By: Ateeb Ahmad Parray, Sophia Kaufman, Md. Imtiaz Khalil Ullah and Saha Naseri
From July 2019 to December 2019, I worked in Afghanistan for a project funded by the Bill and Melinda Gates Foundation. During these six months, I visited many Afghan health care facilities: sub-health centres, comprehensive health centres, district hospitals, and a tertiary level hospital. Across these spaces, I met with health workers who were providing life-saving services in the country’s most conflict prone zones. I was especially moved by the experiences shared by the female community health workers (CHWs during a training session in Helmand – one of the most fragile provinces of Afghanistan where access to basic health services has been rendered poor due to on-going conflict. The purpose of this feature is to convey a new understanding of what motivates women to work as CHWs and the experiences and challenges they face, while working in the conflict prone zones of Afghanistan.
Who are the CHWs in Afghanistan?
CHWs are mostly community volunteers nominated by a Village Health Council (VHC) or a Health Shuara – a community based advisory committee dedicated to the smooth operation of local health facilities. They are involved in the implementation of the Basic Package of Health Services (BPHS) Sehatmandi, a package of life-saving health services funded by international. These health services are most often implemented by non-governmental organizations and monitored by the Afghanistan Ministry of Public Health.
CHWs are the first point of contact for most health-related concerns for communities living in the most peripheral and remote areas of the country. Limited by scant resources, CHWs are able to provide only the most basic health services. They receive highly targeted training and, despite being classified as non-qualified health professionals, provide family planning services and treatments for a variety of illnesses and health conditions commonly occurring in children and adults.
Cultural and religious norms often restrict a female CHW’s geographic mobility. To overcome this barrier, they are accompanied by a Mahram – a male religious guardian who is often their husband, brother, or father. The BPHS program is designed to recruit these CHW couples and partners to ensure the smooth delivery of community-level health services. Most of the CHWs I encountered had no formal education.
Motivation to work as a CHW
Saira is a middle-aged CHW and mother of three children known in her community as Khala Saira . She identified ‘altruism’ and ‘monetary benefit’ as her main motivations to perform as a CHW. She described participation in the CHW program as a voluntary activity requiring ‘interest to work,’ ‘liaison with community leaders,’ and ‘permission from family.’ Having lost her first-born child to diarrhoea, she was particularly motivated to work in community health to prevent the same tragedy from happening to others.
The motivations reflect the perceptions of many other female CHWs. In many cases, these women communicated that their sense of empowerment lay in gaining knowledge, being able to serve others, being asked for health advice, and earning respect within their society. Through their community work, many women also experience an opportunity to have greater mobility and socialize with other women in ways others often lack. This was the case of Suraiya, a married woman in her twenties also known in the community as Suraiya Jaan (beloved). During one conversation, she mentioned that her husband was a ‘Mulla’ – a religious leader who wouldn’t allow her to go outside of the house. Her father, also a Mulla, did not let her enroll in school, instead requiring that she only read religious books because he believed that ‘women are jewels and should be kept hidden [safe]’. When she reached her twenties, her father married her off to his acolyte who also happened to be a CHW.
Accepted by the community, yet neglected by the hierarchy
Although the Afghan health workforce is comprised of mostly women, they often work in low-paying positions as CHWs, nurses, and midwives. Conversely, males predominately maintain high-paying health-related managerial and policy-oriented positions. The limited social, financial, and political mobility of Afghani women is exacerbated by restricted or limited educational opportunities that limits their ability to obtain skills and knowledge to climb the ranks in Afghan society. When I asked middle-aged CHW Fatma why she did not leverage her robust experience to apply for a supervisory position, she smiled and said:
“I am a woman. How can I become manager? It is for men […] I am more [comfortable] in the community where my people need me…”
With this sentiment, she attributed her inability to receive a promotion to gendered power relations, norms, and stereotypes. The CHW role as the first point of contact in the healthcare system is often ignored despite tremendous community acceptance and demand for them, especially in patriarchal contexts where women seek female providers to address their health care needs. Moreover, CHWs are often considered second-class workers in the broader health system of Afghanistan. Perhaps this is due to a lack of professional recognition and accredited training. Thus, they do not possess career development opportunities. Nevertheless, they are so well received by their communities that community members often refer to them as ‘Village Doctors.’
CHWs in Afghanistan are akin to Community Health Volunteers They do not receive a salary Rather, they are reimbursed for their travel expenses up to $2USD per month. Some of the BPHS programs with additional off-budget funding provide incentives to CHWs l to serve as vaccinators. Despite their meagre income, they are enthusiastic to serve their communities. All of the CHWs I interviewed lived in economically depressed areas and some bore the dual burden of living in areas absent of any health facility. In these areas, health services are usually navigated and provided solely by CHWs. In such contexts, delaying payments or reimbursements can expose CHWs and their patients, to high health risks. Khala Saira, Suraiya Jaan, and Fatima mentioned that their reimbursements are often delayed as much as four to eight months. For Suraiya, missed payments mattered little becauseher husband, also a CHW, received and controlled the money,
“It does not matter to me when they pay [the money]. I don’t get to see it [anyways]. My husband receives it”.
Threats and violence against CHWs
Afghani CHWs typically provide services in health posts that are often stationed in their own house, shop, or a nearby stand-alone health post); however, CHWs visit the patient’s house to perform delivery-related services. Getting out of the house is challenging for some female CHWs; and working in a patriarchal society like Afghanistan can mean facing domestic violence as well. Since CHWs do not have regular working hours, they are often called upon for help late at night by community members. Late night care is frowned upon by their families and often places the woman at risk of violence . For example, Khala Zarina mentioned once that a man from the neighbouring community knocked urgently on her door because his wife who had recently given birth was bleeding. Zarina’s husband became so angry about his wife leaving to provide care that he started beating her in the courtyard.
For women in the Afghan society,irregularity in working hours and a need to work in public outside of the traditional home space is frowned upon. Nevertheless, additional income, though meagre, is welcomed. Many of these CHWs face harassment from male colleagues and supervisors, and must navigate these murky waters on their own. Talvasa, an unmarried CHW who worked together with her physically challenged brother, mentioned that her male supervisor tried to break her will through employment retribution and quid pro quo harassment. Similarly, Khala Saira was threatened by a male cashier in one of the organizations where she worked. He denied her incentive payment for months, claiming missing documents and verification reports. Then, one day, he asked her to come by after office hours, but Khala Saira said she would rather die than compromise her honour in this way.
In some cases, the community members also harass, humiliate, and abuse the CHWs. This is even more prevalent during vaccination campaigns. Vaccination is frowned upon and stigmatised in Afghanistan because many consider it a ploy against them perpetrated by westerners. Thus, when a CHW knocks on the door of someone in the community offering and providing any sort of vaccination or vaccination information for a mother or baby, they must face inappropriate behaviour from the men. Talvasa mentioned that she once visited a pregnant woman’s house to provide a tetanus-toxoid immunization. The man in the house held her hand and pushed her against the wall.
Stuck between health posts and battle zones
CHWs in Afghanistan experience episodes of violence from Orthodox Fundamentalists – The AGEs. AGEs are against female employment and prevention campaigns, especially immunization. Thirteen out of fourteen districts in Helmand, Afghanistan are fully under AGEs control. These include a population of around 1 million people and sixty to seventy health facilities which are vulnerable to attacks and rampages. The threats are so severe that AGEs have restricted the entry of health workers or the establishment of health facilities in many areas that they control, called “White areas”. Due to this, preventable conditions like Polio are at large, as per the report of Afghanistan Health Survey (2018). Moreover, the AGEs also discourage family planning and other public health campaigns, thus leaving the female CHWs vulnerable in promoted hostile environments.
This feature elucidates the plight of female CHWs in Afghanistan and underpins their vulnerabilities. It encapsulates the various barriers that interfere with the smooth operation of CHWs. First, their unregularized status and lack of financial support from the BPHS program acts as a major challenge. For those who are enrolled in task shifting responsibilities and receive incentives, often their families control their money. Second, CHWs are denied the right to climb up the career ladder or receive opportunities for career development. With every experience, CHWs’ become more. I argue that CHWs status should be supported and recognized within the formal structure of Afghanistan’s system. Finally, the harassment cases shared by many of the CHWs illuminates how exploitation and gender inequality undermines the country’s overall public health efforts. ‘Leave no one behind’ needs to be imparted and prioritized. Without CHWs, an entire country’s rural healthcare system may collapse; their role in promoting health in Afghanistan is paramount and it is time that they are treated as such.