Toward universal coverage in Afghanistan: A multi-stakeholder assessment of capacity investments in the community health worker system

Abstract

Global efforts to scale-up the community health workforce have accelerated as a result of the growing evidence of their effectiveness to enhance coverage and health outcomes. Reconstruction efforts in Afghanistan integrated capacity investments for community based service delivery, including the deployment of over 28,000 community health workers (CHWs) to ensure access to basic preventive and curative services. The study aimed to conduct capacity assessments of the CHW system and determine stakeholder perspectives of CHW performance. Structured interviews were conducted on a national sample from 33 provinces and included supervisors, facility providers, patients, and CHWs. Formative assessments were also conducted with national policymakers, community members and health councils in two provinces. Results indicate that more than 70% of the NGO's provide comprehensive training for CHWs, 95% CHWs reported regular supervision, and more than 60% of the health posts had adequate infrastructure and essential commodities. Innovative strategies of paired male and female CHWs, institution of a special cadre of community health supervisors, and community health councils were introduced as systems strengthening mechanisms. Reported barriers included unrealistic and expanding task expectations (14%), unsatisfactory compensation mechanisms (75%), inadequate transport (69%), and lack of commodities (40%). Formative assessments evidenced that CHWs were highly valued as they provided equitable, accessible and affordable 24-h care. Their loyalty, dedication and the ability for women to access care without male family escorts was appreciated by communities. With rising concerns of workforce deficits, insecurity and budget constraints, the health system must enhance the capacity of these frontline workers to improve the continuum of care. The study provides critical insight into the strengths and constraints of Afghanistan's CHW system, warranting further efforts to contextualize service delivery and mechanisms for their support and motivation.

Achieving maternal and child health gains in Afghanistan: a Countdown to 2015 country case study

“…79 Assessments of community health worker-based services in Afghanistan have shown that despite limited awareness of this group (only about a quarter of civilians are aware), of those who accessed the services, not only were their services generally accepted and used by community members, these workers were preferred over basic or comprehensive health centre use. 94,95 A legitimate question can be asked about the transaction costs and cost-eff ectiveness for many initiatives undertaken in Afghanistan given the estimated $58 billion received in external development and relief assistance from 2001-14, 5 and the subsequent choices made. In view of the almost complete donor dependence for the fi nancing of the health and social sectors, many of these programmatic choices were implemented with close donor coordination and oversight.…”

Best Practices in Achieving Universal Health Coverage: A Scoping Review

“…interventions in countries such as Nepal [82,90], Ugunda [117,118] Rwanda [75], Tanzania [50,77], Ethiopia [119], Afghanistan [62] and…”

Overview of community health worker programmes in Afghanistan, Egypt, and Pakistan

“…The last reviewed is the CHW programme in Afghanistan, which was founded in 2003 as a postwar redevelopment effort (10). This programme is run by 29 international NGOs with some governmental involvement, and being the youngest of the programmes, it has been possible to model its structure and organization on other global CHW programmes (11).…”

“…In Egypt and Pakistan there is an educational requirement for CHWs. Egypt relies on community members, ideally young married women with not too many children, to volunteer for the job of raedat (6,7,11). Community leaders are often relied upon to recruit promising candidates.…”

“…LHWs in Pakistan are trained to provide emergency relief. Other com- 16FP promotion (10) FP provision (11,15) Write referrals (10) Ante/postnatal care (10) Breastfeeding promotion (10) Administer vitamins (10) Diarrhoea treatment (10) Malaria treatment (10) Acute respiratory infection treatment (10) DOT for TB (10) Promote vaccination (10) Promote nutrition (10) Hygiene education (11,15 ) Mental health and substance abuse education (10) Health education (10) Record keeping 10Community development projects (10) Community mapping (10) Mean no. households in catchment 400-600 8 mon non-healthcare responsibilities of CHWs are mapping their communities, and population record keeping (7,8,13,15,16).…”