHAN ET AL.

Health services by NGOs

Interviews with doctors and medical staff

During interviews, the doctors and medical staff explained that the intense armed conflict has
extremely damaged the health facilities in both agencies. Due to the absence of doctors and medical
staff (particularly female staff), and lack of medicine and medical equipment, it’s a great challenge for
the limited doctors to handle all the emergency cases. The people of the area and adjoining villages are
facing huge difficulties in obtaining medical check-ups and proper treatments as there are many
patients with different diseases. The response from the government is very slow, and due to fear the
doctors and nurses hardly visit these health facilities. They further explored that there are very limited
NGOs providing assistance to these damaged hospitals and other health units in both Agencies. They
described the following health services that have been provided by the NGOs according to their
projects’ duration.
From Table 2, it can be seen that these health services are very important for the people who are
affected, but there is a dire need of long-term projects rather than limited and short-term projects. The
hospitals and health units need proper attention and strong support from the government, and the
involvement of more NGOs would lead to overcome the need for health services in the regions.

Interviews with head of household, religious scholars, and community elders

The head of households, religious scholars, and community elders criticized the government for its
disinterest in providing proper health care to the people. They expressed concern over the lack of health
care facilities and shortage of doctors and other staff even in the Agency headquarter hospitals and
other health units in both Agencies. They identified the following health services provided by the NGOs
in their villages (Table 3).
According to the NGOs’ representatives, the humanitarian situation in many parts of the Agencies
remains a concern, particularly for persons who are displaced. Most of the local and international
NGOs continue to deliver basic services in increasingly crowded camps. Although the Ministry of
Health in the tribal Agencies has undertaken several immunization campaigns, primary health services

Table 2. Provision of Health Services within the Damaged Government Health Facilities.
No. Health Services
1. Repair and renovation of existing buildings
2. Provision of essential medical equipment including those for people with disabilities
3. Establishment of Diarrhea Treatment Centers, Malaria Microscopy Centers, and Rapid Diagnostic Test Centers
4. Establishment of primary health care and special treatment centers to save children from starvation and malnutrition
5. Provision of pregnant women with pre- and postnatal care and family planning services
6. Provision of trained doctors and medical staff on a temporary basis
7. Capacity building trainings of Lady Health Visitors (LHVs) and other medical staff
Source. Field data, 2014.

Table 3. Provision of Health Services to the Households.

No. Health Services
1. Distribution of first aid kits and hygiene kits among the children and women
3. Health and hygiene awareness programs at household and community level
4. Provision of basic medicine for pregnant women and infants
5. Vaccination programs for children younger than age 5 to protect them from diseases
6. Establishment of medical camps, mobile clinics and emergency ambulance service
7. HIV & AIDS awareness programs from personal to community level
8. Psychological counseling services particularly for women
9. Installation of water purification and filtration plant for safe drinking water at community and household level
10. Water and sanitation support
Source. Field data, 2014.
 SOCIAL WORK IN PUBLIC HEALTH 225

60%

50%

40% 40%

Percentage
Head of Households
Community Elders
30% Religious Scholars
23% Doctors
20% 20% Average

10% 10%
7%

0%
1 0.75 0.5 0.25 0
Scale

Figure 5. Satisfaction levels of respondents.

are generally in a catastrophic situation in these areas. The respondents from Bajaur Agency reported
that 10 women who worked in grazing fields have died due to unknown disease in the area. The deaths
have spread fear and panic in the area. and people have instructed their women and children not to visit
the fields. On the other hand, the NGOs were of the view that due to scarce health facilities they also
have referral mechanism to reduce the risk of complex emergency situations. However, the respondents
appreciated the health services provided by the NGOs.

Satisfaction levels of the respondents regarding services provided by the NGOs

To understand the experiences and satisfaction of the community regarding health services provided by
NGO in the study area, different stakeholders, that is, head of households, community elders, religious
scholars (Islamic), and doctors in the health facilities were interviewed and asked to rate their
satisfaction levels. Figure 5 indicates that on average 20% of the respondents were highly satisfied from
the services provided by the NGOs in the study area. Similarly, 40% of respondents said that the
services were just satisfactory, 23% said that the services were partially satisfactory, 10% believed that
the services were unsatisfactory, and only 7% reported that the services were highly dissatisfactory.
The respondents explained that the distributions of essential medical supplies to the health centers
were insufficient. They further reported that due to political interference from their agency’s political
agents, the assistance was not equally distributed in the area. The NGOs worked under the directions of
political forces and also were present where they sought their own interests. But the respondents agreed
that compared to the government overall performance of the NGOs is satisfactory.

Overall perception of the respondents about NGOs

When the respondents were asked about their perception toward NGOs, the majority (79%) of them
reported that they believed if there were no NGOs during the critical situation and insurgency in FATA,
it would be very hard for them to survive. They agreed that the role of NGOs compared to that of the
government was effective. On the other hand, only 21% of the respondents expressed that the presence
of NGOs in the area is based on Western hidden agenda. They believe that NGOs are providing aid, but
they have a secret agenda behind the aid that involves personal benefits. They reported that NGOs are
trying to demolish our cultural norms in the name of women’s rights and girls education and promote
Western culture. In addition, they claimed that the polio vaccination is used as a tool to damage
the reproductive abilities of our new generations and that the day is not far away when these spies make
us slaves. Figure 6 illustrates the perception of respondents toward NGOs.
226 M. A. KHAN ET AL.

90%
79%
80%

70%

60%
Percentage 50%

40%

30%
21%
20%

10%

0%
Positive Negative

Figure 6. Overall perception of respondents.

In a study, Noor Akbar (2010) also described that in recent years NGOs have made efforts toward
the social uplift of FATA. Aside from their visible achievements in the humanitarian and development
sector, there are many negative perceptions attached with NGOs. However, when the NGOs’
representatives were asked about the negative perceptions that the people held, they described that
NGOs know all about such perceptions in the area. The negative perceptions were created by the
militants and extremists by using tactics in the name of religion. Moreover, they explored that some
FATA-based local NGOs have unqualified workers who don’t prioritize humanitarian principles.
That’s why there are some negative perceptions attached with NGOs. Under these circumstances the
NGOs are now also working on awareness and informal educational activities for the people to create a
positive image of NGOs and their workers.

Challenges faced by NGOs

The representatives of selected NGOs explored that need assessment of the people who are affected,
negotiation for access, resource mobilization, delivery of services, coordination, and strategic planning
are all issues that NGOs tackles. However, Figure 7 illustrates the challenges faced by the NGOs in the
study area. The majority (68%) of the representatives reported that NGOs are confronting militancy
issues. Due to the current insurgency, foreign workers of international NGOs and donor agencies
cannot visit the tribal areas directly. Due to the threats received by the militants, they cannot freely
move in FATA. They experienced snatching of their vehicles, attacks on their offices, and kidnaping of
their workers. Due to insecurity, their offices are established in Peshawar,8 and they can’t open full-
fledged offices in the tribal region. About 12% of the representative expressed that the government
influence and strict directions caused complications in launching their projects. The NGOs must bow
to the political aspirations of the government to obtain No Objection Certificate (NOCs) from the
authorities that is a very complicated and time-consuming process. About 7% described that sometimes
delays occur in the field activities due to curfew imposed by the security forces in the region and that
prevents families from visiting health facilities, even for emergency cases. Of the total 9%, the
representatives said that due to illiteracy, rumors, and religious extremism in the community, NGOs
face hardships in running their project activities. This resistance affects the success of projects. Not
surprisingly, the situation has been more problematic for women, who are generally limited in their
access because of poverty, cultural norms, or a lack of female staff; these obstacles severely affect their
use of natal care and other related services. Some 4% of the representatives further described that NGOs
themselves are pressured by the wants of their donors. Lack of funding is a limitation that has prevented
 SOCIAL WORK IN PUBLIC HEALTH 227

80%
68%
70%

60%

50%
Percentage

40%

30%

20%
12%
9% 7%
10% 4%

0%
Militancy Community Government Security Donors
Agencies

Figure 7. Challenges faced by NGOs.

them from expanding their activities and reaching a wider range of beneficiaries. They could expand
humanitarian work if they had increased access to funds.

Conclusion and recommendations

Health care is a highly demanded service in FATA. However, the government does not have the capacity
nor the resources to ensure decent health coverage for all the people of this region. As a consequence,
public authorities have lost the monopoly on public health service provision and now share
responsibilities with NGOs. Not only building the capacity of the government and community, NGOs no
doubt are playing a major role in service provision but also have cultural sensitivity and security
challenges to operate in the region. In FATA’s tribal society, it is important for NGOs to achieve
consensus and support from all members of the community before launching a project. It is important
to work with local organizations and individuals because they have “the most direct contact” with
communities in highly divided conflict-affected environments. Microlevel projects yield quick, tangible
results and are very effective in building initial trust and working relationships, which can be leveraged for
further long-term projects. Given the instability and security concerns in FATA, NGOs cannot expect to
implement sustainable development schemes in the center of conflict zones. As a result, international
NGOs have had limited mobility and have been unable to directly monitor their programs.
Bringing an end to war and civil strife in FATA must be the overriding priority for the national
government and the international community. However, the government, UN agencies, and
international donors can do more to meet the basic survival needs of the FATA’s population. The
government should take urgent action to address the humanitarian needs of the FATA people.
Measures should include:
1. Explicit orders should be given to the security forces that they, like all armed groups, should not
harm civilian life, property, or infrastructure, and should respect the population’s right to
assistance.
2. Given security concerns, NGOs should begin by implementing programs in the stable
peripheries of FATA. The success of graduated programs would encourage neighboring regions
within FATA to replicate the efforts.
3. To create a program for FATA and engender trust, NGOs programs have to adhere to local
cultural norms, gender relations, and tribal customs. Projects cannot be seen as challenging
these norms.
228 M. A. KHAN ET AL.

4. NGOs should work closely with moderate religious leaders, who, as educators and social service
providers, are naturally positioned to counter radical ideologies as well as supportive in
spreading awareness.
5. Donors should provide increased emergency funding that is readily accessible and flexible.
In particular, donors must build on discussions underway with NGOs to better understand
“remote programming” and mechanisms for monitoring and verification.
6. Local authorities should assume greater responsibility for providing health services and
essential facilities to displaced people arriving in their jurisdiction, and to vulnerable local
populations. They should also be given the power and resources by to do so by the government.

Notes

1. Complex emergencies often refer to the designation of complexity reflected in the multiple political, economic, social, ethnic,
and religious factors that lead first to the conflict, and then, prevent its resolution (Burkle, 2002).
2. The incidence of terrorists’ attack on the World Trade Center, New York, USA on September 11, 2001.
3. In 1893, British civil servant Sir Henry Mortimer Durand and the ruler Amir Abdul Rehman Khan demarcated boundaries
between Afghanistan and British India that was named as “Durand Line” (Aslam, 2008).
4. The seven agencies of FATA are Bajaur, Mohmand, Khyber, Orakzai, Kurram, North Waziristan and South Waziristan, and
the six frontier regions (FR) are Peshawar, Kohat, Bannu, Lakki, Tank, and D.I. Khan.
5. In Pakistan, particularly in FATA, women are largely dependent on men (family members), and access to health services is
nothing more than a nightmare to tribal women during pregnancy. The Lady Health Visitors (LHVs), therefore, visits the
homes for women counselling, provide basic health care assistance and family planning advices.
6. The health facilities included the agency headquarter hospital, tehsil headquarter hospitals, rural health centers, basic health
units, community health centers, dispensaries and clinics, and so on.
7. Humanitarian principles of humanity, impartiality, neutrality, and independence form the basis of the “Code of Conduct for
the International Red Cross and Red Crescent Movement and NGOs in Disaster Relief.” The code provides a set of common
standards for organizations involved in humanitarian activities, including a commitment to adhere to humanitarian principles.
These principles provide the foundations for humanitarian action and are central to establishing and maintaining access to
affected people, whether in a natural disaster or a complex emergency, such as armed conflict.
8. Peshawar is the nearest settled city to FATA and also the capital city of Khyber Pakhtunkhwa province of Pakistan.

References
Ahmad, K., Naveed, A. T., Ullah, S., & Rashid, T. (2011). Role and performance of government and NGOs in relief
assistance: A case study of 2005 earthquake. Interdisciplinary Journal of Contemporary Research in Business, 3(2),
1726 –1736.
Akbar, N. (2010). Women rights in FATA Pakistan: A critical review of NGOs’ communication strategies for projects’
implementation (master’s thesis). Department of Social Anthropology, University of Tromsø, Tromsø, Norway.
Aslam, R. (2008). Rethinking “Wana”: A game theoretic analysis of the conflict in the tribal region of Pakistan. Studies
Conflict Terrorism, 31(8), 665 –683.
Branczik, A. (2004, February). Humanitarian aid and development assistance. Beyond Intractability. Conflict Information
Consortium, University of Colorado, Boulder, CO. Retrieved from http://www.beyondintract ability.org/essay/humani
tarian-aid
Brinkerhoff, D. W., & Bossert, T. J. (2008). Health governance: Concepts, experience, and programming options (Policy
Brief for Health Systems 20/20). Retrieved from: https://www.hfgproject.org/wp-content/uploads/2015/02/Health-
Governance-Concepts-Experience-and-Programming-Options.pdf
Bryman, A. (2004). Social research methods (2nd ed.). New York, NY: Oxford University Press.
Bureau of Statistics (FATA Cell). (2012). Important agency/FR wise socio-economic indicators of FATA. Peshawar,
Pakistan: FATA Secretariat, Planning and Development Department.
Burki, A. U. (2014). Frontier Crimes Regulation restricts citizen rights. FATA Reforms. Retrieved from http://fatareforms.
org/2014/07/01/frontier-crimes-regulation-restricts-citizen-rights-aamirusman-burki/
Burkle, F. M. (2002). Complex emergencies: An introduction. Prehospital and Disaster Medicine, 16(4), 182 –183.
Din, N. U. (2010). Internal displacement in Pakistan: Contemporary challenges. Human Rights Commission of Pakistan.
Retrieved from http://hrcp-web.org/hrcpweb/wp-content/pdf/ff/22.pdf
End Polio Pakistan. (2015). Polio cases in provinces. Retrieved from http://www.endpolio.com.pk/polioin-pakistan/polio-
cases-in-provinces
Farooq, M., Hedieh, M., & Waleed, Z. (2009). Developing FATA, A white paper for USAID. WORDE Reports. Retrieved
from http://www.worde.org/wp-content/uploads/2011/12/DevelopingFATA.pdf
 SOCIAL WORK IN PUBLIC HEALTH 229

FATA Development Statistics. (2005). Peshawar, Pakistan: Government of NWFP, Planning and Development
Department, Bureau of Statistics.
FATA Development Statistics. (2010). Peshawar, Pakistan: Government of NWFP, Planning and Development
Department, Bureau of Statistics.
FATA Directorate of Health and Population Welfare. (2006). Brief on health care. Peshawar, Pakistan: FATA Secretariat,
Planning Cell.
FATA Disaster Management Authority. (2012). Monsoon contingency plan for FATA. Peshawar, Pakistan: Author.
FATA Research Centre. (2013a). A seminar on IDPs of FATA: Issues and challenges. Retrieved from http://frc.com.pk/wp-
content/uploads/2013/06/IDP-SEMINAR-REPORT_2.pdf
FATA Research Centre. (2013b). Social and psychological impact of violence in FATA. Islamabad, Pakistan: Author.
Government of Pakistan. (1998). Economic survey of Pakistan, 1997 – 98. Islamabad, Pakistan: Finance Division,
Economic Advisor’s Wing.
Guion, L. A. (2002). Triangulation: Establishing the validity of qualitative studies. Gainesville, FL: University of Florida,
Institute of Food and Agricultural Sciences. Retrieved from http://rayman-bacchus.net/uploads/documents/Triangulati
on.pdf
Huma, Z. (2012). Mainstreaming gender into conflict and peace building through women led madras’s in Pakistan.
International Journal of Academic Research in Business and Social Science, 2(7), 290 –305.
International Crises Group. (2006). Pakistan’s tribal areas: Appeasing the militants (Asia Report 125). Islamabad,
Pakistan: Author.
International Crises Group. (2009). Pakistan: Countering militancy in FATA (Asia Report 178). Islamabad, Pakistan:
Author.
Internal Displacement Monitoring Center. (2014). Pakistan IDP figures analysis. Retrieved from http://www.internal-
displacement.org/south-and-south-east-asia/pakistan/figures-analysis
Keane, V. O. (2007). Depression during pregnancy. British Medical Journal, 334, 1003–1005.
Khan, Z. A. (2012). Military operations in FATA and PATA: Implications for Pakistan. Journal of Strategic Studies,
31(4) – 32(1), 129 –146.
Khyber Pakhtunkhwa Bureau of Statistics. (2011). Khyber Pakhtunkhwa in Figures 2011. Retrieved from http://www.
khyberpakhtunkhwa.gov.pk/Departments/BOS/fatadevstat-abs-health.php
Macrae, J. (1997). Dilemmas of legitimacy, sustainability and coherence: Rehabilitating the health sector. In K. Kumar
(Ed.), Rebuilding societies after civil war: Critical roles for international assistance (pp. 183 –201). Boulder, CO: Lynne
Rienner.
Maqbool, S. (2012, September 7). Save the Children leaves anti-polio programme in disarray. The News International.
Retrieved from http://www.thenews.com.pk/Todays-News-6-130493-Save-the-Children-leaves-anti-polio-programme-
in-disarray
Muriuki, D. W. (2005, May). Contribution of NGOs in complex emergencies humanitarian health action. Paper presented
at World Health Organization Conference on the Health Aspects of the Tsunami Disaster in Asia, Phuket, Thailand.
Murthy, R. S., & Lakshminarayana, R. (2006). Mental health consequences of war: A brief review of research findings.
World Psychiatry, 5(1), 25– 30.
Orakzi, A. M. J. (2009). Situation in FATA: Causes, consequences and the way forward. Policy Perspectives, 6(1), 27–42.
Organization for Economic Cooperation and Development. (2008). Service delivery in fragile situations: Key concepts,
findings and lessons (OECD Development Assistance Committee Discussion Paper). Paris, France: Author. Retrieved
from http://www.oecd.org/dac/governance-peace/conflictandfragility/docs/40886707.pdf
Pavignani, E., & Colombo, A. (2001). Providing health services in countries disrupted by civil wars: A comparative analysis
of Mozambique and Angola 1975-2000. Geneva, Switzerland: World Health Organization, Department of Emergency
and Humanitarian Action.
Pinar, P., Ross, S. R., & Peters, J. (2008). Mid term evaluation the USAID/Pakistan Maternal, Newborn and Child Health
Program. Retrieved from http://pdf.usaid.gov/pdf_docs/PDACM873.pdf
Roberts, B., Guy, S., Sondorp, E., & Lee-Jones, L. (2008). A basic package of health services for post-conflict countries:
Implications for sexual and reproductive health services. Reproductive Health Matters, 16(31), 57– 64.
Rucht, D. (2006). Critique of capitalism in the era of globalization – Old wine in new bottles? In J. Richter, S. Berking, &
R. Muller-Schmi (Eds.), Building a transnational civil society. Global issues and global actors (pp. 109 –134). London,
England: Palgrave.
Sondorp, E., Palmer, N., Strong, L., & Wali, A. (2009). Afghanistan: Paying NGOs for performance in a post-conflict setting.
Performance incentives for global health, potential and pitfalls. Washington, DC: Center for Global Development.
South Asia Terrorism Portal. (2014). FATA assessment 2014. Retrieved from http://www.satp.org/satporgtp/countries/
pakistan/Waziristan/index.html
United Nations Children’s Emergency Fund. (2011). Early Recovery Working Group bulletin for FATA. Peshawar,
Pakistan: FATA Disaster Management Authority. Retrieved from http://www.undp.or.jp/uploads/pdfs/133006439001.
pdf
Vaux, T., & Visman, E. (2005). Service delivery in countries emerging from conflict (Report for DFID). Bradford, England:
University of Bradford, Centre for International Co-operation and Security, Department of Peace Studies.
230 M. A. KHAN ET AL.

Waters, H., Garrett, B., & Burnham, G. (2007). Rehabilitating health systems in post-conflict situations. (Working papers
6). Helsinki, Finland: United Nations University, World Institute for Development Economics Research.
Wazir, M. A. K., & Din, U. I. (2014). Impact of war on terror on maternal mortality. TIGAH: A Journal of Peace and
Development, (5), 19 –44.
Worthington, S. A. (2013). The role of U.S. NGOs in global development and humanitarian work. (Policy Paper).
InterAction: A United Voice for Global Change. Retrieved from http://www.interaction.org/files/FABB%
202013_Sec01_PolicyPaper_RoleOfNGOs.pdf
Yusufzai, A. (2012, April 16). War on Terror traumatises Pakistani women. Inter Press Service (IPS) News Agency.
Retrieved from http://www.ipsnews.net/2012/04/war-on-terror-traumatises-pakistani-women/