Video Spotlight

"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.

By: 
Iain Aitken, Advisor on Community-Based Health Care to the Ministry of Public Health, Afghanistan, and Said Habib Arwal, Head of the Community-Based Health Care Department of the Ministry of Public Health, Afghanistan

Case Studies of Large-Scale Community Health Worker Programs was derived from the Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers, edited by Henry Perry, Lauren Crigler, and Steve Hodgins.

Originally published in May 2014 by USAID’s flagship Maternal and Child Health Integrated Program (MCHIP), it was created in response to the rapid increase in and expansion of CHW programs in low- and middle-income countries over the past decade. In January 2017, a companion document was prepared to provide guidance on 13 case studies, including Afghanistan, Bangladesh, Brazil, Ethiopia, Niger, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe. CHW Central is serializing the case studies over time.  

The first case is about Afganistan.


Summary

Background
The Afghanistan CHW program is part of the community-based health care (CBHC) component of the Basic Package of Health Services (BPHS), which was developed in 2003 after the end of 25 years of violence and conflict. At the present time, there are approximately 19,000 CHWs.

Implementation

CHWs are based in pairs at health posts as a male and female team, usually as spouses or as family members. They are trained and supervised by NGOs who have contracts from the government to implement the BPHS, including CHW training and supervision, in specific districts.

Training
CHWs receive three separate three-week modules with a month of field experience in the village in between. Trainers attempt to visit all the trainees in their villages during the month of field experience.

Roles/responsibilities
CHWs provide a comprehensive set of services from health promotion to provision of health services to referral to the next level of care at a Basic or Comprehensive Health Center. Of note is their capacity to carry out community case management of acute childhood illness (pneumonia, diarrhea, and malaria, where malaria is endemic), treatment of patients diagnosed with tuberculosis (TB), and provision of family planning (FP) commodities.

Incentives
CHWs are volunteers.

Supervision
Each health facility supporting health posts has a Community Health Supervisor (CHS). CHSs visit monthly each health post where a pair of CHWs is based, and the CHWs come monthly to the “parent” health facility where the CHS is based for a joint meeting with the other CHWs.

Impact
CHWs now provide a major portion of primary health care (PHC) services in Afghanistan and are widely recognized as one of the important contributors to Afghanistan’s marked improvement in health status during the past decade.

 

What is the historical context of Afghanistan’s Community Health Worker Program?

For almost 25 years, from 1978 to 2002, Afghanistan suffered from war and internal conflict. Before 1978, the health system had not been very well developed, and after conflicts ceased in 2002, there were only a limited number of health facilities, and these were run by the government or by NGOs. Most health professionals had fled the country if they could. The population was largely illiterate and social and economic structures were very weak.

The transitional Islamic Government of Afghanistan made two key decisions for the development of the health services in 2003. The first was the development of the BPHS. In consideration of the primary health needs of the population; the availability of effective, evidence-based interventions; the levels of resources required; and the goal of creating an equitable health system, priority was given to the health of women and children. The second decision, in light of the nonfunctioning of the government health delivery system, was to contract out health care delivery to NGOs through a series of partnership agreements. Funding of these contracts was provided by the World Bank, the US Agency for International Development (USAID), and the European Union. This arrangement has continued and has been developed over the past 10 years.

A key element of the BPHS was the inclusion of a CBHC component, centered on the use of CHWs at a village health post. The innovation that had not been a part of previous attempts to use CHWs was that each health post should have one female CHW as well as one male CHW. The inclusion of female CHWs was considered necessary because of the constraints that women and their children faced in obtaining services at health facilities. These constraints arose because of security issues as well as cultural norms.

In 2004, agreement was reached on a job description for the CHWs, a CHW training curriculum and training manual were completed, and training of CHWs by NGO trainers started. The NGOs had targets for the numbers of CHWs to be trained. Within the first year it became very clear that the expectation that health facility staff would be able to make time to provide supervision to the CHWs was proven unrealistic. In 2005, therefore, a new category of CHSs was created. These were envisioned as full-time staff based at the peripheral health facilities.

 

Key health needs
Much of Afghanistan’s population is scattered across deserts, and another major portion of the population lives in remote mountain valleys that are usually cut off for several months during winter. So the development of accessible health services is a major health challenge that can only be met through the development of community-based programs.

A further challenge was the weakness of the existing health facilities. In 2003, for instance, only 24% of hospitals had the capability of performing cesarean sections. Furthermore, only 21% of health facilities had female health staff (a necessity if women are going to be examined by a trained health provider), and only 467 midwives were available in the entire country. This all contributed to a maternal mortality ratio (MMR) estimated at 1,600 per 100,000 live births, an under-5 mortality rate of 257 per 1,000 live births, a child stunting rate of 48%, a total fertility rate of 6.7, and a crude birth rate of 48 per 1,000 population. Only 23% of the population had access to safe water and 12% had improved sanitation. More than 50% of the population was at risk of malaria. Only 8% of pregnant women received skilled antenatal care (ANC) and only 14% of women delivered in a health facility. The contraceptive prevalence rate (CPR) was 8.5% and the child immunization rate was 30%. As a result of the war there was also a considerable burden of disability among soldiers and the civilian population, including mental illness.

Health system structure
The government health system operates in each of the 34 provinces. Each province has a provincial referral hospital, and each district in the province has a district hospital. In addition, there are many Basic Health Centers and Comprehensive Health Centers staffed by doctors, nurses, and midwives, whose numbers correspond to the size of the populations they serve and their workload. Each of the district-level facilities has a network of health posts with CHWs in its catchment area. The median number of health posts per health facility is now between 15 and 20. However, some facilities support up to 50 health posts. Each health post is supposed to have one male and one female CHW, and serve a maximum of 150 households.

Scope of work of the CHWs
The CHW is active in the following activities.
Health promotion (through personal and group activities, including Family Health Action (FHA) Groups, with the support of a village health committee, the Shura-e-sehie). Topics addressed are the following:

  • Safe water and sanitation, personal and food hygiene
  • Prevention of malaria, including use of insecticide-treated bed nets (ITNs)
  • Safe pregnancy, childbirth preparedness, and care in the postpartum period
  • Pregnancy and child nutrition, including breastfeeding
  • Immunization
  • Birth spacing and contraception
  • Use of maternal and child health (MCH) and birth spacing services at the health facility

Direct patient care services:

  • Community case management of childhood illnesses and referral of complicated cases
  • Screening for and referral of suspected TB cases, and community-based treatment of cases with directly observed therapy (DOT)
  • Counseling about and provision of contraceptives
  • First aid and trauma management

Management activities:

  • Getting to know the families in the community and maintaining a community map showing families requiring or using particular services
  • Reporting vital events (births, maternal deaths, and deaths among children younger than 5 years of age), and submitting a monthly report for the national health management information system (HMIS) of all health post activities
  • Managing the health post and maintaining all equipment, supplies, and drugs

Community roles
Each community with a health post has a health committee—the Shura-e-sehie. The shura members are selected by the community with help from the CHW, the CHS, and the head of the health facility. The health shuras provide leadership and support to all health-related activities in their communities. They select, support, and supervise the CHWs in the community. They encourage families to make full use of preventive and curative health services. They provide leadership in the adoption and promotion of new behaviors and social norms.

Attempts at different times to form women’s health shuras have met with varying degrees of success. However, women’s FHA Groups have proved very effective in promoting healthy behavior change among women and their families. The female CHW selects a group of 10–12 women who are respected in the community and whom she trusts. They are given a series of monthly “lessons” on important health topics, including home hygiene, diet and nutrition, care of newborns and young children, and use of health services. Each woman is encouraged to put the lessons into practice and then demonstrate and share them with the women from 8–10 of the households in her neighborhood. In about one-third of the provinces, the FHA Groups have also carried out growth monitoring of children in the community.

CHW selection process and criteria
CHWs are selected through a consultation process between the NGO staff and the community elders. Each health post is supposed to have a male and a female CHW; these are frequently spouses or other close relatives, allowing them to work together. They should be more than 18 years old and be respected members of the community. There has been no upper age limit.
There is no education requirement, but if a person with education meets the other criteria, they may be preferred.

Training of CHWs
The basic training course for the CHWs consists of three separate 3-week modules with a month of field experience in the village in between when CHWs can practice their new skills before moving on to the next module. The trainers attempt to visit all the trainees in their villages during the practical month.

The modules are designed to take the CHWs from simpler to more complex skills. The first module deals with common infectious diseases, environmental and personal hygiene, the prevention of malaria and diarrhea, some principles of health education, and the management of diarrhea and eye and skin infections. The second module is on promoting MCH. This includes the CHW’s role in ANC and birth preparedness, postnatal and newborn care, breastfeeding and nutrition, and immunization. The CHWs also learn some basic first aid. The third module includes community case management of childhood illnesses, TB, birth spacing promotion and provision of contraceptive methods, and further skill development in talking with people about sickness, treatment, and birth spacing.

While the basic scope of the CHW’s work has not changed, over the last five years the details of the job have been modified somewhat and training methods and job aids have been improved. New tasks given to the CHWs include postpartum FP and provision of injectable contraceptives, newborn care, and growth monitoring of children. An improved training package and pictorial job aid for community case management as well as TB-DOT have been developed. These have been incorporated into a revised training manual and curriculum.

Support and supervision
Each health facility supporting health posts has a CHS, who is almost always a man. In less than 10% of facilities there is also a female CHS. Their selection criteria include a high school education, residence in the district where they will work, and good communication skills.

Their job description includes:

  • Regular on-the-job training provided to the CHWs,
  • Assurance on a monthly basis that the health posts have adequate supplies and drugs,
  • Supervision of the quality of the community maps and monthly reports,
  • Planning and management of all community health activities in the catchment area, and
  • Support of the community health shuras.

These activities are managed through monthly visits to each health post and a monthly meeting of CHWs at the health facility where the CHS is based. CHSs frequently have a motorcycle and a fuel allowance that makes it possible for them to visit the health posts. CHSs participate in all the training programs provided for CHWs. In addition, special training courses are provided specifically to the CHSs to build their capacity as supervisors, trainers, and managers.

Linkages with the formal health system
The Afghan CBHC system is an essential part of the national health system and a key element in the BPHS. CHWs are linked to a health facility and given technical supervision and supplies by the CHS. Their monthly reports are part of the national HMIS. In the province, the NGO that is responsible for managing the community-based work has a CBHC Coordinator and CHW trainers to manage and support the CBHC program. In the Provincial Health Office, there is usually someone who is the CBHC focal point. Since 2012, about one-third of provinces have specific CBHC Officers to oversee and promote all CBHC activities in the province.

At the national level, there is a CBHC Department in the Ministry of Public Health (MOPH). Its role within the overall stewardship role of the MOPH is to promote CBHC, oversee policy and program development, monitor implementation, and coordinate the inputs of other technical departments (e.g., the Departments of Child Health, Reproductive Health) in the MOPH that are stakeholders in CBHC.

Compensation and motivation
Afghan CHWs have been volunteers from the beginning of the program. This policy has been reviewed and reaffirmed periodically because the issue of salary is constantly raised. Attempts to encourage financial support for CHWs from the community itself have never been very successful. Since 2008, CHWs have received allowances to cover travel and food for all monthly meetings at the facility and any training courses they attend. In some provinces, CHWs participate in the polio campaign and in the National Immunization Days, and for this they receive an honorarium. In some areas, CHWs may receive financial or “in-kind” rewards for referrals of particular categories of patients.

Since 2010, December 5 has been recognized as National CHW Day in Afghanistan. Celebrations are held for CHWs at both the national and the provincial levels. The quarterly Salamati Magazine is designed for and distributed to all CHWs.

Monitoring and data use
At the community level, the CHWs prepare and update a community map. This displays all households in the community and, with use of different symbols and colors, locates women and young children requiring/receiving preventive health services, FP, or TB treatment.

The CHWs keep a monthly record of their activities and any births or deaths on the Pictorial Tally Sheet. This is designed so that it can easily be used by illiterate CHWs. For every service provided, the CHW puts a line (tally) in the appropriate box indicated by a picture representing that service. At the end of each month, the CHS transfers this information into a health post report, which is then combined into an aggregated CBHC report for the health facility. These and the health facility reports are all entered into a database at the provincial level and forwarded quarterly to the national HMIS Department. Checks and analyses of the data are done at both national and provincial levels. Usually, a specific set of priority indicators are monitored regularly for program management purposes.

Demonstrated impact of the CBHC Program
HMIS data on the management of sick children and the provision of contraceptives are the best data to illustrate the relative contribution of CHWs to these services. Since 2003, the numbers of health services being provided to the population have increased dramatically. At present, CHWs are treating 30% to 36% of all cases of childhood acute respiratory infections and diarrhea recorded by the HMIS. Of the reported provision of contraceptives, 55% of women who are using short-term methods are being supplied by CHWs. Rates of ANC, skilled birth attendance, and immunizations have all also increased markedly. While CHWs and FHA groups have, no doubt, contributed to these, the presence of a female health worker in most health facilities has also been essential.

The Afghan Mortality Survey 2010 found marked improvements in utilization of services and health status compared to the levels observed in 2003. The CPR was 20% (compared to 8.5% in 2003); the total fertility rate was 5.1 (compared to 6.7 in 2003); 68% of women had obtained ANC (compared to 8% in 2003); 34% of births were attended by a skilled birth attendant; 64% of children with diarrhea were given oral rehydration solution (ORS) or safe home fluids; and 64% of children with symptoms of pneumonia were given antibiotics. The under-5 mortality was estimated at 105 per 1,000 live births (compared to 257 in 2003) and the MMR was estimated at 372 per 100,000 live births (compared to 1,600 in 2003). Although its contribution cannot be precisely measured, the CBHC system has undoubtedly played a major role in the dramatic progress that has been achieved.

Financing of CBHC and its development

The BPHS implementation by NGOs, including the CBHC program, continues to be financed by the World Bank, USAID, and the European Union. Most of the funding for development of the CBHC program has come from USAID. GAVI Alliance; the Global Fund to Fight AIDS, Tuberculosis and Malaria; the Japan International Cooperation Agency; and some smaller donors have also supported these activities.

Program scale-up

Because CBHC has been part of the BPHS from the beginning, its scale-up has been part of national health planning. Each provincial NGO contract and each contract renewal has included a target for the training of CHWs. The current total of 29,000 CHWs is approaching the total anticipated to provide national coverage at the desired ratio of health posts to population. Two additional population groups have received attention in the past three years: nomads and those living in urban communities. Modifications to the CHW job descriptions and to the training programs have been made according to the special circumstances of these populations.

Impact and continuing challenges
CHWs now provide a major portion of primary health care (PHC) services in Afghanistan and are widely recognized as one of the important contributors to Afghanistan’s marked improvement in health status during the past decade.

Afghanistan has developed considerably over the past 10 years. However, security has worsened in the past few years, illiteracy persists in the adult population, and poverty has not diminished, especially in rural areas. All of these challenges remain barriers to reaping the full health benefits of the services provided by CHWs.

 

References:  Management Sciences for Health/REACH (2006). Rural expansion of Afghanistan's community- based healthcare program: Measuring program outcomes through household surveys.

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