operations research study on...

Operations Research Study on Community Health Worker Performance in Afghanistan

Findings

2006-2007

Afghanistan National Health Services Performance Assessment

Ministry of Public Health General Directorate of Policy and Planning

Monitoring & Evaluation Department with

Johns Hopkins University Bloomberg School of Public Health &

Indian Institute of Health Management Research

Photographs courtesy: Luke Powell P.O. Box 888 88 Bristol Avenue Liverpool, Nova Scotia Canada B0T1K0 [email protected]

Table of Contents Acknowledgements Acronyms Section A: Operations Research Study on Community Health Worker Performance in Afghanistan

Overview of Current Investments in Community Initiatives in Afghanistan 1 Rationale for CHW Operations Research 2 Methodology and Sampling Design 3 Results: Highlights of Selected Findings 5 Summary Findings 8 Conclusions 9 Recommendations for Enhancing the CHW System 10 Study Limitations 13 Section B: Key Informant Interviews with Policy Planners Summary of Key Informant Interviews 15 Dr Wahidi, DG, Primary Health and Preventive Medicine, MOPH, Afghanistan

16

Dr Arwal, National Coordinator of the CBHC Department, MOPH, Afghanistan

17

Dr Mohammed Daud, Advisor to Deputy Minister of Public Health, MOPH, Afghanistan

18

Section C: Desk Review of CHW Program Operations Methodology 19 Results 19 Recruitment of CHWs 19 Responsibilities 20 Training of CHWs 21 Role of CHS 22

Incentives 23 Performance appraisals 25 Role of Shura-e-Sehie 25 CHW Drop outs 26 Challenges and Aspects of the Program Least Satisfied With 27 Satisfaction with CHW program 29 Conclusions and Recommendations 30 References 33 Section D: Findings on CHW Knowledge, Satisfaction and Performance Design and Sampling 40 Selected Findings from CHW Interviews on Knowledge and Satisfaction 41 Profile of CHW 41 CHW Training and Knowledge on Select Disease Conditions 42 CHW Feedback on Service Provision and Drug Availability 44 Fee for Services 45 Feedback on Health System Support and Supervision 45 Salary and Incentives from MOPH and NGO 46 Recommendations for Community Support, Presence of Shura-e-sehie and Reported Support from Shura Members

47

Satisfaction and Reported Constraints to Performance 48 CHW Recommendations for MOPH and NGO to Support their Performance

49

Awareness and Utilization of CHW services from Exit Interviews with Patients and Caretakers of Children Attending the Health Facility

50

Feedback on Presence of CHWs and Community Health Supervisor from Facility Interviews with Supervisor/Facility-in-charge

51

Awareness and utilization of CHW Services from Afghanistan Household Survey, 2006

52

Summary Findings from CHW Interviews 54 Section E: Community and Shura-e-sehie Perceptions of CHW Performance in Afghanistan

Design and Sampling 55 Highlights of Findings 57 Distribution of FGD and Participant Profiles 57

Perceived Value and Attitude to CHW services 60 Types of CHW Health Services and Reasons for Utilization 61 Competency of CHW and Perceived Quality of Care 69 Cost and Willingness to Pay for CHW services 70 Community Support to CHW 72 Shura-e-sehie Support to CHW 74 Feedback on Performance of Shura-e-sehie 74 Participant Concerns and Recommendations for CHW services 75 Summary Conclusions of CHW Performance 77 Limitations 79 Program Recommendations for Strengthening CHW Capability 79

Acknowledgements

The Ministry of Public Health, Johns Hopkins University and Indian Institute of Health Management Research would like to thank Dr Arwal, Coordinator of the

Community Based Health Care program, all members of the assessment teams who took considerable risks to obtain data from communities and health facilities, and the Community Health Workers, caretakers and patients who participated in the

assessments. We extend our gratitude to the community and shura-e-sehie members who made valuable contributions of their perspectives and experiences with CHW in

their villages. We also appreciate the efforts of the NGOs, in particular BDF, BRAC, CAF and MRCA, and health facility staff for facilitating the teams in the

villages and the translators and analysts for their meticulous work.

Anbrasi Edward, Dr. Arwal, Dr. Haseeb, Gilbert Burnham, Laura Steinhardt, LP Singh and Peter Hansen contributed to the design of the assessment. Anbrasi

Edward, Laura Steinhardt, Vikas Dwivedi, Kavitha Viswanathan and Salelesh Abebe conducted data analysis. Anbrasi Edward led the writing of Sections A, B,

D and E. Laura Steinhardt led the writing of Section C.

Acronyms ARI Acute Respiratory Infection ANC Antenatal care BHC Basic Health Center BPHS Basic Package of Health Services DG Director General CBHC Community Based Health Care CHC Comprehensive Health Center CHW Community Health Worker CHS Community Health Supervisor EC European Commission FGD Focus Group Discussions FP Family Planning HF Health Facility HMIS Health Management Information System HP Health Post HSSP Health Services Support Program IIHMR Indian Institute for Health Management Research JHU Johns Hopkins University KII Key Informant Interview MUAC Mid Upper Arm Circumference MNBC Maternal and New Born Care MOPH Ministry of Public Health NGO Non-Governmental Organization NHSPA National Health Services Performance Assessment ORT Oral Rehydration Therapy PHC Primary Health Care PNC Post Natal Care TBA Traditional Birth Attendant TB Tuberculosis USAID United States Agency for International Development WB World Bank

Section A: Introduction and Summary Findings

1

Section A: Introduction & Summary Findings

Overview of Current Investments in Community Initiatives in Afghanistan The Ministry of Public health (MOPH) and its partners have made enormous investments to strengthen the health infrastructure and improve access to basic health services. However, effective delivery of the Basic Package of Health Services (BPHS) is hampered by a myriad of factors in addition to the prevailing challenges presented by the geographic, cultural and political and security constraints. Given the current financial and health infrastructure investments it is unrealistic to achieve universal coverage and uniformly high quality for health service delivery through the formal health system without employing community based initiatives to address the volume of demand for health services. Populations in remote and rural areas will need to rely heavily on the availability and quality of services offered at the health posts that are operated by community health workers (CHWs). Several measures have been executed by the MOPH in partnership with non governmental organizations (NGOs) to train and equip these community providers to ensure equitable access to basic health services. According to the 2003 BPHS, CHWs were expected to serve through community health posts. These health posts were to provide a limited array of curative services which included diagnosis and treatment of malaria, diarrhea and ARI, micronutrient supplementation and distribution of condoms and oral contraceptives. To ensure optimal performance of these services at the health post level, CHWs require increased investments for operational support and supervision to effectively deliver health services. This is particularly challenging and critical as the rural population of Afghanistan faces severe constraints related to poor road access, low literacy and cultural barriers to utilization of health services. The health post, consisting of two trained CHWs (one male and one female), is expected to serve a catchment area of 1,000-1,500 people, equivalent to 100-150 households. The BPHS was revised in 2005 to incorporate additional health priorities, specifically mental health and disabilities, and amend parts of the BPHS structure. Specific changes relevant to the CHW role include:

1) Provision of subsequent depo progesterone injections under supervision of BHCs and CHCs; 2) Provision of immunizations to children using Uniject (a prefilled injection device) once the cold

chain is available at the health post level; 3) Addition of mental health promotion and case detection, as well as disability awareness and

referral; 4) Provision of mini delivery kit to health post; 5) Provision to CHWs of firstline antibiotics for ARI and cholorquine for malaria treatment; and 6) Addition of a Community Health Supervisor (CHS), who supervises the CHW, among other

activities. The 2005 BPHS also revised the job description of the CHW. Issues related to remuneration of CHWs are still outstanding. In March 2005, the MOPH Technical Advisory Group approved policy that recommends against regular payments by MOPH and other BPHS implementing agencies to CHWs, but rather encourages communities to find ways to compensate the CHWs for their work. The 2005 BPHS states that compensation must be sustainable, with “full-time work to be paid and part-time work compensated only by incentives”. The BPHS further recommends that when possible, traditional compensation and in-kind contributions will be maintained. The CHS is responsible for assisting in training new CHWs, providing regular in-service training and supervision of CHWs, regular replacement of CHW kits, assisting with HMIS reporting, formation of community health committees (shura-e-sehie) and overall coordination of community health activities.

Section A: Introduction and Summary Findings 2

The institution of the Community Based Health Care Unit (CBHC) at the MOPH was one of the measures to support the execution and performance of the NGOs contracted to support the establishment of CHW systems in their contracted areas. In the past year, the CBHC has undertaken considerable efforts through the institution of working groups and a task force to examine the various support mechanisms for CHWs, including the role of the CHS and payment and incentive systems, and measuring the reasons for attrition of CHWs. A number of NGOs have conducted routine evaluation and research activities to examine the viability of the CHW system in their contract areas and demonstrate sufficient evidence to continue investments in the provision of community based care. The schematic below presents the relationships between key stakeholders in CBHC in Afghanistan. Figure 1: Framework for CHW Operations Research

Rationale for CHW Operations Research The global evidence on the institution of community health volunteers has demonstrated success in reducing the disease burden, through improved access and utilization of basic health services, including health promotion, education, reducing harmful practices, prompt treatment for common illnesses, facilitating referrals and managing simple health information systems. The health gains are particularly impressive in vertical disease prevention efforts for improved EPI coverage, malaria control, treatment for TB and advocating for increased investments at the community level to facilitate appropriate behavior change. Although the CHW system holds potential to effectively address a majority of community health needs for preventive and curative care, failures to sustain the gains over time have been mostly attributed to unrealistic task expectation, lack of or inadequate incentives, lack of effective community and health system support and poor supervision. These factors result in poor performance and high turnover of this cadre of health workers.

Health Facility

CHW

Shura

CHS

MOPH CBHC

NGO


According to the 2006 estimates, more than 14,000 CHWs have been trained nationally to provide basic health care at the community level in Afghanistan. Yet evidence from the National Health Services Performance Assessments (NHSPA) conducted in 2004 and 2005 indicated low awareness of CHW services among users of health facilities (18-22%). The ongoing monitoring and evaluation of national health services has been documenting the evidence on the quality of health services, including the knowledge and performance of the CHW through quantitative and qualitative measurements. However the existing methods do not fully examine the operational issues that support or impede the performance of the CHW. For meaningful and sustainable policy measures, it is important to assess and document the gaps in the system to effectively address the deficiencies and strengthen the system. In 2006, the MOPH in partnership with the Johns Hopkins University and the Indian Institute of Health Management Research (JHU/ IIHMR) incorporated into the ongoing NHSPA an operations research component to examine the CHW system in Afghanistan with the following objectives:

1. Measure the changes in CHW knowledge and performance between 2004 and 2006 2. Document and compare innovative practices for CHW recruitment, training, retention, and

engagement of community support systems by NGOs 3. Determine community and shura-e-sehie perspectives on CHW services and performance 4. Explore the perspectives and investments of key policy makers at the MOPH to support the

community based initiatives through the CHW system The assessment package included key informant interviews with MOPH policy makers, quantitative measures on CHW performance and satisfaction through a national health facility survey, national household surveys on service utilization, and focus group discussions with the community and shura-e-sehie members in four provinces. The quantitative measures provide information on current levels and patterns of utilization of CHW services but the qualitative research findings provide a deeper understanding of community beliefs, perceptions and behaviors that attempt to describe the factors that influence the acceptance and utilization of CHW health services. By conducting a comprehensive review of current CHW program operations and NGO perceptions, researchers hoped to assess the status of the current programs and to provide feedback to NGOs, the Ministry of Public Health (MoPH), and other relevant stakeholders in the health sector, about how the CHW programs can be further strengthened to best meet the health needs of Afghanistan’s communities. The activity was jointly conducted by the Ministry of Public Health (MOPH), specifically the Monitoring and Evaluation Department and the Community Based Primary Health Care Unit of the Ministry of Public Health, Johns Hopkins University and Indian Institute of Health Management Research.

Methodology and Sampling Design: The research was conducted through a multiple assessment process (see Figure below) which included the following quantitative and qualitative measures:

1. Key Informant Interviews (KII) with MOPH Policy Makers 2. Desk reviews using structured interviews with field managers of NGOs implementing the BPHS

and review of their protocols and guidelines. 3. CHW and Health worker interviews (F6 and F7 of NHSPA) 4. Exit Interviews with patients and caretakers of children under five: (F2 and F4 of NHSPA) 5. Community and Shura-e-sehie Focus Group Discussions (FGD) with male and female

participants in 4 Provinces: Baghlan, Badakshan, Logar, Balkh 6. Interviews with women of reproductive age from the 2006 Afghanistan Household Survey


Figure 2: Methodology and Sampling Design

Further details on the study design, methodology and findings are discussed in different sections: Section B: Key Informant Interviews with MOPH Policy Makers Section C: Desk Reviews with NGOs on CHW Systems Section D: CHW Awareness, Utilization and Performance: CHW Interviews, Patient Exit Interviews,

Facility In-charge Interviews and Household Surveys Section E: Community and Shura-e-sehie Perspectives of CHW Performance

MOPH Policy Makers 3 KII

Community and Shura Perspectives

52 FGD

Desk Review 21 NGOs

CHW Interviews n=902

Household Surveys n=8278

CHW

Qualitative Measures Quantitative Measures


Results: Highlights of Selected Findings The following Table illustrates the sample for each of the measures employed and highlights some of the critical findings of the performance of the CHW system from each survey measure. Key Informant Interviews with Policy Makers Key Informants: DG, PHC, National Coordinator, CBHC and Advisor to Deputy Minister of Health

All the informants had prior experience either in Afghanistan, Pakistan and Iran managing PHC programs with CHW and reported benchmarking some of these ideas in the current policy.

Concerns on sustainability: heavy task load and absence of CHW incentives. Recommended construction of a two room health post/home for the CHW, although currently there are no resources allocated for these health posts.

The CBHC unit was established in 2006 and has been instrumental in instituting an advisory group consisting of donors and NGOs and various task forces to address the prevailing concerns of the CHW system; incentives/payment, attrition, CHS role and CHW refresher training manual. Although they were very supportive of the CHW services and valued their contributions, the informants noted that investments for human and financial resources are very minimal as the CBHC unit is currently staffed by only one person and has no operational budget. They perceived their role to be regulatory, in coordinating the activities of the NGO and donor communities.

Results from Desk Review with NGOs Sample: 21 of 26 NGOs implementing BPHS Training and Recruitment: Most of the NGOs adhered to the MOPH guidelines except for some variation in task expectations of CHW, refresher training format and termination procedures. Most reported increasing the numbers of trained female CHWs. Drop outs: Reported to be between 1-8%, and higher among male CHW as they were likely to get gainful employment Coverage of HH: 100-150, except for remote areas 50-100. Some variations were evident. Supervision: Evolving role of CHS, >65% NGOs reported that CHS supervise >15 CHW Salary/Incentives: AMI, SCA and BRAC mentioned monetary incentives for Eid, training, referrals etc. Non monetary incentives (bicycles, sewing machines, literacy training, Learning for Life course, gift kit, furniture for HP etc) were mentioned by some NGOs. No formal fee structure (except SCA) 2-5 Afs for consultation permitted. CHW Performance: NGO managers reported improved referrals, family planning acceptance, health education, community mobilization, HMIS reporting etc, and better performance if CHW pair were married couples Results from CHW Interviews and Exit interviews with patients, and Facility In-charge National Health Services Performance Assessment CHW Recruitment: Improvement in recruitment of female CHW since 2004, although proportion of male CHW in sample is still higher than female CHW (63% vs 37%); In 2006, 95% of CHWs were <50y old, 80% were married and 75% had some schooling.


Training and Knowledge: 30-40% had received refresher training in maternal, child and new born care, TB, malaria, diarrhea and hygiene, Immunization and nutrition. 80-90% of the CHW were knowledgeable about the dangers signs for referral, vaccine preventable illnesses, safe water sources, age at weaning, signs of TB and danger signs for Malaria. Type of Services: 50-60% reported providing all basic health services and more than 70% reported child and adult consultations. A few reported preventive mental health services. Fewer CHW (5%) reported >300 households in the catchment area in 2006, and most (80%) reported 100-150 households. 50% reported 50 household visits in the past month. Health System Support: >90% reported 3 or more supervisory visits in the past 6 months and reported specific activities conducted by supervisor (checking records, observing service provision, training etc). Availability of essential drugs had improved since 2004, with 65-80% reported availability of the various drugs in 2006. Commonly Reported Performance Constraints: lack of transport, lack of community support or appreciation, salary support or incentives, inadequate supplies, poor working environment Shura-e-sehie: 72% reported active shura-e-sehie, and support measures from this body included mobilizing communities to utilize health services, payment for services, donations to HP, in kind contributions and other forms of appreciation. Community Support: 30-40% of CHWs recommended assistance in health post construction, payment for services, support from village leader, transport assistance, and in-kind contributions as appropriate support measures from the community Exit Interviews: Small increase in proportion aware of CHWs in their communities (18% in 2005 to 22% in 2006). Of those aware of CHWs, 65% reported making or receiving CHW visits, and 80% reported satisfaction with the services provided. Facility In-charge: 63% of the facilities reported active CHWs in their catchment areas, 57% reported a CHS. Main support activities of CHS include training, supervision, HMIS monitoring, and shura meetings. 70% of the CHS reported having other responsibilities at the health facility including clinical care, vaccinations, growth monitoring, management of ORT corner, etc Results from Focus Group Discussions with Community and Shura-e-sehie Shura-e-sehie: Male groups (n = 16), Female groups (n = 2); Community: Male groups (n= 17) Female groups (n= 17) Perceived value and attitude toward CHW: Many respondents reported that CHW are ‘God’s angel’ as they provide equitable, accessible and affordable services and are therefore in some cases more effective than doctors. Free services at HP were appreciated, in comparison to expenses previously incurred for travel, consultation, drugs, lost work time and long waiting time at health facilities Preferred 1st provider: With the exception of those who live in close proximity to the health facility most reported seeking care first with the CHW. Women and children utilized CHWs more frequently, particularly for pregnancy related issues, vaccination and childhood illness. Men accessed services for injuries and gastrointestinal disorders. Health education, immunization, treatment of diarrhea and malaria were commonly reported services that the community members utilized. Gender issues: There was very high demand for more female CHWs. It was often viewed as culturally inappropriate for women to disclose information to male providers even in the presence of male family members.


Perceived quality of services: Most were satisfied with the quality of the service, particularly the CHW-patient relationship and said they were kind and respectful. Some reported that the quality is questionable due to lack of knowledge of CHW or absence of effective drugs. Improved knowledge and practices due to health promotion messages: Several men and women reported seeking immediate care for danger signs, better hygiene and preventive practices, realization and reduction of harmful traditional practices and improved knowledge of drug prescriptions due to the efforts of the CHW. Mortality decline for selected conditions after institution of CHW services: Perceived reduction in deaths due to measles, diarrhea, malaria and pregnancy related causes was reported in several FGD. Equitable services: Poorest can access services, especially female headed households, and Kuchis. Evidence of in kind contributions and fee for service: Several participants reported in kind contributions and willingness to pay for services (5-50Afs), depending on the availability of quality services. Many community members considered CHWs to be salaried government workers and were astonished that they provided free services without any remuneration and expressed a willingness to help construct the HP and support their work. Opportunity for Social Gathering for Women: Unlike seeking care at health facilities which often requires a male family escort, women are more likely to be able to access services from the female CHW without seeking permission from male family members. Many women find that the HP is an opportunity for them to congregate and share their family or health concerns. Reported Deficiencies of the CHW system: There was fear that CHWs may prescribe wrong medications as they were illiterate, as well as concern over the inability to treat more serious illnesses, and the lack of transport for house visits. Recommendations: More trained female CHW, construction of health post, salary, transport, adequate and effective drugs, transparent recruitment procedures, community regulation and supervision of CHW activities. Safety and security of CHWs was considered to be a major factor affecting service provision. Results from Household Survey National Sample N=8,278 Awareness and utilization of CHW services: Only 25% of HHs interviewed were aware of CHW services in their community, but 62% of those aware mentioned utilizing the CHW services in the past 3 months. 88% of those aware of CHWs reported that they provided useful services in the community Number of CHWs and Type of Services: Of those aware of CHW services, 18% reported 1 CHW in their village, 38% reported 2 CHW and 21% reported >2 CHW in the community. However 42% of the respondents reported only male CHW in the community. Commonly reported services were health education, treatment for illness or injury, ORS, Vitamin A, Referral and maternal care. Use of CHWs as first source of curative care: In only 3% of cases in which a household member experienced an illness or injury in the past month did the respondent report that a CHW was used as the 1st provider. Reasons for non-use of CHW services: Most common reasons cited for non-use of CHW services were their reported lack of knowledge, low competency of CHWs and lack of drugs.


Summary Findings and Recommendations for Enhancing the CHW System Comparing the findings from each part of the assessment, it is evident that the CHW system needs to be further enhanced with appropriate support from the MOPH, health system, NGO and the community, particularly it’s leaders. The figure below summarizes the key findings from the multi-method assessment of stakeholder perspectives and feedback on CHW performance. Summary Findings of Stakeholder Analysis of CHW Performance

Key Constraint factors are in italics

CHW Performance

-Commitment to support the CHW system -Concerns about CHW sustainability and retention -Consider payment/incentive systems, HP construction -Establishment of CBHC, advisory committee and task force to address factors related to CHW performance - Limited resource investments in CBHC unit for supporting community efforts

-High satisfaction and acceptable service utilization among those aware of services -Awareness and use of curative services remains low, partly because many communities do not have CHW -Appreciative of free and accessible services in the community, where available -Recommend further training of CHW to address other disease conditions -Some evidence of support and payment for services and willingness to pay for quality services -Higher utilization of services by women and children -Social support infrastructure for women -Many communities do not have active CHW -Low community awareness of CHW services -Misconception that CHWs are salaried workers requiring no support -High demand for female CHW -Potential threat from existing community power structures -Demand for additional training of CHW and improved drug supply

MOPH Policy Level

Community Level

Shura-e-sehie Level -More communities reporting Shura activities -Support CHW by increasing awareness, mobilizing community to access services, assist in transport for referral, payment and assistance in HP construction -CHW not satisfied with shura support -Need to equip shura with problem solving skills, clarify role and task expectations

NGO and Health Facility Level

-Compliance with BPHS protocols -Improved training and knowledge gains of CHW -Increased efforts in recruitment of additional CHW, particularly female CHW -30-40% provide full set of basic health services -Improved supervision, feedback, drug supply, appreciation, recognition - >50% facilities reporting CHS - CHW expectation for salary support, transport and HP construction -Some variations in refresher training, incentive systems, and job expectations. Need to evaluate effectiveness for application to NGO programs -Unrealistic task expectations for 150HH if demand increases -Safety/security factors, considering pairing of female CHW -Attrition of Male CHW to paid jobs -CHS engaged in other HF services. Supervise >15 CHW


Conclusions The findings from the quantitative and qualitative assessments demonstrate that the MOPH and NGOs have made enormous progress in improving the CHW capital of trained providers, ensuring essential drug supplies, and improved supervision. Feedback on CHW satisfaction indicated favorable support from the health system, except for salary or payment expectations. The institution of CHW services in the community has facilitated to some extent autonomous decision making for women to seek care for themselves or their children if the provider is female. In addition, many community members perceive improved accessibility, reduced waiting time, lower costs, confidentiality and comfort in accessing care from a known community member, as well as access to social support networks, as a result of CHW services. The CHW is often the preferred provider for first level of care and for emergency services, though results from the household survey indicate that a majority of women report having no knowledge of a CHW working in the community and in only a small percentage of cases did women report that care was sought from a CHW for an illness of injury experienced by someone within the household in the previous 30 days. Evidence from the discussions with community and shura-e-sehie members indicated that these workers are highly valued, even more than physicians in some villages as they provide equitable, accessible and affordable services almost 24 hours of the day in all seasons. In comparison to accessing services in the health facility, which can entail high costs and in some cases facilities that were closed before patients reached them, community members felt a CHW provided effective free services immediately and drugs were either free or subsidized. Moreover, they also compared the opportunity cost of lost time from work when they had to access services from the doctors and now their women could go to the CHW without being escorted by a man. In most villages these community workers were appreciated for their personal dedication, integrity and loyal service to the community members, particularly the women and children who could in some cases access services without male family escorts. Male community members were more appreciative of the preventive aspects of health education, which they saw evidenced by reduced deaths in the villages, particularly reductions in deaths due to malaria and vaccine preventable illnesses. The opportunity to access health care during pregnancy and assistance during delivery and new born care was highly valued by the female community members who felt comfortable to share even non medical issues with the female CHW and reported reduced deaths due to pregnancy related causes and diarrhea in children since the institution of the CHW in the community. Based on the evidence from the assessments it is apparent that the evolving CHW system in Afghanistan has significant potential in addressing and alleviating a major proportion of the disease burden, especially among women and children. The MOPH, donor community and NGOs have made considerable investments to create an effective system that is accessible and affordable to a majority of the rural population. However the global evidence from other CHW programs that rely heavily on volunteer services has demonstrated that these providers require continuous motivation and appropriate support systems to sustain the quality and coverage of these services. The current BPHS model lays an enormous task burden on these providers, who in the long term may be challenged to continue service provision if community demands increase. Some NGOs have introduced innovative strategies for phasing in training, incentive policies (BRAC, AMI and SCA) and developing a wider support structure with women’s action groups, pairing 2 female CHW and training younger women to assist as community statisticians for routine disease surveillance and vital events registration (Future Generations), and instituting health post shura-e-sehie (REACH). The role of the shura-e-sehie also needs to be further enhanced with training on problem solving methods so they form an effective link between the CHW, community and health system as REACH has attempted in some settings. Specific recommendations for stakeholder consideration are listed in the following section.


Recommendations for enhancing CHW Performance As in all health systems that use an extensive capital of volunteer human resources, the ongoing performance and sustainability of CHW services face considerable challenges, though the community appreciates and demonstrates demand for these services. The Ministry of Public Health A. Increase investments for supporting CBHC activities: The CBHC unit has made impressive progress in terms of engaging the donors and NGOs in regular meetings and discussions and instituting an advisory committee and task force to review and coordinate the efforts of the NGOs in introducing innovative strategies for supporting community efforts. A number of operations research efforts are underway to review the retraining manual for CHWs, incentive policies, recruitment and training procedures and the role and task expectations of the CHS. The Director has made considerable efforts to conduct field visits to examine the activities and models of NGO implementation of the BPHS, particularly the CHW system, and facilitate communication and interaction between the MOPH and NGOs. The June 2007 Technical Roundtable on CBHC, sponsored by HSSP and USAID, was an excellent forum to improve the visibility and endorse the CHW program nationally, with representation from the Minister, the Deputy Minister for Technical Affairs, donors, NGOs and CHW participants. However the department requires additional resource investments in terms of personnel and financing to organize meetings, conduct field visits, perform assessments, and generate timely reports for policy makers. B. Incentive Policy for CHWs: Global evidence on CHW motivation and performance has demonstrated that in comprehensive programs where CHWs have high task expectations the lack of appropriate incentives and support has resulted in high attrition of volunteers, and failure of CHW programs. Evidence also indicates that if CHWs are paid a regular salary for a period of time and if this salary is withdrawn in the future, due to decreases in the level of funding for the health sector or changing priorities, this is likely to result in a high level of attrition and loss of motivation among CHWs. Monetary Incentives: Payment for services or regular salary has been discouraged due to minimal national resources, but the cost savings of instituting these community based services have not been thoroughly examined. Payments of $10 per CHW for a workforce of 25,000 CHWs translates to an annual cost of $3 million. Community based healthcare is, however, an investment in improved health and, if successful, is likely to save money in the long term. The cost per death averted for diarrhea, malaria, maternal causes, and vaccine preventable illnesses must be estimated through a cost benefit analysis to more critically examine the merits of investing in these frontline health workers. The annual savings that can be achieved through an effective community based delivery of preventive and curative health services can potentially reduce the expenditures incurred at the health facility for treating severe cases. This requires further review and analysis. In the short term, an annual monetary bonus during Eid or other significant events like a National CHW Day may be viable alternatives that would help in motivating and retaining CHWs. One option that merits further consideration is linking incentives to the types and quantities of services provided by a CHW. Non-monetary Incentives: Support for the construction of the health post, minimal furnishing or the provision of an annual gift or token of appreciation from the MOPH are potential alternatives to monetary reimbursement for services provided. The provision of free health services for consultation and drugs required by CHWs and their family may be considered as an additional incentive to motivate CHWs and enhance their satisfaction. C. Support and Advocacy for CHWs Nationally and within the Health Sector: The CHW system should be an active and integral part of the MOPH. In the planning of future health policies, the following issues related to CHWs should be given strong consideration: appropriate


supportive supervision mechanisms, infrastructure support for health posts, ensuring the supplies of essential drugs, integrating CHW support processes in routine assessments and national advocacy within the health sector and for integrated community services. D. BPHS Guidelines for CHWs and CHS Task Expectations: Although community awareness of CHW was very low both in the patient exit interviews and household surveys (22-25%), utilization of services was relatively high at 60% for those who were aware of CHWs. The focus group discussions also demonstrated that their services were highly valued and women and children accessed services more frequently than men. The high task expectations of the CHW for preventive and curative care, referrals, HMIS and health promotion activities for 100-150 households may pose a challenge in the future if the demand for services increases. The global evidence on CHW has demonstrated that increased work load of CHW is a critical factor that can negatively affect their performance and lead to high attrition. Hence, the MOPH and NGOs need to carefully examine current strategies and determine the optimal level of services a female or male CHW can perform in these situations. More than 60% of the CHS reported that they have responsibilities for other activities at the health facility apart from supervision of CHWs. These include clinical care, growth monitoring, management of the ORT center and other activities. This raises concerns about the quality and effectiveness of their supervision visits to the CHW in the community as each of them is responsible for 15-20 CHWs on average. NGO and Health Facility Support A. Recruitment and Training of CHWs: Findings indicate the need for increased efforts by NGOs to train and equip additional CHWs, particularly female CHWs. The demand for female CHWs far exceeds the demand for male CHWs, whose services are mostly limited to providing health education and first aid. Training additional female CHWs particularly in reproductive and child health and limiting the responsibility to a smaller number of households may facilitate a more viable system that reduces the burden on CHWs without diminishing their role and type of services provided. This would also facilitate the provision of services in potentially high risk areas. Other alternatives such as creating women’s action groups, like the Future Generations program, may be considered to improve the advocacy and support structure for female CHWs. Alternatives for refresher training and the introduction of job aids may be considered particularly for treatment of common illnesses, similar to the IMCI algorithm for community providers. B. Introduction of Trained CHWs in the Community: For several reasons, the way that CHWs are introduced into the community is critical to the success of the CHW system: 1. Although considerable efforts have been spent in recruiting and training CHWs, the awareness of community members is low. 2. The introduction of the CHWs to the community as a non-salaried government worker was not evident to community members, as many participants considered them salaried workers and expressed shock to discover that they had been demanding and utilizing free services from the CHWs. 3. CHWs that are supported by existing authorities within the community are in much better position to provide services effectively than CHWs who have a neutral or negative relationship with existing authorities. The mechanisms for introducing the CHWs into the community requires leveraging the support of existing power structures to facilitate awareness of CHWs and acceptance of services to reduce the incidence of conflicts in the community due to the presence of a new health provider. The support of existing authorities should be sought as early as possible in the process of selection and introduction of CHWs into the community. Sign posts may also be considered in areas where security is not a risk factor, so community members are aware of the CHW health post. C. Type, Quality and Coverage of Services: The optimal level of quality and coverage of services that can be expected of a CHW volunteer must be examined by each implementing NGO, based on the focus of the interventions in the community and


existing support structures, and other factors that support or hinder performance. The reported availability of essential drugs and supplies was high in 2006, but continued efforts must be made to ensure the sustained availability of these supplies and equipment. D. CHW Expectations for Monetary Support and Performance Incentives: Though they are aware of the voluntary nature of their services, CHWs may have unspoken expectations that in the future they may receive a promotion or salary remuneration from the government. The initial enthusiasm is likely to wane gradually when the monetary rewards are not forthcoming. Other competitive forces in the community or district that engage salaried workers may also adversely affect the system, particularly the male CHW. Some vertical programs remunerate the CHW, which distorts the national system of promoting voluntary workers. Some NGOs have developed innovative mechanisms to motivate and sustain the CHW through incentives. These approaches should be examined, and incentive mechanisms that are found to be effective and have a high likelihood of being sustainable should be nationally recognized and endorsed. This may include in-kind contributions, bicycles for transport, opportunities for school education for the children of CHWs, opportunities for literacy training for CHWs, promotions, monetary contributions for referral, active case finding for TB, and other mechanisms. These innovative incentive systems should be further examined and evaluated for effectiveness, to inform the future development of a standardized national policy. Supportive supervision with timely feedback and recognition of good performance are additional health system factors that need to be improved and sustained. The construction of a health post emerged in several of the assessments as a requirement to support the services of the CHW. This could be jointly implemented with the support of the MOPH, NGO, shura and the community to ensure that each CHW has a two room physical structure with minimal furnishing to provide appropriate clinical services and health education. Community Support Structures and Governance Increased demands of both the health system and community for providing various preventive and curative services may result in overuse or abuse of the CHW. This may overwhelm and diminish the quality of the CHWs’ performance in the long run. As reported in some focus groups, many CHWs provide services on a 24 hour basis and also provide referral services and resolve disputes between community members. CHWs are perceived as problem-solvers not just for health but for many community needs, such as ensuring water supply and road construction and being a liaison to the government. Different types of support structures need to be examined, such as those where the CHW is supported by a network of responsible community members. This is particularly critical in Afghanistan, where security and cultural factors may impede the ability of female CHWs to do their work. Support structures may facilitate the equitable delivery of services to populations living in remote areas. In the future, if CHW utilization levels increase substantially, it is important to examine appropriate community support structures to sustain CHW operations. A. Clearly Defined Role of Shura-e-sehie Members:

As described earlier, shura-e-sehie members must be actively engaged in the selection and introduction of the CHW once he/she returns from training. Where feasible these members should be included in the decision making process. The role and expectation of the shura must be clearly defined and they need to be equipped with both technical knowledge and problem solving skills to address community conflicts. Some NGOs have standardized the activities of the shura where they are expected to create awareness in the community about CHW services, encourage utilization, assist in vaccination and environmental clean up campaigns, ensure the safety of the CHWs, and other related activities. B. Leveraging the support of other community leaders:

Evidence from the focus groups indicated that the exisiting health providers in the community or decision makers could pose a potential threat to the safe functioning of the CHWs. Hence Mullahs and other


community leaders must be engaged in a constructive manner when introducing the CHW into the community, so that they support the CHW rather than compete with or hinder them. CHW are likely to have a much greater impact on the health of a community if their work is supported by the Mullah, other traditional leaders, and new bodies with authority, like the shuras. NGOs and others who are training CHWs and deploying them to communities should engage existing community leaders in a constructive dialogue to see how they can best work together to improve the health of the community and support CHW services. C. Community Accountability and Regulation of CHW Services This issue was raised mostly by the male community and shura-e-sehie members who felt that there should be a mechanism to regulate the activities of a CHW. Although supervision is conducted by the MOPH or NGO, other community structures need to be engaged in supporting and supervising the CHW, especially in services like vaccination campaigns, health education, delivery and management of drugs, and referrals. Other functions could include assistance with the HMIS, planning emergency transport, assisting with CHW recruitment, regulation of user fees, encouraging community members to pay for services and make in-kind contributions, and supporting health post operations. D. Facilitating Community Empowerment and Ownership of CHW services As illustrated in the focus group discussions, community members can play an active role in supporting the CHW through in-kind contributions, including supporting the health post construction, monetary payment for services, encouraging other community members to utilize services, assisting CHWs in adverse circumstances, and ensuring their safety and security. It was encouraging to see that a school teacher offered free services to the children of the CHW. In several instances community members claimed to support the CHW with labor and materials for construction, vegetables, fruits, yoghurt, oil, cloth material, and small rewards for delivering babies. This contributes to community empowerment and ownership of the CHW services but more importantly motivates the CHW and gives her a sense of self esteem and satisfaction that contributes to sustained motivation and performance. E. Quality and Availability of Drugs The issue of inadequate, ineffective drugs is a recurring complaint in all focus groups conducted as part of the National Health Services Performance Assessment over the past several years (2004-2006). Improving the availability of standard drugs would likely increase community satisfaction with and utilization of CHW services.

Study Limitations The research was designed as a multi-assessment process to determine operational deficiencies and best practices in the CHW system, but it is important to highlight the following study limitations; 1) Although the revised BPHS has been implemented since 2005, the CHW system is still evolving as many innovations have been introduced by the NGOs and various aspects are currently under examination by the CBHC advisory group. 2) The sampling for the various assessment methods differed and could have potentially introduced selection bias, skewing the findings favorably or unfavorably toward the performance of the CHW system. 3) Observations of clinical care at the CHW health post level were not conducted to assess the quality of services provided by CHW. 4) Estimates on drop outs or reasons for drop outs were approximate measures provided by the NGO field managers; these may not be completely accurate. In addition, retention rates do not provide information on the level of activity of the CHW. Some individuals may remain CHWs in name, while operating at a low level of activity. 5) The assessments did not include any cost measures for comparing the variations in CHW recruitment, training, incentives, and supervision, which could have provided useful information for determining the cost effectiveness/cost benefit of these strategies. 6) The institution of the CHS was in the initial stages when the assessments were conducted, which may explain the additional responsibilities of the CHS at the health facility. 7) As mentioned earlier, other agencies have conducted CHW assessments and examined their performance but these findings are not compared in this report. 8) This assessment did


not examine certain questions of policy relevance, such as whether deploying a CHW to a community is associated with increased utilization of preventive health services, such as family planning, skilled antenatal care, use of skilled birth attendance and child immunizations, and/or use increased use of curative through health education and referral to the health facility. The CHW system in Afghanistan shows great promise as demonstrated by the deployment of an increasing number of trained CHW, whose services are accepted and utilized when community members are aware of their presence. Deficiencies highlighted in CHW performance and satisfaction need to be addressed jointly by the MOPH and NGOs, applying the lessons learnt globally.

Section B: Key Informant Interviews 15

Section B: Key Informant Interviews The key informant interviews with the Ministry of Health Policy Makers were conducted as part of a multi-assessment process to assess the performance of CHW in Afghanistan. The interviewees were purposively selected from the team of policy makers who were responsible for crafting the MOPH’s policy on CHW-related issues to determine their priorities for the CHW system in Afghanistan and the role of the CBHC unit. Although a generic guide was developed to standardize the interviews, the discussion was customized based on the role and experience of the key informant.

Summary of Key Informant Interviews All the participants had past experience in operating CHW programs and there was evidence of benchmarking success strategies from CHW systems in other countries like Pakistan and Iran based on their experiences. They were very supportive of the efforts of the CHW and recognized the value of sustaining these services. However there was no clear evidence of supporting these policies with the required financial or administrative resources to monitor and develop these systems. Their role was primarily limited to the regulation of these polices and coordinating the activities of the NGOs and donors. It was apparent that all three key informants were aware of the heavy task load of the CHW and the risk of suboptimal performance due to lack of appropriate incentives and long term sustainability. All expressed the need to construct a health post that could serve the dual purpose of providing health services and a residence for the CHW. In their opinion, effective regulation is only possible when appropriate incentives are available to CHW. The CBHC unit, currently a one man operation, needs to be enhanced with additional personnel and an expanded role in supporting and coordinating the efforts of NGOs and donors if they plan to develop a sustainable model of CHW services. The establishment of several task force teams to address critical issues of job descriptions, supervision and incentives will facilitate the sharing and benchmarking of best practices and also support the effective delivery of community based services.


1. Dr Wahidi, DG, Primary Health and Preventive Medicine, MOPH, Afghanistan

Role of CHW in Health System: In his opinion the MOPH is concerned about the role and performance of CHW and is eager to support the delivery of CHW health services in the community. CHWs provide a unique opportunity as they live in the community and are familiar with the culture and practices of the community and therefore best able to mobilize the community to access services. Creating community relationships is critical as the MOPH cannot tailor services that are specific to the different cultures in Afghanistan. They are better equipped to implement programs and deal with sensitive issues such as family planning by advocating through Mullahs as role models of behavior change. Dr. Wahidi has considerable experience in Pakistan as Director of the MCH services for the refugee camps. The concept of CHW is not new in Afghanistan as they have worked through a similar cadre of voluntary heath worker (VHW) and basic health worker (BHW) in 1992-3. The Institute of Public Health trained over 2800 BHW, who underwent a three-month residential program and received a monthly salary of $50 and were remunerated for transportation costs. They also received a kit that included heath education materials. His experience as the Deputy Director of the BHW program was instrumental in developing the current curriculum for the MOPH Policy for CHW. In his opinion the program functioned well as the BHW were remunerated and there was a mechanism for accountability and performance measures. Incentives: Dr. Wahidi’s experience in Afghanistan and observations of CHW performance in Iran, where CHWs are remunerated $200-300 per month, compels his conviction that optimal performance from CHWs can be expected only if there are appropriate incentives to performance. As the current MOPH policy is not advocating for payment of CHWs, he has initiated a research study on the types of incentives currently provided to CHW by NGO’s and donor agencies and their impact on sustainability and motivation. He believes that other incentives like repeated refresher training, supervision, life skills training, provision of health education materials could be alternative non-monetary incentives to motivation and performance. Advocating for payment was not feasible since Afghanistan’s 35,000 villages would require 70,000 CHW to be paid a monthly salary of $50 each. In his experience community payment of services had both advantages and disadvantages as it provided a cost recovery system for CHW and served as a motivator but also resulted in misuse of services, for example the over-prescription of antibiotics and referrals for patients not requiring the services. He also felt this will lead to a greater focus on curative services and neglect of preventive services like health education. When questioned about the introduction of microenterprise initiatives, he remarked on the success of the Basic Development Need and Basic Minimal Need programs that provided loans to VHW in 1996 in promoting EPI coverage close to 100%. However he still felt that there was insufficient evidence to include this aspect in the MOPH policy. He recommended that the MOPH or community construct a two-room health post for CHW. However in the current policy there was no evidence of resources allocated for building these health posts. Span of Control. The current policy advocates an extensive number of services to be provided by the CHW to 100-150 households. Although he believes that it is not practical to expect CHW to successfully complete all these tasks, he would like NGOs to be creative in their training, supervision and selection of critical services to be performed by CHW particularly for Control of Diarrheal Diseases (CDD), Malaria prevention and control, ARI, EPI, Nutrition, family planning, and TB control. The MOPH has also distributed 18,000 talking books to CHW to support their performance. He felt that addressing the competency of the CHW through training will result in improved credibility and prestige in the community and serve as a motivator to performance. Dr Wahidi was very knowledgeable and experienced with CHW programs and was eager to benchmark best practices for supporting the CHW system and willing to address policy change based on available evidence.


2. Dr Arwal, National Coordinator of the CBHC Department, MOPH, Afghanistan Since 2002, task force meetings were conducted to determine how to establish and define the role of a community based health care unit. In January 2006, the Community Based Healthcare Unit (CBHC) was officially established and action plans were created for strengthening community based primary health services in Afghanistan. One of the major events of the CBHC was the establishment of a task force with a standard TOR and representative members from NGO implementers of the BPHS, REACH and WHO. Although WHO has been instrumental in strengthening the capacity of the CBHC department and supporting the initiatives, Dr. Arwal remarked that he had not had much success in leveraging interest or support from UNICEF. Determining priorities and decision making for standardizing the activities of the community based initiatives was conducted collaboratively with full consensus from the NGO community, REACH and WHO. He remarked that the CBHC unit has minimal resources as there was no budget allocated for its operations. Except for a monthly salary he functions independently with no administrative or financial support. However he has been instrumental in leveraging and sharing resources like office space, stationery and computers from departments that are endowed with substantial funding, like the disability department. The WHO office currently supplements his salary support for supervisory and coordination activities. Although the department was primarily established as a policy regulating body, he felt that it should assume a more active role in monitoring, supervision and coordination of NGO activities through field visits. Some NGOs have offered to facilitate his visits to the field by providing transport and other logistical support. He also reported that many NGOs have requested support for facilitation and for the CBHC to act as a liaison between the NGO and community, as some communities do not welcome NGO services. SC-UK was mentioned several times in the interview as one of the NGOs that has requested his assistance. He has been engaged in several problem solving measures, and also ensures that NGOs closely adhere to the MOPH policy. He recently visited the CHW programs of Future Generations in Bamyan and was impressed with the sustainability of the model and women’s empowerment. However he felt that the program had some weaknesses, for example that it focused only on female CHWs and did not have a strong link with the health facility for referral in accordance with the MOPH policy. He reported having facilitated discussions with the directors and staff of the program to take appropriate measures to address this issue. He has observed that the current workload for CHWs as described in the MOPH policy was too intensive. He also remarked that although the CHW services were provided free of charge, CHWs ought to be given some type of incentive for transport, Eid allowance, food, cloth, and so forth, to keep them motivated. He also felt that in the past few years, communities accepted provision of free CHW services, as Afghanistan was emerging from war, but now they feel that the government had sufficient capacity to support the work of the CHW. He also mentioned the need for constructing a two room health post for the CHW to serve as a residence and health post. He has made considerable effort to examine and study the effectiveness of CHW incentives, standardize CHW payment for transport, training per diem, as well as developing and standardizing the supervisory checklist for CHS, and developing a certification system for CHW. He felt that some provinces had significant NGO presence and therefore a wider coverage of CHW activity, but other provinces did not. He felt that all stakeholders and the MOPH in particular had a primary role in establishing CHW services in these remote areas to improve access to minimal preventive and curative services. Since the CBHC department has just been initiated he feels hopeful that the future would bring in additional resources to enable the department to function at a higher capacity to strengthen community based health services in Afghanistan.


3. Dr Mohammed Daud, Advisor to Deputy Minister of Public Health, MOPH, Afghanistan Dr Daud requested a detailed description of the CHW research study and questioned the rationale of sampling only 4 provinces for the qualitative research. He reflected that although the MOPH had developed a policy after a series of discussions and debates with donors and MOPH policy makers, it was not evidence based and therefore did not include a strategy for execution. He also raised questions regarding the possibility of duplication of efforts due to parallel research efforts on CHWs, as the CBHC has instituted a study on CHW incentives and performance. However he felt that these research efforts were important as they would provide evidence to direct policy, since most of the current evidence on effectiveness is from individual NGO or donor agencies. When questioned about the lack of financial resources and budget to support the activities of the CBHC, he felt it was under the umbrella of the BPHS package and therefore did not require a separate budget. However he was in agreement that the NGO activities at the community level required monitoring and standardization, as there was no formal mechanism for monitoring with the exit of the REACH program. The PHD and the NGO play a critical role through the Provincial Health Coordinating Committee (PHCC) to establish a task force for improving health system performance. As the MOPH is reliant on donor aid, he felt it was challenging to dictate MOPH priorities for program integration or resource allocation. He also felt it was critical for the MOPH to develop a phase out strategy as donor funding begins to decline in the next few years. In his opinion the Afghanistan National Developmental Strategy (ANDS) was primarily responsible for raising awareness and strengthening activities at the community level between the health facilities, health posts, shura-e-sehie and communities. They were also responsible for facilitating regular meetings with the different stakeholders from the community to support mobilization for EPI activities and strengthening the referral system. As the in-charge of two Basic Health Units (BHUs) and Team leader in the IRC refugee camps in Pakistan, Dr. Daud had witnessed the effectiveness of CHW services and remarked that it was partially due to the limited workload: 1 CHW per 30 households, and 1 CHS for 60 CHW. As stated earlier, he felt that the current MOPH policy ought to be revisited in light of evidence from successful local initiatives in Afghanistan. Although he felt that the integration of PHC services was satisfactory at the district level, there was not much evidence beyond the provincial level as this was primarily dictated and governed by the donor community. He mentioned the possibility of congregating a group of experts from NGOs, donor agencies and MOPH to address the sustainability of future programs and exploring financing mechanisms through a tax based financing system to reduce the burden on the MOPH and gradually decrease reliance on donors for the provision of health services. He concluded that his discussion with the facilitator of the key informant interview raised important issues to discuss with the GCMU and Health Care Financing department, particularly for resource allocation for community based health services. He also recommended that the results of the study be shared and disseminated with all concerned stakeholders from the MOPH, Donor and NGO community. He also requested that the research be continued as an ongoing activity and not just a one time assessment of CHW performance issues.

Section C: Desk Review of CHW Program Operations 19

Section C: Desk Review of CHW Program Operations This Section presents the results of this research on CHW programs operations in Afghanistan. Results are based on a desk review of current CHW programs being operated by NGOs working in Afghanistan in order to assess: current approaches to recruitment, training and supervision of CHWs; types of incentives provided to CHWs; status of Community Health Supervisor (CHS) position; and NGOs’ major challenges and perceived successes regarding the CHW program.

Methodology Through discussions with Ministry of Public Health (MoPH) staff in the Grants and Contracts Management Unit (GCMU), researchers generated a comprehensive list of NGOs providing the Basic Package of Health Services (BPHS) and other agencies working with Community Health Workers (CHWs). Researchers contacted the NGOs to schedule an in-person interview with the health coordinator, community-based health care (CBHC) coordinator, or other relevant personnel of each NGO. In addition, researchers interviewed MoPH personnel and other stakeholders knowledgeable about or involved in CBHC in Afghanistan. Interviews were conducted using a structured questionnaire and typically lasted between 1 and 2.5 hours. Quantitative information from the questionnaire was entered into a database using CSPro Version 3.0, and frequencies were tabulated in SPSS Version 13.0. Supplemental qualitative information was recorded through note-taking during the interview by the researcher conducting the interview. Researchers were able to interview 21 of 26 NGOs contacted about their CHW programs. Twenty of the interviews were conducted in-person in Kabul, Afghanistan, and one NGO returned the structured questionnaire by email to the researchers, as none of their staff were based in Kabul during the data collection period.

Results The following section presents results from the structured interviews with NGOs. A detailed table of the quantitative results is also given in Table 12. Of the 21 NGOs interviewed for this research, most follow the MoPH CBHC model very closely in their implementation of CHW programs.1 Most of the NGOs are very experienced; the majority of NGOs (61.9%) have been working in Afghanistan for more than five years, and the NGOs interviewed had an average of 10.8 years of experience in the country. According to data collected by the CBHC task force of the MoPH in August 2006, there are 14,136 active CHWs in Afghanistan, slightly more than half of whom are women. NGOs plan to recruit another 2,790 CHWs in the future.

Recruitment of CHWs More than three-quarters of NGOs began recruiting CHWs more than one year ago (i.e. before summer 2005) under the BPHS. All NGOs interviewed noted that they used the MoPH-developed criteria2 to select CHWs. There was slight confusion about the age range recommended in MoPH CHW selection policy; some NGOs said it was 20-50, while others thought it was 25-50, or 25-35, and some 18-50. In some areas, former traditional birth attendants (TBAs) were kept on as CHWs, and

1 The major exception is Future Generations, who follow an innovative approach to working with CHWs in Bamiyan and Ghazni. Researchers interviewed staff members of Future Generations, but their program is not included in the analysis that follows. A comprehensive picture of their CHW model can be found in the USAID-REACH report on the Future Generations program. 2 The MoPH criteria for CHWs are: 1) resident of local area; 2) age 20-50; 3) volunteer, motivated and interested to serve as a CHW; 4) respected person in the area; 5) women encouraged (and should be at least 50% CHWs); and 6) literacy preferred.


some of them are above 50 years. Other selection criteria beyond the basic MoPH criteria used by NGOs included that candidates be married, and that they not have children less than 2 years of age. Most of the NGOs did not track the marital status of CHWs, although they noted that the vast majority of CHWs, especially the women, are married. Several NGOs also remarked that when the CHWs are related (e.g., a husband-wife, brother-sister, father-daughter, male relative-female relative) the coordination between the two members of the health post is typically much better than when the CHWs are unrelated to one another. For example, they can coordinate their activities to travel to people’s homes together. According to the recent CHW Performance Assessment that BDF conducted, about 50% of CHWs in Baghlan, 80% in Ghazni, and 44% in Balkh are related to each other (either as couples, close relatives (e.g., brother/sister) or distant relatives) (BDF 2006). While 80% of CHWs who were married met on a daily basis to discuss their work, 36% of those who were relatives (but not spouses) met on a daily basis to discuss their work, and only 17% of those who were not related met on a daily basis to discuss their work. While all NGOs preferred to recruit literate CHWs, they acknowledged that this was not possible in many communities, especially for female CHWs. Only one NGO, SCA, had literacy as a specific criterion for selection in Wardak province. This was only for male CHWs, however. Regarding recruitment strategy, NGOs noted that either NGO or facility staff typically approached communities in the catchment area and spoke with community members directly about CBHC, the role of the CHW, and what types of people to nominate as CHW candidates. About 62% of the NGOs reported that community members initially nominate CHW candidates, and an equal percentage reported that shura-e-sehie members nominate CHWs initially, in places where shura-e-sehie were previously established. One NGO noted that TBAs nominate the candidates, while two NGOs asked for nominations from previously trained health promoters.

Responsibilities

Activities Conducted In all cases, CHWs were providing most of the recommended set of activities per the MoPH CHW job description. All NGOs reported that CHWs provided the following services: home visits; health education (including promotion of hygiene and safe drinking water and recognition of pregnancy danger signs, among other activities), mobilization for immunization, participation in national campaigns; meetings with the shura-e-sehie; supporting midwife activities; referral of complicated cases to the health center; detection and treatment of ARI, diarrhea, and malaria; promotion of good nutrition, exclusive breastfeeding for children under six months, and antenatal and post-natal care (ANC and PNC); provision of first aid treatment; promotion of family planning and distribution of contraceptives; vital registration; and completion of HMIS forms. However, not all NGOs reported CHW responsibility for provision of certain activities, including mental health and some pregnancy-related activities. For example, 3 of 21 NGOs (14.3%) reported that their CHWs do not promote community awareness of addictive substances; 10 NGOs (47.6%) reported that CHWs are not responsible for promoting psychosocial and mental well being; and 9 NGOs reported that CHWs are not yet responsible for implementing community-based DOTS. These results are not surprising, given that in the summer of 2006, mental health and community-based DOTS had not yet been operationalized within the revised BPHS. Only 11 of 21 NGOs (52.4%) reported that CHWs were responsible for providing a mini-delivery kit to women delivering at home. Some NGOs were not aware that CHWs were supposed to provide a mini-delivery kit (in fact, one NGO thought this was expressly forbidden), and one NGO (AHDS) has chosen not to have their CHWs promote use of clean delivery kits and instead has given this responsibility to the more than 2,000 former TBAs the NGO used to work with. Some NGOs expressed confusion about the MoPH policy regarding the mini-delivery kits: they did not see the purpose of having CHWs promote the mini-delivery kit for home deliveries if they are not allowed to assist in home deliveries in cases when midwives are not present.


Finally, not all NGOs reported that CHWs were responsible for tracking drug utilization. In 4 of 21 NGOs (19.0%), this was not viewed as a responsibility of CHWs but was carried out either by the CHS or not tracked at all (new kits are given during every supervision visit).

Number of Households Responsible for In most cases, CHWs are responsible for 100-150 households, as recommended in the BPHS. However, several NGOs noted that in more remote or geographically dispersed areas, their responsibility may be for only 50-100 households. Save the Children-US, for example, is in the process of recruiting and training 50 additional CHWs in order to reduce the individual CHW responsibility from 100-150 households to 50-100 in some areas. On the other hand, in some areas in the south, CHWs working in AHDS areas may cover up to 200 households. The table below presents information on the population coverage per CHW reported by NGOs. Table1. Population coverage per CHW, reported by NGOs* Items Number Percent <30 families 1 4.8 30-50 families 2 9.5 50-100 families 9 42.9 100-150 families 14 66.7 Other (100-200 HH, >200HH) 2 9.5 Missing/Don’t Know 1 4.8 *Categories do not sum to 100 percent, as NGOs may employ different strategies for CHW responsibility in different geographic areas they work in. Most NGOs (90.5%) do not have required minimum hours that CHWs must work, as they are volunteers in their community. In addition, there is no official MoPH policy on the level of activity that CHWs must maintain on a regular basis. However, some NGOs have their own requirements for CHWs’ level of activity. For example, SDF expects that CHWs visit a minimum of three homes daily. Two NGOs noted that they expect CHWs to work at least one hour per day.

Training of CHWs Many NGOs previously used their own training manual before the official MoPH training manual (prepared with the help of USAID-REACH) was released in March 2005. All NGOs reported using the new MoPH manual, except one NGO that reported using a modified version of the MoPH training manual. In some of the non-REACH provinces, the second phase of initial training was only two weeks (versus three), as community mapping was not included. CHWs are now receiving a one-week training course in community mapping. In some areas, parts of the basic curriculum were not included if they were not relevant (for example, Save the Children-US did not include malaria training for CHWs in Faryab, an area where malaria is non-endemic). Only one NGO, SCA, uses a different training structure than the recommended MoPH structure of three three-week classroom sessions over a period of six months. Instead of the MoPH three-phase training, SCA has gained approval from the MoPH to use a two-phase training for its CHWs. The initial phase is four weeks, followed by CHWs’ working in their communities for two weeks, and then a return to SCA for a second four-week training program. SCA uses this training structure for reasons related to ease of transportation and convenience for the CHWs. It was previously a problem – particularly for female CHWs – to come to the facility three times for training. According to SCA, the two-phase training structure has worked well, and SCA will follow it for the next group of female CHWs it is training. However, instead of staying overnight at the clinic, SCA will provide transportation to the female CHW candidates to travel back and forth during the training. In general, the methods that NGOs used to train CHWs were diverse and very participatory, as many of the CHW candidates are not literate. Almost all the NGOs interviewed used a mixture of lectures, participatory methods, group work, drama, and role play. Some also supplemented these classroom


teachings with field visits to the clinic. Almost all NGOs interviewed expressed great satisfaction with and enthusiasm for their CHW trainers, who are widely considered to be doing an excellent job working with literate and illiterate CHWs in creative ways. A few NGOs expressed a lack of clarity on how often refresher training is supposed to be held, and what topics are to be covered, with one NGO noting that they would like to see a clear MoPH policy on this. According to the MoPH3, NGOs should provide refresher training when it is indicated from poor knowledge in a certain area, when there are seasonal diseases and outbreaks (for example, ARI in winter), and when new responsibilities (e.g., mental health) are added to the CHW job description. The timing and structure of refresher training is up to NGOs to decide, but the MoPH suggests that refresher training be held on a monthly basis. The table below provides further information on the frequency of refresher training reported by NGOs interviewed. Table 2: Frequency of refresher training for CHWs* Items Number Percent Once per month 5 23.8 On-the-job 9 42.9 Once per year 4 19.0 Every 3-6 months 6 28.6 Weekly 1 4.8 Not yet 2 9.5 Missing/Don’t Know 1 4.8 * Responses do not sum to 100%, as multiple responses were possible

Role of CHS

Responsibilities and Span of Control Most NGOs employed (or planned to employ) one Community Health Supervisor (CHS) per health facility, although several NGOs were employing more than one CHS per health facility. Two NGOs expressed confusion about how many CHS it is permissible to have at each facility, noting that REACH initially agreed to have more than one CHS per facility, but then put forth the policy of only one CHS per facility. The NGOs felt that this was problematic for facilities that had many CHWs/health posts. One NGO, BRAC, has hired more than one CHS (usually 2) for certain clinics where there are many CHWs to supervise or where the catchment area is very spread out geographically. The table below presents the CHS span of control among the 20 NGOs currently employing CHS. Table 3: CHS span of control Items Number Percent ≤15 CHW 4 20.0 >15 CHW 13 65.0 Missing/Don’t Know 3 15.0 Average 23.2 - Most of the CHS employed were male, although several NGOs (BDF, SC-US, AMI, among others) had managed to hire female CHS. Several NGOs expressed concern about male CHS supervising female CHWs, especially in more conservative areas, such as Kunar, Badakhshan, Badghis, and southern parts of Afghanistan, and worried that their female CHWs will not have adequate supervision. The staff from MEDAIR, for example, expressed regret that their male-female CHW trainer/supervisor teams (previously one per district, now one per 3-4 districts) have mostly been replaced by primarily male CHS. The CBHC Coordinator from SDF also noted that in the absence of female CHS, it is much more difficult for female CHWs to attend the shura-e-sehie meetings in the community.

3 Conversation with Dr. Arwal, CBHC Director, MoPH, 15 July 2006.


A few solutions to this problem included: indirect supervision, where instead of meeting directly with the female CHW, the male CHS meets with community members in the CHW’s village and ask them about CHW activities to get a sense of their work; and having female clinic staff, such as the vaccinator, midwife or female nurse, accompany the male CHS during CHW supervision visits. Some NGOs employed different CHS models to address this problem; for example, AMI has several male-female couples that go to health posts of several different facilities to supervise CHWs; the team visits the health post together, but the male supervisor conducts the checklist with the male CHW, and the female with the female. However, this required that each CHS is responsible for supervising between 27 and 68 CHWs. The table below presents information on which personnel are responsible for supervising CHWs. Table 4: Personnel responsible for Supervision of CHWs* Items Number Percent CHS 20 95.2 Health Facility staff 6 28.6 CHW Trainer/Supervisor 9 42.9 Other (EPI Supervisor, CBHC Coordinator, Cluster Assistants) 3 14.3

* Responses do not sum to 100%, as multiple responses were possible

Training and Supervision aides For the REACH NGOs, training of the CHS typically took place in Kabul, during a three-week REACH-organized training that focused on CHW responsibilities and skills, inter-personal communication, BPHS orientation, community mapping, community leadership, HMIS, and supportive supervision. Most CHS had not previously attended the CHW training, and condensed content from the CHW curriculum was therefore included in their CHS training. Other NGOs not previously supported by REACH held their own training for CHS. For example, AMI held a 45-day CHS training. Some NGOs have developed their own supervisory checklist for the CHS to use; for example, AMI has significantly expanded the checklist the MoPH developed to include 57 supervision questions. The MoPH has recently created a job description for the CHS, and MoPH officials noted that the current focus of the CHS support for the CHW should be two-fold: 1) capacity building for the CHW, including on-the-job and refresher training; and 2) helping build the referral system by reinforcing appropriate referrals by CHWs.

Incentives

NGO/Facility-supported As reported in Table 5, no NGOs reported providing a regular salary or stipend to CHWs, although some NGOs, such as AHDS, paid their CHWs in the past. Prior to the BPHS, AHDS recruited only literate CHWs, and paid them $40 to $50 per month. In the mid-1990s, SCA also hired CHWs, who worked three days in the clinic and three days in the community and who were paid between $16 and $26 per month. The incentive that is closest to regular support for CHWs is currently provided by AMI in PPA-contracted Samangan province, where CHWs receive 200 Afs (males) to 300 Afs (females) per month; however, the CHWs claim this amount is too low. SCA provides an occasional monetary bonus to its CHWs, such as an Eid bonus, and a recent 2,000 Af bonus to all CHWs. Only one NGO, AHDS, reported giving bicycles to males and sewing machines to females, as well as a twice-yearly Eid bonus of 500 Afs, and cloth to female CHWs for women’s day. Other incentives provided included literacy training through a one-month UNFPA course (for ADRA CHWs), or through


a Learning for Life Course (CAF CHWs in Takhar and SDF CHWs in Ghazni). Some NGOs with REACH contracts mentioned that REACH had once provided CHWs with a gift kit of a nail cutter, a towel, toothbrush, and toothpaste. Some NGOs have also provided chairs and cupboards for the health posts. Almost all NGOs reported providing transport money and food during the initial CHW training. Only one NGO interviewed, BRAC, provides incentives for referral for TB and delivery cases. BRAC pays 40 Afs for each delivery referral. They have partnered with the National Tuberculosis Program and with a small grant from the International Union against TB and Lung Disease have begun implementing mobile clinics for TB detection and community-based DOTS. Beginning in January 2006, CHWs were trained for two days on DOTS, and began detecting and referring suspected TB cases to mobile labs when they came to the area for diagnosis. For each patient that is sputum smear positive, CHWs receive 50 Afs. After a patient successfully completes community-based DOTS under their supervision, CHWs receive 150 Afs. They receive referral money during the monthly supervision/refresher training meeting at the clinic. Since January 2006, 950 patients have been identified and started on DOTS treatment, and BRAC’s target is 4,200. According to BRAC staff interviewed, these referral incentives will not be the incentive that keeps the CHW working; it is merely a way to help reinforce certain behaviors that BRAC wants to encourage, such as referrals for suspected TB cases and for delivery: “The incentive did not make much difference because the CHWs are volunteers; the important thing is encouragement at different levels for sustainability,” one BRAC staff member said. They feel that verbal encouragement and visible support at all levels (central BRAC office personnel; CHW trainer; supervisor; the provincial health director (PHD) who comes to the CHW refresher course) is the most important way to encourage CHWs to keep working as volunteers. Table 5: Incentives provided by NGO/Health Facility Items Number Percent Microcredit loan 1 4.8 Bicycle/ Sewing Machine 1 4.8 Literacy training 3 14.3 Cloth 3 14.3 Eid bonus 3 14.3 Shoes 1 4.8 Transport money for training 21 100.0 Food for training 18 85.7 Money for referrals 1 4.8

Community In most cases, support provided by the community, if any, was relatively informal. Even within the same NGO, incentives differed widely by community. Further information on types of community support to CHWs is provided in Table 6 below. In-kind or informal fees for service were reported by several NGOs. Two NGOs, BRAC and AHDS, reported a more formal 2 Af consultation fee charged by CHWs. SCA also has a more formal policy for CHWs to charge fees from community members. In Wardak, CHWs with SCA charge 5 Afs to patients for consultation; according to SCA staff, approximately half of patients end up paying a fee to the CHW for their services. Some NGOs expressed hope that the shura-e-sehie, especially those recently trained in community leadership training, would begin to provide support for the CHW: “The best way to support CHWs is to encourage communities to support them, which is not happening yet,” one NGO staff member said. As another NGO remarked, “In the future, we need to focus on how to strengthen the role of the shura-e-sehie so they can decide whether CHWs should receive compensation… If the village shura understands what the CHW program is, the shura will be a big supporter of the program.” However, some NGOs noted that they have worked very hard to accomplish this without much success. For example, AMI has spent almost one year working directly with communities to explain the importance


of supporting CHWs and encouraging them to do so; however, based on recent CHS supervision checklists of CHWs, not a single CHW reported receiving support from communities. Several NGOs commented that one barrier to getting communities to support the CHWs is that they believe that the NGOs are already supporting the CHWs with salary/stipend: “The community doesn’t even believe that CHWs are volunteers; when they see the rich NGO behind them, they think we are paying them a salary,” said one NGO. In other cases, communities have claimed they are too poor or that the CHW is proud and do not want to receive any kind of direct support. Table 6: Community payments/cost recovery for CHWs* Items Number Percent None 8 38.1 In kind contributions 8 38.1 Formalized fee for service 4 19.0 Informal fee for service 5 23.8 Other (monthly stipend for one CHW) 1 4.8 * Responses do not sum to 100%, as multiple responses were possible

Performance appraisals In most CHW programs, the CHS typically visit the CHWs at their health posts on a regular basis (e.g., once per month) and use a supervisory checklist to assess the overall knowledge of the CHW, level of activity, and status of the health post. The CHS is then expected to discuss the findings of the supervisory visit with the CHW and, if appropriate, write his or her findings in the supervision book. In some NGOs, a more formal performance appraisal takes place on a regular basis. For example, MEDAIR uses a shorter monthly supervisory checklist, and every three months uses a long one to more critically assess the CHW performance. As noted above, some NGOs, such as AMI and AKDN, have developed more extensive monthly supervision checklists for the CHS to use. Many NGOs (AHDS, ADRA, AKDN, AMI, BRAC, NAC, and others) hold a monthly meeting at the facility that includes a combination of: 1) submitting HMIS reports; 2) sharing feedback with facility staff and discussing problems; 3) informal review of CHW’s performance; and 4) refresher training. The MoPH recommends that CHWs have a monthly meeting at the facility with the CHS and the facility staffs to discuss issues, solve problems, submit reports, and if appropriate, hold refresher training. Most of the NGOs did not have guidelines for promoting or terminating CHWs, as they felt CHWs cannot really be terminated because they are volunteers. However, four NGOs have dismissed CHWs from their work, primarily for reasons of inactivity (shura-e-sehie complained to NGO), and in one NGO for selling drugs from the bazaar to patients. Only a few NGOs have specific guidelines for termination of CHWs. For example, AMI will terminate CHWs if they miss 3 or more monthly meetings at the clinic or if on at least 2 visits the CHS concludes that they are not active. However, AMI has not terminated any CHWs to date. SDF also has specific termination guidelines and has terminated several CHWs because of the following reasons: missing more than 3 shura-e-sehie meetings; or complaints from the community that the CHW is not working properly or was selling medicines in their private shop.

Role of Shura-e-Sehie While all NGOs have established facility-level shura-e-sehie, only the REACH-grantee NGOs have consistently established shura-e-sehie for each health post.4 Some non-REACH grantees are beginning to do this; for example, BRAC, which has PPA contracts in 3 provinces, is just starting the process of establishing health post level shura-e-sehie. In most REACH areas, selected shura 4 According to a recent USAID-REACH report, approximately 60% of health posts in REACH grantee areas now have a functioning shura-e-sehie. For further information on the community-level shura-e-sehie and its functioning in REACH areas, please refer to USAID-REACH. January 2006. Community Leadership Assessment Report.


members (typically one male and one female from each health post shura) have received training in community leadership development at the health facility as part of the REACH program. The training was typically two days and addressed creating an action plan for the shura, responsibilities of the shura, monitoring/supervision of CHW activities, and mobilizing the community to use CHW and health services. A few NGOs, including AHDS, also have shura-e-sehie at the district level to assist in planning and implementation. NGOs typically visit communities several times to explain the BPHS, the concept of CBHC, and the shura and CHW role. They will then ask the community to select appropriate members for the health shura. Among the NGOs surveyed, 81.0% reported that community members nominate shura-e-sehie members, 14.3% reported that they are jointly recruited by the NGO and the community, and 9.5% reported other mechanisms of recruiting shura-e-sehie members, including through National Solidarity Program (NSP) shuras and through CHWs. Many NGOs have created a memorandum of understanding (MOU) between the NGO/facility and the shura-e-sehie that outlines the expectations and responsibilities of both parties. However, some NGOs remarked that much of the MOU has not been executed in practice: “there are nice things written, but they are not working,” especially the part about communities supporting the CHWs, said one NGO representative. Facility-level shura-e-sehie are typically expected to be a link between the facility/NGO and the community, but it is the local village shuras who are expected to mobilize the community to use CHW services. NGOs typically worked to establish the shura and then ask the shura to nominate CHW candidates, although in some cases this took place concurrently, and in areas without health post-level shura, NGOs worked with village elders and existing institutions, such as the village-level shura or the NSP shura, to explain the BPHS and ask for CHW candidate nominations. One NGO, SCA, questioned whether the current facility-level shura-e-sehie members are really representative of the community, or whether the members represent primarily the more influential elders in villages. SCA is in the process of looking into this issue and has begun to change some of the shura-e-sehie members; in Wardak, SCA is asking the National Solidarity Program (NSP) shura to nominate one member to the facility-level shura-e-sehie.

CHW Drop outs Reported drop-outs from the CHW program have remained quite low, typically well under 10%. For example, AMI reported that drop-outs from their CHW program in Kunar province were approximately 8%, and about 1% in Laghman province. AHDS reported an overall drop-out rate of about 8% across the southern provinces it works in. In many cases, more male than female CHWs dropped out, as they found other (paying) work in the community, and women tend to have fewer opportunities for work in the villages. The table below presents the most common reasons for CHW drop-outs, as reported by NGOs who knew the number of drop-outs. Table 7: Reasons for CHW Drop Outs* Items Number5 Percent Moved from community 13 86.7 Other job with compensation 7 46.7 Minimal/no compensation 6 40.0 Illness or death 6 40.0 Lack of community support 1 6.7 Other (security, marriage, quit, low level of education) 7 46.7

Missing/Don’t Know 1 6.7 * Responses do not sum to 100%, as multiple responses were possible

5 Among NGOs who knew the number of drop-outs (15 of 21 NGOs)


Challenges and Aspects of the Program Least Satisfied With During interviews, researchers asked NGOs both about their biggest challenges currently with the CHW programs and the aspects of the program they are least satisfied with. The results are presented in Tables 8 and 9 and discussed below.

Lack of payment/incentives for CHWs Lack of a regular payment or incentive for CHWs was a major challenge cited by nearly 62% of NGOs (including ADRA, AHDS, AMI, SCA, and others). Staff from AHDS felt strongly that there should be payment for CHWs, which was AHDS’ policy before BPHS implementation. According to the AHDS staff, “We need to pay CHWs in order to have authority over them. If CHWs have some payment, then there is no need for them to work hard for income, and they can stay in health posts during official times.” Several NGOs, including SCA, felt that the MoPH policy should be revised to allow direct payment of CHWs; according to SCA staff, “If we pay [CHWs] a monetary incentive, at least 1,000 Afs per month, then the program will be sustainable.” Other NGOs felt that the policy should at least be clarified regarding what types of payment are allowed and to more explicitly specify how CHWs should be supported by the community (for example, are CHWs allowed to charge consultation fees? Can the NGO provide incentives to CHWs using facility cost-sharing revenue?). Staff from ADRA noted that one shura-e-sehie had recommended that CHWs charge a small consultation fee, but ADRA recommended against this, since they feared it might be against current MoPH policy. They would like to have the MoPH policy specify that CHWs can charge for services provided. AMI staff noted that they believe communities will not support CHWs (after trying to facilitate this for one year with no success), and in their next proposal are planning to pay CHWs for referral to facilities (10 Caldar for ARI, TB, or delivery case referred). CAF would like to use facility cost-sharing revenue to support the CHW, but is concerned that this is against MoPH policy; they also would like to partner with another NGO to offer CHWs microcredit loans for small businesses. A few NGOs thought that the MoPH had brought in outside models that may not be appropriate for the local context in Afghanistan. According to one NGO, “The MoPH policy [on CHWs] is not effective and should be revised; they simply copied the policy of Bangladesh in Afghanistan, and it will not work…. In Malaysia, there are health volunteers, but they are only responsible for their family and not for their neighbors. In Kenya, there is payment for CHWs.” As noted above, several NGOs would like to use facility cost-recovery money to support the CHWs (either with cash or at least by providing lunch during refresher trainings); some would like to have CHWs charge more formal consultation fees, pending approval by the MoPH, and several are considering referral rewards, either monetary or in-kind, to improve the community-facility link.

Other major challenges/dissatisfying aspects of CHW programs There were several other issues cited as the major challenges by NGOs with the CHW programs (see Tables 8 and 9 for more). The diversity of responses indicates that aside from the issue of compensation, there are not necessarily overarching issues that are common concerns to most NGOs, but rather a variety of issues that NGOs see as their top concerns. Several of the other concerns mentioned by NGOs are as follows:

• Lack of community understanding/support for CBHC: Many of the NGOs reported that despite initial, brief introductions, it was difficult for communities to grasp the concept of community-based health care and the role of the CHW. Many communities have come to believe that CHWs are doctors, and they demand more services and medicines than the CHW is trained to provide. In some cases, the CHW feels pressure to focus on curative care or dispense drugs more freely than they were trained to do.


• Objection from male community and other family members: Several NGOs working in more conservative areas noted that it was difficult to find appropriate female CHW candidates because male community members did not think it was appropriate for females to serve as CHWs. In areas with only male CHWs, it was difficult for females to seek care from them.

• Security: Several NGOs reported security as their top concern, particularly in Eastern and Southern Afghanistan. Poor security conditions made it difficult to work closely with the community and carry out supervision at the community level.

• Lack of coordination with other sectors: Several NGOs, including AKDN, BDF, Future Generations, and NAC, mentioned a lack of coordination with implementers in other sectors working on development at the community level. As one NGO health program manager noted, “In every village, you have a water shura, a polio eradication shura, a health shura, an education shura, an NSP shura. If you have 100 houses for 15 different shuras, then everyone is a member of the shura, and they lose their effectiveness.” One NGO noted the need for improved coordination between, for example, the WHO bed net distribution program and CHWs’ malaria work, and between water and sanitation programs and the CHWs and shura-e-sehie. NAC, an NGO working with CHWs in Ghazni province, created district-level integrated shuras in 2005 with 10-12 representatives from health, education, government, and local villages. NAC claimed that these shuras have been quite successful in facilitating cross-sectoral cooperation.

• Lack of literacy and poor technical knowledge among CHWs: Several NGOs noted that low literacy levels among poor CHWs made it more challenging to train CHWs to be effective health promoters and providers. Many NGOs also mentioned a desire to partner with a literacy organization, such as Learning for Life (see more below), in order to improve literacy skills among CHWs.

• Difficulty in supervising CHWs: NGOs noted a few issues related to difficulty in supervising CHWs, including:

o Span of control too large for CHS: One NGO noted that if CHS were responsible for 10 CHWs, instead of the 20-50 that most supervise currently, supportive supervision would be enhanced.

o Questionable quality of supervision: One NGO, whose CHS have a much smaller span of control, was concerned with the quality of supervision and questioned what actually occurred during the supervision visits between the CHS and CHW.

o Difficulty supervising CHWs due to far distances: For a few NGOs, the distance between certain health posts and the health facility made it difficult for the CHS to effectively supervise all the CHWs.

• Poor coordination and relations between facility staff and CHWs: A common frustration expressed by NGOs was a lack of cooperation between facility staff and CHWs. Facility staff tend not to trust the skills and abilities of CHWs, making collaboration very difficult between these groups.

• Diffusion of focus and multiple responsibilities for CHW: As an increasing number of tasks and responsibilities are added to the CHWs’ plate, NGOs felt that their focus and effectiveness is diluted. This issue is exacerbated by the fact that CHWs are technically volunteers. As one NGO put it, “Day by day, the CHW job description keeps increasing, but we forget that they are volunteers. We treat them like paid employees, and this is a problem. We need to bear this in mind…. If we want this program to be sustained, we can’t just add to the job description.”

• Other issues, including: o Lack of space for health posts o Low CBHC budget from MoPH o Monitoring of drug kits o Lack of transport for CHWs, including to refer patients to facilities o Training difficult in remote areas o Lack of female CHS


Table 8: Major challenges faced by NGOs with CHW programs* Items Number Percent Lack of/Demand for payments 13 61.9 Lack of community understanding/support for CBHC 6 28.6 Objection from male community/family 5 23.8 Security 5 23.8 Lack of literacy 4 19.0 Lack of coordination with other sectors working in the community 4 19.0 Inability to supervise 3 14.3 Poor CHW technical knowledge 2 9.5 Difficult to find good CHW candidates 2 9.5 CHWs have to travel far 2 9.5 Other (one each of the following: lack of space for health posts, unclear MoPH policy on compensation, low CBHC budget from MoPH, poor coordination between CHWs and facility, lack of MoPH leadership on CBHC, monitoring of drug kits, poor coordination between CHWs and facility, lack of transport for CHWs, training difficult in remote areas, lack of female CHS, finding non-monetary ways to support CHWs; quality of CHS supervision unknown)

12 57.1

* Responses do not sum to 100%, as multiple responses were possible Table 9: Aspects of the CHW program least satisfied with* Items Number Percent Future sustainability/volunteer aspect 4 19.0 CHWs behaving like doctors 2 9.5 Giving drugs too freely/focusing on curative care 2 9.5 Poor CHW knowledge 2 9.5 Lack of community understanding of CHWs 2 9.5 Diffusion of CHW focus 2 9.5 Other (one each of: mental health and HIV/AIDS, incorrect mapping/tally sheet, nutrition, family planning, low community awareness of health behaviors, lack to transport for CHWs to take patients to facilities, inability to attend home deliveries, lack of female shura-e-sehie members)

11 52.4

* Responses do not sum to 100%, as multiple responses were possible

Satisfaction with CHW program Most NGOs were relatively satisfied with the CHW program overall, and many saw it as the only feasible way to provide services in remote areas of Afghanistan. On a scale of 1-4, with 1 being very dissatisfied and 4 being very satisfied, the average NGO rating of their overall satisfaction with the CHW program was 3.2. Though lack of payment/support from communities was mentioned by many NGOs as a major challenge and concern, many mentioned that they were impressed by the motivation levels of the CHWs overall. Most NGOs noted that it took a lot of time at the beginning to establish the CHW program and community understanding, but communities are gradually becoming more accepting of the CHWs. The aspect of the CHW program that NGOs are most commonly satisfied with is increased referrals to the health facility, mentioned by nearly 62% of NGOs, indicating that the community-facility link is functioning relatively well in spite of the challenges in coordination. NGOs were also very satisfied with increased community knowledge about health practices (mentioned by nearly 43% of NGOs). Many of the NGOs were also very satisfied with the large increases they had noted in family planning uptake, as being able to obtain contraceptives from a nearby CHW makes family planning much more accessible and widely used than when family planning services are offered at facilities only. Other aspects of the CHW program that NGOs are most satisfied with are provided in Table 10 below.


Table 10: Aspects of the CHW program most satisfied with* Items Number Percent Increased referrals to health facility 13 61.9 Increased community knowledge 9 42.9 Increased uptake of family planning 7 33.3 Increased utilization of CHW services 3 14.3 Training 2 9.5 Motivation of CHWs 2 9.5 Community Satisfaction/acceptance 1 4.8 Other (one each of: care for children, women, immunization, improved access, health education, home visits, supplies for CHW

7 33.3

* Responses do not sum to 100%, as multiple responses possible According to NGOs, the services that communities valued the most from CHWs were child consultations, including for diarrhea and ARI, and health education (mentioned by 52.3% and 47.6% of NGOs, respectively). They also believed that drugs and curative care were especially valued by the community (28.6% of NGOs). Many NGOs noted that increased uptake of family planning in the community has been a big success of CHW work. As noted above, it is much easier for women in the communities to visit the nearest CHW to receive condoms or oral contraceptives than to travel all the way to the clinic. One NGO, STEP, remarked that CHW referrals have dramatically increased immunizations at the facility, from an average of 13 DPT-3 injections per month to more than 60. Further information on the services valued by communities is provided in Table 11 below. Table 11: Services most useful to community, according to NGO* Items Number Percent Child consultations 11 52.4 Health education 10 47.6 Drugs/curative care 6 28.6 Family planning 6 28.6 Adult consultations 6 28.6 Vaccinations 5 23.8 ANC 4 19.0 PNC 4 19.0 Referrals to facility 3 14.3 Sanitation /hygiene 2 9.5 TB treatment 1 4.8 Other (maternal and newborn care, injections/dressings) 3 14.3

* Multiple responses possible

Conclusions and Recommendations Conclusions From interviews with NGOs about the current status of their CHW programs, the following conclusions can be made:

• NGO CHW programs are relatively standardized at this point; there is little variation/deviation from MoPH policy. NGOs are following recruitment and training guidelines closely, with all NGOs using the MoPH training manual (or a modified version). The CHW responsibilities and activities also seem to be quite uniform, with the only notable exceptions being activities that were newly integrated into the BPHS, including distribution/promotion of mini-delivery kits, mental health promotion, and community-based DOTS. Although many NGOs are actively working to integrate these new activities into the CHW curriculum and


responsibilities, a few NGOs expressed confusion about the promotion of mini-delivery kits and how this should function.

• NGOs expressed satisfaction with the training curriculum and the creative approaches employed by CHW trainers. Most NGOs used quite diverse and participatory methods to train CHWs, which were reported to have worked well, given the low literacy levels of many candidates.

• Although the initial training was well standardized and seemingly effective, NGOs expressed some confusion and concern about refresher training. Specifically, several NGOs were unclear when and how often refresher training should take place, and what the content should emphasize.

• Several NGOs expressed concern about the newly created role of the CHS, particularly in terms of supervising female CHWs. However, a few NGOs have devised creative approaches to overcoming this potentially sensitive issue, including male-female CHS pairs, male CHS eliciting community feedback on female CHW activities, and use of female staff from the health facility for supervision. This review of NGO practices occurred shortly after the implementation of the CHS role, and thus captured a system in transition. It is possible that those NGOs which initially expressed concern about the CHS role in supervision for female CHWs have refined their supervision mechanisms to be both culturally acceptable and effective.

• None of the NGOs interviewed are providing a regular salary or stipend to CHWs, in line with the current MoPH policy on CHW compensation. All NGOs provide per-diem for transport and/or food during the initial training, and only a few provide other incentives for active CHWs, including an occasional bonus or a bicycle or sewing machine. Only one NGO, BRAC currently provides incentives for patient referrals, although several other NGOs are contemplating this approach.

• Community support of CHWs tends to be informal and varied. Only three NGOs reported that their CHWs have more formal cost sharing mechanisms (charging small fees from community members who use their services). Many NGOs expressed optimism regarding the potential for community/shura-e-sehie support of CHWs, although certain NGOs were quite skeptical of this; one NGO has invested a large effort in community mobilization for CHW support with no apparent results.

• Although reported drop-out rates tend to be low at the present time, most NGOs expressed concern about the future sustainability of the CHW program. Many NGOs felt that the job description of the CHW was continuing to grow, without adequate or appropriate incentives for CHWs to keep working. A few NGOs noted that they would like to compensate CHWs from facility cost-sharing funds but were unsure whether this was against MoPH policy.

• Other major concerns expressed by NGOs were varied and included issues such as security, low levels of literacy, lack of community understanding of and support for CBHC, and other issues.

• Despite an overwhelming concern about lack of CHW payment, most NGOs were quite positive about the CHW program, noting that it is functioning relatively well and serves an important role especially in rural communities. NGOs expressed greatest satisfaction with CHWs’ facilitation of increased referrals to the health center, increased community knowledge, and increased uptake of family planning in communities.

Recommendations Based on the above results, a few general recommendations concerning the CHW emerge:

• While certain aspects of the CHW program seem quite standardized, there appears to be a need to clarify the MoPH policy on a few issues, including:

o CHW compensation/incentives – While it is clear that regular salaries/stipends are not permissible under current MoPH policy, a few further clarifications should be made. For example: Can CHWs be compensated from facility cost-sharing revenue? Is it allowable for CHWs to charge consultation fees or fees for drugs? How much flexibility are contracted NGOs allowed in interpreting MOPH policy and exploring innovative approaches?


o Refresher training – As several NGOs mentioned a lack of clarity about the frequency and recommended content of refresher training, further clarification from the MoPH on this would be useful. While refresher training should be customized based on the performance gaps and needs of CHWs, it would be helpful to provide more guidance to NGOs on the general protocols for refresher training, based on best practices.

o Role of mini-delivery kits – A few NGOs were unclear about the role CHWs should play with regard to delivery kits. One was unclear about whether CHWs are supposed to promote the delivery kits, and two others questioned the current policy prohibiting CHWs from assisting with delivery: if CHWs are supposed to promote use of mini-delivery kit for home deliveries, and in the absence of a midwife, who will ensure that the kit is used?

• Continued attention should be given to how to promote better coordination among the multiple community-based implementers working in different programs/sectors. One possible model for further investigation might be the integrated district-level shura currently established by some NGOs (e.g., NAC in Ghazni province).

• Given the high interest among NGOs in literacy programs for CHWs, such as Learning for Life, a literacy program with health messages implemented by the University of Massachusetts/Amherst and International Rescue Committee (IRC) in some parts of Afghanistan, it may be worthwhile exploring the potential to scale up literacy programs for CHWs in many part of the country. For example, the possibility of an MoPH-led initiative to provide literacy training for CHWs, either through partnership with another Ministry, donor, or existing community-based literacy programs, should be investigated.

• In addition to CBHC task force that meets regularly, targeted workshops should be conducted to address some of the common concerns of NGOs and promote the sharing of information between NGOs on lessons learned related to effective and ineffective practices. For example a series of CBHC workshops could help clarify MoPH policies and promote inter-NGO learning on issues such as recruitment, training, compensation and other incentives, support, the role of the CHS, and other issues of common concern.


References BDF. 2006. Evaluation of Community Health Workers. USAID-REACH. January 2006. Community Leadership Assessment Report.


Table 12: CHW Desk Review Results 2006

Indicator N Percent Years in Country <5 7 33.3 5-10y 4 19.0 >10y 9 42.9 Missing/Don’t Know 2 9.5 Average 10.8 - # Provinces Working in 1 8 38.1 2 3 14.3 3 5 23.8 4 3 14.3 5 2 9.5 # Districts Working in <5 2 9.5 5-10 5 23.8 >10 10 47.6 Missing/Don’t Know 4 19.0 Average number of facilities BHC 20 95.2 CHC 11 52.4 DH OPD 2 9.5 Years since recruitment of CHWs ≤1y 2 9.5 >1y 16 76.2 Missing/Don’t Know 3 14.3 Initial Recruitment of CHWs Community members 13 61.9 Shura-e-sehie 13 61.9 TBA 1 4.8 Other (previously trained promoters/shura) 2 9.5 Missing/Don’t Know 1 4.8 Use of selection criteria Yes 20 95.2 Missing/Don’t Know 1 4.8 Selection criteria designed by: NGO/MOPH 18 90.0 Community 1 5.0 NGO and community 1 5.0 Lower age limit of CHWs 18 6 28.6 20 12 57.1 25 1 4.8 Missing/Don’t Know 2 9.5 Upper age limit of CHWs 35 1 4.8 40 3 14.3 45 2 9.5 50 8 38.1 >50 2 9.5 Missing/Don’t Know 5 23.8 Educational requirements Literacy preferred 18 85.7 Read and write 1 4.8


Indicator N Percent Educational requirements (contd…) None 1 4.8 Missing/Don’t Know 1 4.8 Population coverage per CHW6 <30 families 1 4.8 30-50 families 2 9.5 50-100 families 9 42.9 100-150 families 14 66.7 Other (100-200 HH, >200HH) 2 9.5 Missing/Don’t Know 1 4.8 Job description Home visits 21 100.0 Health Education 21 100.0 Community awareness of addictive substances 18 85.7 Mobilization of women and children for immunization 21 100.0 Administration of Vitamin A to children 6m-5y 17 81.0 Participation in National Campaigns 21 100.0 Participation in meetings with Shura-e-sehie 21 100.0 Support midwife activities, pregnancy related referrals 21 100.0 Promote Hygiene, sanitation and safe drinking water 21 100.0 Detect and treat ARI, Diarrhea and Malaria 21 100.0 Promote use of ORS/home available fluids for diarrhea 21 100.0 Refer complicated cases to health center 21 100.0 Support community based DOTS 12 57.1 Promote exclusive breastfeeding for children < 6m 21 100.0 Promote good nutrition practices 21 100.0 Promote ANC and PNC visits 21 100.0 Promote use of clean delivery kit 11 52.4 Educate women to recognize pregnancy complications 21 100.0 Support preparedness for obstetric emergencies 20 95.2 Promote FP services and distribute condoms 21 100.0 Provide first aid treatment 21 100.0 Promote psychosocial and mental well being 11 52.4 Job description (continued) Community mapping for eligible service beneficiaries 20 95.2 Vital registration – births and deaths 21 100.0 HMIS forms 21 100.0 Maintain drug list and report drug utilization 17 81.0 Other: caution against overdose of meds, lead participatory work in village 1 4.8

CHW hours of service Unspecified 19 90.5 Other (at least 1 hour/day) 2 9.5 CHW Training NGO 20 95.2 MOPH 1 4.8 Missing/Don’t Know 1 4.8 Training manual MOPH 19 90.5 Other (Adapted by NGO) 1 4.8 Missing/Don’t Know 1 4.8 Training content Family planning 19 90.5 Antenatal care 20 95.2 Postnatal care 20 95.2 Referral for facility deliveries 20 95.2 Home deliveries 16 76.2 Tuberculosis 19 90.5

6 Categories do not sum to 100, as multiple responses were possible.


Indicator N Percent Training content (contd…) Vaccinations 20 95.2 Malaria 19 90.5 Nutrition 20 95.2 Hygiene 20 95.2 Mental health 17 81.0 Childhood diseases (ARI, diarrhea, fever) 20 95.2 Community mapping and HMIS 20 95.2 Other (first aid/physical trauma, addictive substances, leishmaniasis) 3 14.3

Missing/Don’t Know 1 4.8 Training structure 3 sessions over 3 weeks for 6 months) 19 90.5 Other (2 4-week sessions over 2.5 months) 1 4.8 Missing/Don’t Know 1 4.8 Type of training Classroom/lectures 19 90.5 Participatory methods 19 90.5 Drama, songs, role play 18 85.7 Group work 19 90.5 Other (pregnancy histories, field visits, demonstrations) 4 19.0 Missing/Don’t Know 2 9.5 Refresher training1 Once per month 5 23.8 On-the-job 9 42.9 Once per year 4 19.0 Every 3-6 months 6 28.6 Weekly 1 4.8 Not yet 2 9.5 Missing/Don’t Know 1 4.8 Training materials Job aids 16 76.2 Posters/pamphlets 19 90.5 Models/kit 15 71.4 Missing/Don’t Know 2 9.5 Supervision1 CHS 20 95.2 Health Facility staff 6 28.6 CHW Trainer/Supervisor 9 42.9 Other (EPI Supervisor, CBHC Coordinator, Cluster Assistants) 3 14.3 CHS Span of control7 ≤15 CHW 4 20.0 >15 CHW 13 65.0 Missing/Don’t Know 3 15.0 Average 23.2 - Number of CHS Hired Average No. Male CHS 27.3 - Average No. Female CHS 3.6 - Venue of training for CHS1, Kabul 10 50.0 Provinces 12 60.0 Training by1 NGO 14 70.0 USAID-REACH 9 45.0

7 Responses to this and the four following questions include only those NGOs who have already hired CHS (20 of 21 NGOs interviewed).


Indicator N Percent Duration of CHS training ≤ 1w 2 10.0 1-2w 3 15.0 2-3w 5 25.0 >3w 5 25.0 Missing/Don’t Know 4 20.0 Continuing to hire CHS? Yes 13 61.9 Missing/Don’t Know 2 9.5 Incentives by NGO/Health Facility Regular salary or stipend 0 0.0 Microcredit loan 1 4.8 Bicycle 1 4.8 Literacy training 3 14.3 Computer training 0 0.0 Cloth 3 14.3 Food for work 0 0.0 Eid bonus 3 14.3 Shoes 1 4.8 Food (nuts, fruit, flour etc) 0 0.0 Transport money for training 21 100.0 Food for training 18 85.7 Money for referrals 1 4.8 Community payments/cost recovery1 None 8 38.1 In kind contributions 8 38.1 Formalized fee for service 4 19.0 Informal fee for service 5 23.8 Other (monthly stipend for one CHW) 1 4.8 Fee exemptions (among CHWs charging fees) NGO guidelines 1 7.8 CHW decisions 5 38.5 Shura recommendation 1 7.8 Performance appraisals None 10 47.6 Every 1-2 months 6 28.6 Every 3 months 2 9.5 Every 6 months 1 4.8 Annually 1 4.8 Missing/Don’t know 1 4.8 Guidelines for promotion/termination? Yes 7 33.3 Missing/Don’t Know 2 9.5 Termination of CHW in the past year? None 12 57.1 1-5 CHWs 4 19.0 Missing/Don’t Know 5 23.8 Reasons for Termination1 Selling drugs 2 50.0 Community not satisfied 2 50.0 Not active in community 1 25.0 Recruitment of shura-e-sehie members Community 17 81.0 NGO and community 3 14.3 Other (NSP shuras and CHWs) 2 9.5 NGO expectations of Shura-e-sehie Communication with NGO 20 95.2 Create awareness of CHW services 20 95.2


Indicator N Percent NGO expectations of Shura-e-sehie (contd…) Mobilize community to use services 20 95.2 Determine fee exemptions 1 4.8 Payments mechanisms for CHW 14 66.7 Support problem solving 20 95.2 Support national campaigns 20 95.2 Other (provide place for health post, monitor CHW) 3 14.3 Missing/Don’t Know 1 4.8 # Drop outs to date Avg. # Male 3.4 - Avg. # Female 2.5 - Total8 12.5 - Reasons for Drop Out9 Minimal/no compensation 6 40.0 Moved from community 13 86.7 Illness or death 6 40.0 Lack of community support 1 6.7 Other job with compensation 7 46.7 Other (security, marriage, quit, low level of education) 7 46.7 Missing/Don’t Know 1 6.7 Challenges Faced by NGOs with CHW Programs Demand for payments 13 61.9 Lack of community understanding/support for CBHC 6 28.6 Objection from male community/family 5 23.8 Security 5 23.8 Lack of literacy 4 19.0 Lack of coordination with other sectors working in the community 4 19.0 Inability to supervise 3 14.3 Poor CHW technical knowledge 2 9.5 Difficult to find good CHW candidates 2 9.5 CHWs have to travel far 2 9.5 Other (includes one each of the following: lack of space for health posts, unclear MoPH policy on compensation, low CBHC budget from MoPH, poor coordination between CHWs and facility, lack of MoPH leadership on CBHC, monitoring of drug kits, lack of transport for CHWs, training difficult in remote areas, lack of female CHS, finding non-monetary ways to support CHWs)

12 57.1

Aspects of the CHW program Least Satisfied With Future sustainability/volunteer aspect 4 19.0 CHWs behaving like doctors 2 9.5 Giving drugs too freely/focusing on curative care 2 9.5 Poor CHW knowledge 2 9.5 Lack of community understanding of CHWs 2 9.5 Diffusion of CHW focus 2 9.5 Other (one each of: mental health and HIV/AIDS, incorrect mapping/tally sheet, nutrition, family planning, , low community awareness of health behaviors, lack to transport for CHWs to take patients to facilities, inability to attend home deliveries, lack of female shura-e-sehie members,

11 52.4

Missing/Don’t Know 1 4.8 Services most useful to community, according to NGO1 Child consultations 11 52.4 Health education 10 47.6 Drugs/curative care 6 28.6 Family planning 6 28.6 Adult consultations 6 28.6 Vaccinations 5 23.8 ANC 4 19.0 PNC 4 19.0

8 Male and female does not sum to total, as there were 10 missing/don’t know responses for male and female but only 6 for the total number of drop-outs. 9 Among NGOs who knew the number of drop-outs (15 of 21 NGOs)


Indicator N Percent Services most useful to community, according to NGO (contd…)

Referrals to facility 3 14.3 TB treatment 1 4.8 Sanitation /hygiene 2 9.5 Other (maternal and newborn care, injections/dressings 3 14.3 NGO Satisfaction with CHW Program Average satisfaction with CHW program on scale of 1-4 scale (1=very dissatisfied; 4=very satisfied)

3.2 -

Aspects of the CHW program Most Satisfied With Increased referrals to health facility 13 61.9 Increased community knowledge 9 42.9 Increased uptake of family planning 7 33.3 Increased utilization of CHW services 3 14.3 Training 2 9.5 Motivation of CHWs 2 9.5 Community Satisfaction/acceptance 1 4.8 Other (one each of: care for children, women, immunization, improved access, health education, home visits, supplies for CHW

7 33.3

Section D: Findings on CHW Knowledge, Satisfaction and Performance

40


This section describes selected findings on community health worker (CHW) satisfaction and performance conducted as a part of a multi-method assessment process to study the factors that contribute to CHW performance in Afghanistan. The activity was jointly conducted by the Ministry of Public Health (MOPH), specifically the Monitoring and Evaluation Department and the Community Based Primary Health Care Unit of the Ministry of Public Health, Johns Hopkins University and Indian Institute of Health Management Research through the ongoing National Health Services Performance Assessment (NHSPA) between 2004 and 2006.

Design and Sampling The two main sources of data included here are from the National Health Services Performance Assessment (NHSPA) and the Afghanistan Household Survey (AHS) 2006. The NHSPA is conducted annually between June and September, using a stratified random sample of all health facilities providing the basic package of health services (BPHS) from all provinces of Afghanistan. The total number of provinces selected varied between 2004 and 2006; in 2004, Daikundi, was not included as there were no functional BPHS facilities. In 2005 and 2006, Daikundi was included, but Kandahar, Helmand, Zabul and Uruzgan were eliminated from the sample due to security reasons. In 2004 and 2005, two CHW were sampled from each facility. Although initial efforts were made to list all CHW reporting to the facility and randomly select two for interview, the assessment teams had to use a convenience sampling approach in order to complete their assessment of one facility in one day. This was necessary for security purposes. In 2006, the sampling approach was modified and up to four CHW were randomly sampled from the list of CHW reporting to the facility and who could be located and interviewed on the same day. Therefore the sampled CHW are not representative of all CHW; CHW who reside closer to health facilities are over-sampled and CHW who reside in remote areas that are difficult to reach are under-sampled. The total number of CHW interviewed were 167, 306, and 907 in 2004, 2005, and 2006, respectively. Between 2004 and 2006, the measurement instruments were modified to include additional questions to obtain information on perspectives of CHW services from the clients utilizing the services.


41

Selected Findings from CHW Interviews on Knowledge and Satisfaction

Profile of CHW As mentioned earlier, this was a purposeful sample and therefore is not representative of the national cadre of CHW. In 2006, a higher proportion of female CHW was sampled compared to 2004, but there were still fewer women in the sample than men (36.9% female in 2006). Of the CHW who were interviewed, 80% were married, 15% single and 5% were widows. Only 5% of the CHW were 50 years or older, and 45% were 30 years or younger. In comparison to 2004, there was a higher proportion of illiterate CHW in 2006: 12% vs 24%. More than 60% of the CHW had received high school education. It is evident that considerable efforts have been made by NGO’s and the MOPH to train additional CHW in the past two years. 66% of the CHW had less than 2 years of experience in 2006. Table 1: Profile of CHW: 2004-2006

Year CHW Profile 2004 2005 2006

Total CHW N=167 N=306 N=907 n(%) n(%) n(%) Sex Male 122 (73.1) 207 (67.6) 571 (63.1) Female 45 (26.9) 98 (32.0) 334 (36.9) Marital Status Married NA NA 725 (80.0) Single NA NA 134 (14.8) Widow NA NA 47 (5.2) Age of CHW 30 years or less NA NA 402 (44.8) 31-50 years NA NA 456 (50.8) Above 50 years NA NA 40 (4.5) Years of formal schooling No schooling 20 (12) 61 (19.9) 217 (24.0) 6 years or less 23 (13.8) 57 (18.6) 125 (13.8) 7-12 years 112 (67.1) 174 (56.9) 394 (43.5) More than 12 years 8 (4.8) 14 (4.6) 169 (18.7) Years as CHW <1 62 (37.1) 139 (45.4) 209 (23.1) 1-2 33 (19.8) 102 (33.3) 391 (43.3) 2-3 20 (12.0) 27 (8.8) 210 (23.2) 3-4 13 (7.8) 17 (5.6) 61 (6.7) 4-5 11 (6.6) 3 (1.0) 11 (1.2) >5 28 (16.8) 19 (6.2) 22 (2.4)


42

CHW Training and Knowledge on Select Disease Conditions In 2004, 25% of the CHW interviewed reported receiving their initial training from the MOPH. By 2006, these figures were much lower as more than 96% of CHW reported receiving training from the NGO and other donor agencies. The CHW were trained in several technical areas for child and family health. At least 20 to 40% had been trained in each technical area as shown in Table 2. Additional efforts are required to ensure that these community providers have basic competencies in addressing common IMCI conditions and essential maternal and newborn care, including FP and TB. Twenty four percent of the CHW also reported receiving training on mental health. The CHW interviews also indicated impressive knowledge gains for common disease conditions and essential community services. In 2006, the majority of the CHW (>70%) knew the importance of handwashing, and 99% demonstrated correct knowledge on sources of safe drinking water. More than 95% correctly identified vaginal bleeding and swelling of the face and extremities as signs that a pregnant woman needs emergency care. Similarly, danger signs for referring children were correctly identified by more than 80% of the CHW. More than 98% of the CHW knew that lack of iodine caused goiter, although there were some CHW who also mentioned scurvy and night blindness as consequences of iodine deficiency. Appropriate age for weaning was correctly stated by more than 98% of the CHW. Almost all CHW (>95%) were knowledgeable about the vaccine preventable illnesses, although some also mentioned AIDS (22%). Oral contraceptive pills, depoprovera and IUD were stated as effective methods of contraception by more than 85% of the CHW, and breastfeeding was also mentioned by 78%. Ninety five percent of the CHW correctly identified blood in sputum, weight loss and cough, and fever and sweats at night as signs of TB. Similarly, 80% of the CHW correctly identified convulsions, repeated vomiting, reduced urine output and yellow conjunctiva as signs of severe malaria. There were no major differences in the knowledge of male and female CHW. Table 2: CHW Training and Knowledge on Select Conditions

Year CHW Training and Knowledge 2004 2005 2006 Total CHW N=167 N=306 N=907 n(%) n(%) n(%) Place of initial training MOPH 42 (25.1) 31 (10.1) 135 (14.9) Other 125 (74.9) 273 (89.2) 769 (85.1) Who provided initial training MOPH 30 (18) NA 32 (3.5) NGO 137 (82) NA 872 (96.5) Training since basic training Family planning 39 (23.4) 164 (53.6) 431 (47.6) ANC 25 (31) 152 (49.7) 365 (40.2) Post-natal care 30 (18) 147 (48.0) 356 (39.3) Facility delivery 16 (9.6) 48 (15.7) 159 (17.5) Home delivery 28 (16.8) 102 (33.3) 227 (25.1) TB 36 (21.6) 98 (32.0) 322 (35.5) Vaccination 50 (29.9) 179 (58.5) 417 (46.2) Malaria 38 (22.8) 146 (47.7) 371 (41.0) Nutrition 33 (19.8) 151 (49.3) 325 (35.9) Hygiene 58 (34.7) 187 (61.1) 443 (48.9)


43

Year CHW Training and Knowledge 2004 2005 2006 Training since basic training (continued) Mental health 16 (9.6) 92 (30.1) 213 (23.6) Childhood illness 44 (26.3) 140 (45.8) 347 (38.3) Other 8 (4.8) 32 (10.5) 211 (23.4) None 74 (44.3) 27 (8.8) 48 (5.3) CHW Knowledge on: Hand washing after latrine use: Removes dirt from hands NA 290 (94.8) 881 (97.1) Prevents UTI NA 252 (82.4) 661 (72.9) Avoids diarrhea, cholera, typhus, parasites NA 296 (96.7) 889 (98.0) Prevents skin infections NA 230 (75.2) 728 (80.3) Safe water source: Water near animals NA 1 (0.3) 4 (0.4) Standing water NA 3 (1.0) 9 (1.0) Water from a spring or deep well NA 301 (98.4) 898 (99.2%) Water in streams and rivers NA 35 (11.4) 141 (15.6) Danger signs for pregnant women: Fever NA 226 (73.9) 703 (77.6) Vaginal Bleeding NA 300 (98.0) 896 (98.9) Swelling in hands, face, feet NA 284 (92.8) 865 (95.5) Anorexia NA 158 (51.6) 563 (62.1) Dangerous signs for Infant: Not passed urine or defecated > 24 h NA 253 (82.7) 821 (90.6) Infant jaundiced on 5th day of delivery NA 238 (77.8) 724 (79.9) Repeated vomiting NA 275 (89.9) 871 (96.1) Jaundiced for > 6d NA 264 (86.3) 796 (87.9) Lack of Iodine causes: Scurvy NA 118 (38.6) 388 (43.3) Lowered resistance to disease NA 139 (45.4) 580 (64.7) Goiter NA 280 (91.5) 881 (98.2) Night blindness NA 103 (33.7) 353 (39.4) Age for weaning: Right after birth NA 7 (2.3) 37 (4.1) At 1m NA 9 (2.9) 41 (4.6) At 3m NA 20 (6.5) 69 (7.7) At 6m NA 295 (96.4) 880 (98.4) Vaccine preventable diseases: Poliomyelitis NA 300 (98.0) 896 (98.8) Measles NA 300 (98.0) 902 (99.4) Tetanus NA 301 (98.4) 897 (98.9) Tuberculosis NA 275 (89.9) 864 (95.3) AIDS NA 59 (19.3) 202 (22.3) Effective methods of contraception: Oral contraceptives (pills) NA 263 (85.9) 804 (89.3) Depoprovera injection (DMPA) NA 252 (82.4) 795 (88.3) IUD NA 218 (71.2) 763 (84.8) Breastfeeding NA 182 (59.5) 707 (78.6) Signs of Tuberculosis: Bloody diarrhea NA 76 (24.8) 250 (27.7) Blood in sputum NA 274 (89.5) 853 (94.4) Weight loss and cough NA 284 (92.8) 880 (97.3) Fever and sweating during the night NA 275 (89.9) 865 (95.7) Danger signs in severe malaria: Repeated vomiting NA 241 (78.8) 731 (81.5) Reduced amount of urine that turns brown NA 228 (74.5) 716 (79.8) Eyes turn yellow NA 211 (68.9) 711 (79.3) Convulsions NA 263 (85.9) 813 (90.6)


44

CHW Feedback on Service Provision and Drug Availability In comparison to CHW responses in 2004 and 2005 (42% and 49%), the proportion of CHW reporting that they are responsible for more than 150 households was much lower in 2006 (28%). This may be due to increased numbers of trained CHW or a change in NGO and MOPH policy to reduce the workload of the CHW. Only 5% of the CHW reported covering a population of more than 300 households in 2006, compared to 24% in 2004. Forty nine percent of the CHW interviewed in 2006 reported regular household visits to more than 25 households every month, compared to only 12% in 2004. The CHW perform a myriad of services, including supervision and training of TBA’s, consultations for children and adults (increased from 50% to more than 70% between 2005 and 2006), maternal health services including ANC and MNBC, TB and malaria treatment, nutrition, health education and referrals. It is evident that the MOPH and the NGO community have invested considerable efforts to improve drug supply as reported availability of essential drugs improved between 2004 and 2006. More than 65% of the CHW interviewed reported having Chloroquine, Cotrimoxazole, iron folate, ORT, paracetamol, and family planning supplies. Patient tally sheets were also reported to be available by 88% of the CHW providers. Table 3: CHW Services and Drug Availability

Year CHW Services 2004 2005 2006 Total CHW N=167 N=306 N=907 n(%) n(%) n(%) # Households in catchment area

No response 36 (21.6) - 5 (0.5) 10-150 60 (35.9) 154 (50.3) 640 (79.6) 151-300 31 (18.6) 96 (31.4) 218 (24.0) >300 40 (24.0) 56 (18.3) 44 (4.9)

# Households visited regularly in previous Week: Month: Month: No response 43 (25.7) 1 (0.3) 5 (0.5) <10 82 (49.1) 38 (12.4) 72 (7.9) 10-25 21 (12.6) 104 (34.0) 386 (42.6) 26-50 10 (6.0) 68 (22.2) 257 (28.3) >50 11 (6.6) 95 (31.0) 187 (20.6)

Services provided by CHWs in previous 3 months

Supervise TBAs NA 149 (48.7) 300 (33.1) Train TBAs NA 78 (25.5) 178 (19.6) Consultations for children NA 157 (51.3) 668 (73.6) Consultations for adults NA 155 (50.7) 679 (74.9) Family Planning NA 238 (77.8) 780 (86.0) ANC NA 202 (66.0) 566 (62.4) PNC NA 199 (65.0) 552 (60.8) Home deliveries NA 110 (35.9) 279 (30.8) TB treatment/diagnosis NA 74 (24.2) 211 (23.3) Vaccination NA 214 (69.9) 548 (60.4) Malaria NA 165 (53.9) 523 (57.7) Nutrition NA 179 (58.5) 479 (52.8) Health education NA 277 (90.5) 850 (93.7) Referrals to health center NA - 849 (93.6) Other NA 26 (8.0) 71 (7.8)


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Year CHW Services 2004 2005 2006 Drugs/supplies currently available

Chloroquine 38 (22.8) 131 (42.8) 593 (65.4) Cotrimoxazole 58 (34.7) 160 (52.3) 630 (69.5) Iron Folate 46 (27.5) 173 (56.5) 668 (73.7) ORTS 83 (49.7) 179 (58.5) 694 (76.5) Paracetamol 75 (44.9) 193 63.5) 612 (67.5) Patient tally sheet 56 (33.5) 227 (74.2) 793 (87.7) MUAC Measure 18 (10.8) 83 (27.1) 422 (46.5) Family planning supplies (not asked) 189 (61.8) 758 (83.6)

Fee for Services A small percentage of the CHW (12-14%) reported charging fees for services provided to community members in surveys conducted in 2005 and 2006. The average fee for consultation was reported to be 5 Afghanis; the amount reported for drugs was similar. Contributions of fruits, vegetables, nuts, eggs, livestock and other items were reported by some CHW as in kind contributions for services. Table 4: CHW Reporting Fee for Services

Year Fee for Services 2004 2005 2006

Total CHW N=167 N=306 N=907 n(%) n(%) n(%) CHW reporting fee for service 39 (12.7%) 130 (14.4%) Average fee charged NA NA

Consultation NA NA 5.0 Afs drugs NA NA 5.0 Afs

Non-monetary payments received NA NA 17 (1.9) Type of non-monetary payment: NA NA Food (fruits, vegetables, nuts, eggs, flour)

NA NA 12 (70.6)

Other NA NA 7 (41.2)

Feedback on Health System Support and Supervision The proportion of CHW reporting that they have a supervisor increased from 71% in 2004 to 91% and 93% in 2005 and 2006, illustrating the improvements in health system capacity to provide supportive services for community providers. The proportion of CHW reporting that they have received three or more supervisory visits in the past six months increased from 61% in 2004 to 71% in 2005 and over 90% in 2006. In 2006, more than half the CHW reported that recommendations were written by the supervisor in a book; this represents a 10% increase since 2004. The most common activities performed by the supervisor during the visit were provision of essential supplies, reviewing records, observation of service provision, providing technical knowledge or skills and asking knowledge questions, and providing administrative information. However, in 2006 only 7% of the CHW reported that supervisors visited households, compared to 34% in 2005. This may be due to a policy change or a change in the expectations of the supervisor between 2005 and 2006. Less than 10% of the CHW reported the engagement of the supervisor in financial aspects during the visit. In comparison to 2004 and 2005 (48%), a smaller


46

proportion of CHW (29%) reported supervising TBA’s. This may also be due to a change in the policy for CHW tasks and expectations during this period. Table 5: Supervision of CHWs

Year Health System Support Factors 2004 2005 2006 Total CHW N=167 N=306 N=907 n(%) n(%) n(%) CHW reporting a supervisor 119 (71.3) 280 (91.5%) 848 (93.5) Number of supervision visits in past 6 mos.

None 8 (6.7) 13 (4.6) 19 (2.2) 1-2 36 (30.3) 63 (22.5) 54 (6.4) 3+ 73 (61.4) 203 (70.5) 775 (91.4)

Recommendations recorded by supervisor Book not present 49 (41.2) 102 (36.4) 261 (31.6) Book present, no recommendations written 18 (15.1) 55 (19.6) 99 (12.0) Book present, recommendations written 47 (39.5) 123 (13.9) 467 (56.5)

Activities during supervisor’s last visit Brought supplies 35 (29.4) 128 (45.7) 315 (37.4) Checked records 37 (31.1) 115 (41.1) 372 (44.2) Discussed finance issues 8 (6.7) 21 (7.5) 50 (5.9) Observed service provision 33 (27.7) 54 (19.3) 205 (24.3) Asked knowledge questions 42 (35.3) 101 (36.1) 285 (33.8) Shared technical knowledge 21 (17.6) 118 (42.1) 400 (47.5) Shared administrative information 14 (11.8) 53 (19.9) 231 (27.4) Other 7 (5.9) 23 (8.2) 228 (27.1) Visited households 0? NA? 94 (33.6) 58 (6.9)

CHW supervising TBAs 81 (48.5) 146 (47.7) 260 (28.7)

Salary and Incentives from MOPH and NGO Only 7% of the CHW reported receiving incentives from the MOPH or an NGO in 2006, compared to 11% in 2005. Among the CHW reporting receiving incentives from MOPH or NGOs, 65% reported receiving a regular salary or stipend. Other incentives varied from literacy training, Eid bonus, food commodities (fruits, nuts, grain, flour etc), money for transport and food during training. Payment for referral was mentioned only by one CHW. Table 6: Salary/Incentive from NGO

Year Support from NGO 2005 2006 Total CHW N=306 N=907 n(%) n(%) Receive incentives from NGO 34 (11.1%) 61 (6.7%) Types of Incentives: Regular salary or stipend NA 38 (65.5) Literacy training NA 8 (13.8) Eid bonus NA 7 (12.1) Food (fruit, nut, flour) NA 3 (5.2) Transport money NA 27 (46.6) Food for training NA 7 (12.1) Payment for referral (FP, TB, Obstetric emergency) NA 1 (1.7) Other NA 5 (8.6)


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Recommendations for Community Support, Presence of Shura-e-sehie and Reported Support from Shura Members Results from the 2006 CHW interviews indicated that CHW expected the communities to support them to improve their service delivery. Forty six percent requested payment for services, 30% mentioned donations for improving the health post, 36% requested support from the Mullah or village leader, 37% mentioned assistance in transporting referral cases, and 18% expected in-kind contributions. An increasing trend is observed in the reported presence of active shura at the community level: from 42% in 2004 to 69% in 2005 and 72% in 2006. However, only 27% of the CHW reported being supported by the shura-e-sehie in 2006. This included payment for provision of health services, donations for improving the health post, mobilizing the community members to utilize CHW services, recognition and appreciation of the CHW, and in-kind contributions. In 2006, 80% of the CHW reported that the shura met in the past month. Table 7: Recommended Community Support, Presence of Shura-e-sehie and Reported Support from Shura

Year Community and Shura-e-sehie Support 2004 2005 2006

Total CHW N=167 N=306 N=907 n(%) n(%) n(%) Recommended Community Support:

Payment for health services

NA NA 417 (46.0)

Donation for improving HP NA NA 278 (30.7) Support from shura or CDC NA NA 334 (36.9) Support from mullah or village leader

NA NA 324 (35.8)

Adherence to advice NA NA 273 (30.1) Provide transport NA NA 350 (38.6) In kind contributions NA NA 163 (18.0) Other NA NA 17 (1.9) Active shura-e-sehie 70 (41.9) 211 (69.0) 654 (72.1) Support from shura 174 (26.6) Reported Shura support: NA NA Payment for health services

NA NA 24 (13.8)

Donation for improving health post

NA NA 18 (10.3)

Mobilize community to use services

NA NA 116 (66.7)

Appreciation/recognition NA NA 85 (48.9) In kind contributions NA NA 25 (14.4) Other NA NA 3 (1.7) Last Meeting of shura-e-sehie

In past month 55 (77.5) 185 (87.7) 522 (80.4) In past 2 months 8 (11.3) 14 (6.6) 67 (10.3) In past 3 months 3 (4.2) 3 (1.4) 27 (4.2) In past 6 months 2 (2.8) 3 (1.4) 9 (1.4) No longer meets 2 (2.8%) 6 (2.8%) 24 (3.6)


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Satisfaction and Reported Constraints to Performance A 4 point rating scale (very unsatisfied, unsatisfied, satisfied, very satisfied) was used to obtain feedback from the CHW on job satisfaction and constraints to performance. The figures for satisfaction presented below are based on the percentage of CHW reporting they were satisfied or very satisfied for the item in question. In 2004, 76% of the CHW were satisfied with the level of encouragement from the community and 60% were satisfied with the support from the health facility. However, only 28% were satisfied with the financial or in-kind support from the community, and 27% were satisfied with the regularity of supply of essential drugs. Interviewed CHW were asked to rate their level of satisfaction with various aspects of the job. In 2006, a high proportion of CHW (generally 80-90%) reported being satisfied with the working relationships with facility staff, provincial staff, community leaders, level of respect in the community, security, their ability to meet the needs of the community, living conditions, and supervisor’s recognition of good work. In contrast, a much lower proportion of CHW (generally 50-60%) reported that they were satisfied with drug and equipment availability, training opportunities, and opportunities for promotion. It was clear that the majority of the CHW were dissatisfied with the incentive systems and benefits of the position, with only 4% and 5% reporting that they are satisfied with incentives and benefits, respectively. Rating of the importance of various job aspects indicated that more than 78% of the CHW rated salary, respect of colleagues and community, availability of equipment and supplies, and living conditions as very important. The most commonly reported constraints to performance in 2006 were the lack of training (40%), inadequate transport (60%), lack of payment or financial remuneration (32%), and poor working environment (52%). Although the proportion of CHW reporting lack of essential supplies decreased from 50% in 2004 to 34% in 2006, it is still a major constraint for effective CHW performance in the community, particularly if they are expected to provide primary care services. Other performance obstacles reported were lack of feedback on their performance, poor utilization of the services, poor community and shura support, lack of coordination with health facility, inadequate personnel and conducting household visits. In 2004, 64% of the CHW interviewed mentioned that these constraints were discussed with the supervisor during their visit to the community, but this was not measured in 2006. There were no major differences in satisfaction between male and female health providers Table 8: CHW Satisfaction and Reported Constraints to Performance

Year CHW Feedback 2004 2005 2006 Total CHW N=167 N=306 N=907 n(%) n(%) n(%) Satisfactory rating of the following aspects

Encouragement from the community 127 (76) NA NA Financial or other support “in kind” from the community 47 (28.1) NA NA Support from health unit 100 (59.9) NA NA Training from health unit or from other sources 96 (57.5) NA NA Regularity of supplies received from health unit 45 (26.9) NA NA

Satisfaction with various aspects of job (percent satisfied or very satisfied)

Working relationships with other facility staff NA 233 (76.1) 850 (93.7) Working relationships with Provincial MoPH staff NA 206 (70.6) 744 (82.0) Adequate community support NA 91 (29.7) 364 (40.2) Relationships with community leaders NA 279 (91.2) 827 (91.3) Availability of medicines NA 126 (41.2) 477 (52.7) Availability of equipment NA 90 (29.6) 393 (43.5) Level of respect in the community NA 286 (93.5) 835 (92.6)


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Year CHW Feedback 2004 2005 2006 Training opportunities NA 206 (67.3) 561 (62.3) Ability to meet needs of community NA 244 (79.7) 798 (88.4) Incentives NA 25 (8.2) 32 (3.5) Benefits NA 24 (7.8) 42 (4.6) Security NA 281 (91.8) 781 (86.2) Living conditions NA 172 (56.2) 680 (75.3) Educational opportunities for children NA 183 (59.8) 614 (68.0) Boss’s recognition of good work NA 257 (84.0) 767 (84.6) Opportunities for promotion NA 187 (61.1) 563 (62.1) Overall satisfaction NA 250 (81.7) 800 (88.2)

Importance of various aspects of job (% Rating very important on 4-point scale)

Salary/income NA 204 (66.7) 711 (78.4) Respect of colleagues NA 267 (87.3) 799 (88.1) Respect of community NA 259 (84.8) 783 (86.3) Medicines/equipment needed to do job NA 230 (75.2) 742 (81.8) Living conditions for family NA 227 (74.2) 715 (78.8) Opportunities for a better-paying job NA 178 (58.2) 533 (58.8)

Reported difficulties in job performance

Lack of training 56 (33.5) NA 365 (40.2) Lack of feedback on performance 70 (41.9) NA 75 (8.3) Caretakers don’t bring children to CHW 6 (3.6) NA 49 (5.4) Inadequate transport 70 (41.9) NA 542 (59.8) Lack of time 11 (6.6) NA 47 (5.2) Lack of payment/financial remuneration 77 (46.1) NA 286 (31.5) Lack of appreciation by community 28 (16.8) NA 42 (4.6) Staff shortages 14 (8.4) NA 88 (9.7) Poor working environment 12 (7.2) NA 472 (52.0) Lack of supplies and/or stock 83 (49.7) NA 310 (34.2) Lack of supervision 19 (11.4) NA 32 (3.5) Inadequate salary/remuneration NA NA 660 (72.8) Lack of communication with health facility NA NA 24 (2.6) Lack of coordination with health facility NA NA 22 (2.4) Lack of community support NA NA 195 (21.5) Lack of coordination with Shura-e-sehie NA NA 45 (5.0) Conducting household visits NA NA 18 (2.0) Other 3 (1.8) NA 26 (2.9)

Discussed constraints with supervisor (if one) 81 (63.8) NA NA

CHW Recommendations for MOPH and NGO to Support their Performance A large proportion (88%) of the CHW interviewed recommended that the MOPH or NGO provide a salary or stipend to help them do their work better. Providing transport for conducting home visits and additional training were mentioned by half the providers. Donations for improving the health post physical infrastructure, appreciation and recognition of their services by the health personnel, and improving the supervision process were other recommendations made by the CHW as support mechanisms to be provided by the health system for improving their performance.


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Table 9: CHW Responses for ways that the MOPH or NGO Support their Job Performance

CHW Recommendations 2006 (N=907)

n(%) Salary/stipend 799 (88.2) Donations for improving HP 284 (31.3) Transport for home visits 426 (47.0) Appreciation/recognition 207 (22.8) Improved supervision 115 (12.7) More training 505 (55.7) Other 67 (7.4) The CHW attempt to provide an array of preventive and curative services despite the many challenges they encounter in service delivery. However, efforts must be made to carefully examine the quality of these services and ensure that the CHW workforce is retained. Increasing CHW expectations without the appropriate support structures can cause the decline of these community systems.

Awareness and Utilization of CHW services from Exit Interviews with Patients and Caretakers of Children Attending the Health Facility As mentioned earlier, the CHW sample is not representative and may have included a disproportionate number of CHW operating in close proximity to the health facility and those that were available the day of the interview. Information from exit interviews may also be biased as these represent the users of the health system, who may not access the services of the CHW as they may be living closer to the health facilities. Interviews with caretakers of children under five and patients above 5 years indicated that only 21% of them were aware of CHW services in their community. However of those that were aware of CHW services, more than 65% reported receiving a visit from the CHW in the past month. Approximately 50% of those utilizing the CHW services reported receiving services at home and about 15% reported receiving them at the CHW health post. About 10% reported using services both at home and at the health post. The most common services reported were consultations for illness, vaccinations, care during pregnancy and delivery, health education and referrals. More than 90% of the respondents said they were satisfied or very satisfied with the service and 80% of them agreed or strongly agreed that CHW provide a valuable service to the community. Table 10: Awareness of CHW Services and Report of CHW Home Visits

Exit Interviews with Caretakers of Children Under Five Years 1 2005 (n= 2,824)

2006 (n=2912 )

Awareness of CHW in the community 450 (15.9) 631(21.7)

House visited by CHW in past month 319 (70.0) 424(67.1)

Exit interviews with Children > 5y and Adult Patients 2004

(n=2,966) 2005

(n= 3038) 2006

(n=3051 ) Awareness of CHW in the community 527 (18.2) 554(18.2) 676(22.1)

House visited by CHW in past month 194 (34.9) 394 (70.0) 466(68.9)


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Utilization and Satisfaction of CHW services2 Children Under 5y

N=631 Patients Above 5y

N=676 At home 333 (52.8) 366(54.1) At Health post 99 (15.7) 106(15.7) Both Home and health post 64 (10.1) 57(8.4) Services provided by CHW N=496 N=529 Consultation for children 178 (33.6) Treatment for illness and injury 85 (17.1) - Consultation for adults NA 165 (31.2) Family planning NA 105 (19.8) Antenatal care NA 141 (26.7) Post natal care NA 93 (17.6) Home deliveries NA 107 (20.2) TB treatment/diagnosis NA 8 (1.5) Vaccinations 212 (42.7) 163 (30.8) Malaria treatment NA 53 (10) Nutrition NA 14 (2.6) Vitamin A 83 (16.7) NA ORS 300 (60.5) NA Health education 254 (51.2) 209 (39.5) Referrals 204 (41.1) 128 (24.2) Other (minor surgery, dressing of wounds, etc ) 3 (0.6) 15 (2.8) Overall visit was satisfactory (agree or strongly agree) 468(82.9) 501(95.4) CHW provide valuable service in the community (agree or strongly agree)

N=631 N=676

523(82.9) 566(83.8) 1. Not included in 2004 2. Not included in 2004, 2005

Feedback on Presence of CHWs and Community Health Supervisor from Facility Interviews with Supervisor/Facility-in-charge In 2006, interviews with the facility in charge from the health facilities indicated that 60% had active CHWs working in the catchment area and community health supervisors (CHS). The main activities of the CHS were training of CHWs, supervision and assistance with the health management information system. A higher proportion of CHS reported meeting with the shura in the basic health center (68%) than in the comprehensive health center or the district hospital (56-59%). 63-70% of the CHS reported responsibilities at the health facilities which included health education, provision of clinical care, maternity care, vaccinations, managing the ORT corner, emergency care and growth monitoring, which raises concerns about the type and quality of supervisory support they can provide to the CHWs, especially if the span of control is more than 15 CHWs per CHS. Table 11: Awareness of CHW Services and Report of CHW Home Visits in 2006 BHC

(n=385) CHC

(n=203) DH

(n=42) National (n=630)

Active CHW in catchment area 233 (60.5) 145 (71.4) 25 (59.5) 403 (64)

Presence of CHS 215 (56.2) 121 (59.6) 22 (52.3) 358 (57)


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BHC (n=385)

CHC (n=203)

DH (n=42)

National (n=630)

Activities of CHS (n=215) (n=121) (n=22) (n=358) Training of CHW 82 (38.4) 59 (48.7) 12 (54.5) 153 (43) Supervision of CHW 157(73.7) 105(86.7) 19(86.3) 281(78.9) Replacement of kits 107(50.2) 72(59.5) 13(59) 192(53.9) Assist with HMIS 85(39.9) 45(37.1) 11(50.0) 141(39.6) Meeting with Shura 144(67.6) 68(56.1) 13(59.0) 225(63.2) Other responsibilities not related to CHWs 155(72.0) 85(70.2) 14(63.6) 254(70.4)

Awareness and utilization of CHW Services from Afghanistan Household Survey, 2006 In the Afghanistan Household Survey,a national survey conducted in 2006, 397 clusters were surveyed in 29 provinces, with an average of 21 households interviewed in each cluster. Four of the Southern provinces, including Helmand, Kandahar, Zabul, and Uruzgan, as well as Nooristan province, and several districts in other provinces were dropped from the sampling frame due to poor security. The survey included a series of questions about care seeking behaviors, health expenditures and perceptions of CHW and other available health services. Overall, only 2065 out of 8278 respondents (24.8%) reported being aware of a CHW in the community. In 176 of the 397 clusters (44% of the total), none of the respondents reported being aware of a CHW working in the community. It is likely that there are no active CHW in these communities. In many other clusters, a small minority of respondents reported being aware of a CHW in the community, which may indicate that there is a CHW in the community who is not very active, or perhaps a CHW in a nearby area that only some women in the community are aware of. Among those reporting awareness of a CHW in the community, the total number of CHW reported to be in the community varied, with 18% reporting one CHW, 38% reporting two CHW and 21% reporting more than two CHW in the community. About half the respondents reported the presence of both male and female CHW, but 42% of the respondents reported only male CHW, and about 5% reported only female CHW. Among those who reported being aware of a CHW working in the community, 62% said they or their family members had utilized the CHW’s services within the past 3 months. Most commonly reported services received from CHW were health education, treatment for illness or injury, family planning and care during pregnancy. Receipt of ORS and Vitamin A were mentioned by one quarter of the respondents. Reported reasons for not utilizing the services included no illnesses in the family, lack of drugs, poor quality of service and the perception that CHW did not have adequate knowledge for curing illnesses. A few respondents also mentioned that the health post was too far for them to access or that a family member objected to accessing services from CHW. However 88% of the respondents agreed or strongly agreed that CHW provide useful services in the community. Reported use of CHW for curative care is substantially lower than reported use of CHW for promotive and preventive care. Among household members reported to have sought care for an illness or injury in the previous 30 days, only 3.1% utilized a CHW as the first source of care outside the home.


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Table 12: Awareness of and Utilization of CHW Services CHW Awareness and Utilization N (%) N=8278 Aware of CHW in community 2065 (24.8) Number of CHW in community N=2065 1 373 (18.1) 2 785 (38) 3 139 (6.7) 4 147 (7.1) 5-10 148 (7.1) More than 10 34 (1.2) Do not know 405 (19.6) Sex of CHW N=2065 Male 873 (42.3) Female 104 (5) Both 1050 (50.8) N=2065 Utilized CHW services in past 3 months 1277 (61.8) Services received N=1277 Health education 423 (33.1) Treatment for illness/injury 405 (31.7) FP 238 (18.6) ANC 151 (11.8) PNC 114 (8.9) ORS 400 (31.3) Vitamin A 288 (22.6) Referral to health facility 157 (12.3) Other (analgestic, antipyretic, oxygen, minor surgery and dressing)

7 (0.5)

Reasons for not using CHW services N=788 No illness 332 (42.1) CHW not knowledgeable 101 (12.8) Poor quality of services 126 (16) No drugs 200 (25.4) No equipment 43 (5.5) CHW not female 31 (3.9) Health post too far 45 (5.7) Family member prohibited 27 (3.4) Illness not severe 27 (3.4) Other (no one to take sick person to CHW)

2 (0.3)

N=2065 Agree that CHW provide useful services 1807 (87.5) Family members who were ill in the last 30 days and sought care N=6301 CHW consulted 1st 196 (3.1) CHW consulted 2nd 17 (<1) CHW consulted 3rd 3 (<1)


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Summary Findings from CHW Interviews Performance and Satisfaction Findings Performance Factors to

Address CHW Recruitment and profile Improvement in recruitment of

illiterate CHW, female CHW

Training and Supervision More CHW trained in the past 2y; 20-40% trained in most technical areas

Higher proportion trained by NGO than MOPH in 2006

Knowledge Higher knowledge gains for most common disease conditions

Job expectations - Reduced workload of CHW (CHW reporting coverage of >150 HH) - Higher proportion reporting HH visits in 2006

Supplies and Drugs Higher proportion reporting adequate stocks of essential drugs and tally sheets

Fee for Services 14% reporting fee for services Health System Support Improved proportions reporting

supervision, number of visits, and feedback from supervisor

Proportion reporting HH visits by supervisors decreased in 2006

NGO support and incentives Common incentives received: literacy training, food during training, Eid bonus and transport money for attending training

Decreased proportions reporting incentives from NGOs

Community and Shura support

Proportion of CHW reporting the presence of shura’s increased between 2004 and 2006. This included mobilizing the communities to utilize CHW services, showing appreciation or recognizing the work of the CHW, payment for health services and donations for improving the HP

Payment for health services, donations for improving HP, support from Mullah or shura, adherence to advice, and transport were commonly requested as community mechanisms for improving their job performance. Only a quarter of the CHW interviewed in 2006 mentioned receiving support from the shura in their community.

CHW satisfaction 80-90% reported being satisfied with the support from the health system which included working relationship with other staff, and relationship with community leaders

Only 40% were satisfied with the support from community members.

Constraints to performance Most commonly reported constraints were lack of training, inadequate transport, lack of feedback on performance, and low service utilization of community members

More than 88% requested a salary or stipend – an indicator that flags potential issues with sustainability and retention of CHW

Section E: Community and Shura-e-sehie Perceptions of CHW Performance in Afghanistan 55

Section E: Community and Shura-e-sehie Perceptions of CHW Performance in Afghanistan

This section describes the findings of focus group discussions (FGD) with community and shura-e-sehie members conducted as a part of a multi-method assessment process to study CHW performance in Afghanistan.

Design and Sampling The FGD discussion guides (Annex 1) were developed using standard formative research methodologies to obtain the perspectives of the community and shura-e-sehie members on CHW performance from the list of tasks and expectations of CHW services in the Basic Package of Health Services (BPHS). It included general and specific information on the description and role of CHW, utilization patterns, preference for tasks and services provided by CHW, payments and support from patients, community and shura-e-sehie, and recommendations for strengthening the capacity and support of CHW. Local residents of Kabul were selected for training and consisted of physicians, nurses, paramedical personnel and school teachers. The participants were trained in the Ministry of Public Health, at the Monitoring and Evaluation Department for one week on qualitative research methods, with a special focus on conducting FGD and fundamental aspects of conducting field research. Each team consisted of two males and two females. Male team members conducted FGD with males, and females with females. One team member served as the FGD facilitator, while the second took notes during the FGD. Trained teams spent 2-3 weeks in the four provinces to conduct the FGD. The provinces were selected purposefully to include a mix of ethnic and geographic diversity, donor/contracting mechanisms and implementing agencies (Fig 1). Security for the data collection teams was also a primary consideration in site selection. The following figure illustrates the sampling methodology.


Fig 1: Selection of Study Site and Sampling for FGD

In each province, two facilities (Basic Health Centers (BHCs) or Comprehensive Health Centers (CHCs)) were selected from the NHSPA sample surveyed in 2006. The inclusion criteria for the facilities was the completion of Phase III training of the CHW in the catchment areas at least 6 months prior to February 1, 2006, accessibility, and security. In the catchment area of each selected health facility, two health posts were randomly selected; one within 1.5 hours walking distance and another between 2 and 4 hours walking distance. A maximum of 16 FGD were conducted in each province based on the availability of male and female Shura-e-sehie members at the health post and health facility: 1. Health Facility 2 FGD (1 male and 1 female) with Shura-e-sehie members 2. Health Post 2 FGD (1 male, 1 female) with community members (<1.5h walking distance) 3. Health Post 2 FGD (1 male, 1 female) with Shura-e-sehie members and (2-4h walking distance): 2 FGD (1 male and 1 female) with community members

Purposive Selection of 4 Provinces (security, accessibility, BPHS implementers)

CAF, Badakhshan (USAID/PPG)

BDF, Baghlan (USAID/PPG)

BRAC, Balkh (WB/PPA)

MRCA, Logar (EC)

Random selection of 2 HF -BHC or CHC -Selected for NHSPA 2006 - CHW completed Phase 3 Training (2/06) - security, accessibility

Random selection of 2 HP from each HF 1 HP : <1.5h walking distance 1 HP: 2-4h walking distance

HF Shura FGD 1 Male, 1 Female

HP Shura FGD (2-4h distance)

1 Male, 1 Female

Community FGD 1 Male

1 Female


Highlights of Findings

Distribution of FGD and Participant Profiles Table 1 provides a distribution of the number and type of FGD conducted in each province. There were some discrepancies in the distances of the villages from the health facilities between male and female focus groups of the same village. In Logar, Pad Khob was recorded as 1h in male and 1.5h in female focus group. The number of participants ranged from 4-10 in the community FGD and 3-11 in the shura FGD. Facility FGD were conducted in all provinces, but only villages in the Badakhshan sample had a female shura-e-sehie. In the Balkh sample, there were no reported health post shura-e-sehie. Table 1: Distribution of FGD and Participants in the Four Provinces

Community Shura Health Post Shura Health Facility

Province Village (hours from HF)

M F M F M F Kamal Khil (1.5h) 9 9 - - - - Kunjak (1.5h) 6 9 3 11 11 - Malkh Abad (1.5h) 7 7 4 - - -

Logar

Pad Khob (1h) 6 6 - - 9 - Islamabad (45min) 5 6 - - - - Noorabaay (1h) 9 6 - - - - Haggoi (2h) 8 8 - - - - Aliabaad (3h) 6 7 - - - - Alichopan - - - - 8 -

Balkh

Sherabad - - - - 6 - Kakan (30min) 7 10 3 - - - Etar Chi (1.2h) 10 9 - - - - Shim Qarchi (1.5h) 7 8 - - - - Kham Hafiz (45min) 4 8 3 - - - Qara Kamar (4h) 5 6 5 - 6 6 Qara Qazi - - - - 5 -

Badakh-shan

Aten Jelaw (1.5h) - - - - 4 - Walikhil (2.2h) 6 8 4 - - - Baghlan-e-sanhati (40min) 8 6 - - - Bulkmardad (2h) 9 6 3 - - - Jawhar Tapa (45min) 8 7 - - - - Factory (45min) - - 6 - -

Baghlan

Basharha (45min) - - - - 5 In the male community FGD, participants were mostly between 20-49 years of age, whereas in the shura-e-sehie the participants tended to be much older (more than 65% were above 50 years; data shown in Table 2a). Occupations varied widely, although half of participants were engaged in farming. Some were shop keepers, government workers and accountants in the shura-e-sehie. All shura-e-sehie members were married, but 12% of participants in the community FGD were unmarried.


Table 2a: Profile of Male FGD Participants

Characteristics Community HP Shura HF Shura Age n % n % n % <20 11 9.2 - - - - 20-29 20 16.8 2 6.4 2 4.2 30-39 25 21.0 1 3.2 6 12.8 40-49 18 15.1 6 19.4 8 17.0 50+ 45 37.8 22 71.0 31 66.0 Missing Data 1 - 1 - 1 - Total 119 100 31 100 47 100 Occupation Farmer 62 51.7 15 48.4 24 50 Worker (unspecified) 17 14.2 2 6.4 2 4.2 Shopkeeper 4 3.3 5 16.1 4 8.3 Vendor 1 0.8 - - - - Tailor 2 1.7 - - - - Mason 1 0.8 - - - - Animal Keeper 1 0.8 - - - - Driver 3 2.5 - - - - Butcher 1 0.8 - - - - Gardener - - 2 6.4 - - Restaurant Owner 1 0.8 - - Public Representative 2 1.7 1 3.2 4 8.3 Mulha 3 2.5 - - 2 4.2 Religious Leader 1 0.8 - - - - School Gatekeeper 1 0.8 - - - - Student 8 6.7 - - 2 4.2 Teacher 5 4.2 - - 2 4.2 Former NGO Worker 1 0.8 - - - - Government employee - - 1 3.2 - - Accountant - - 1 3.2 - - Retired officer - - 2 6.4 3 6.2 Unemployed 6 5.0 2 6.4 5 10.4 Total 120 100 31 100 48 100 Marital Status Married 105 88.2 31 100 48 100 Single 14 11.8 0 0 - - Missing Data 1 - - - - - Total 120 100 31 100 48 100 Except for the shura-e-sehie members from the health post, more than 80% of the female participants were less than 50 years (Table 2b). A majority said they were housewives or unemployed and a few said they were carpet weavers, tailors or vaccinators. Like the male FGD participants, 12% of the women who participated in the community FGD were single and only one female shura-e-sehie member was unmarried.


Table 2b: Profile of Female FGD Participants

Characteristics Community HP Shura HF Shura Age n % n % n % <20 3 2.4 - - 1 16.7 20-29 32 25.2 1 9.1 1 16.7 30-39 39 30.7 4 36.4 2 33.3 40-49 32 25.2 4 36.4 2 33.3 50+ 21 16.5 2 18.2 - - Total 127 100 11 100 6 100 Occupation Housewife 76 60.3 11 100 - - Tailor 2 1.6 - - - - Carpet Waver 2 1.6 - - - - Vaccinator 1 0.8 - - - - Unemployed 45 35.7 - - 6 100 Missing data 1 - - - - - Total 126 100 11 100 6 100 Marital Status Married 105 88.2 10 90.9 6 100 Single 14 11.8 1 9.1 - - Missing Data 1 - - - - - Total 119 100 11 100 6 100 Overall most of the participants in the focus groups were willing to share their experiences and perspectives about the role and performance of the CHW with the research team with the exception of some participants in Badakhshan, who were somewhat reluctant to share their own opinions. Most community and shura-e-sehie members were enthusiastic and eager to participate in the discussions, although in some instances they were hesitant to share confidential information or provide negative reports. In one focus group a woman left a wedding ceremony in her home to participate in the discussion. The teams were received well in most villages and most praised what they perceived to be the faithful work of the CHW in their community. Appreciation was expressed for the services provided by the CHW. A majority of participants recommended the institution of additional female CHW. As in previous FGD conducted by the MOPH, they were glad to voice their concerns and opinions with survey teams representing the MOPH who conducted the discussions. Other prevailing issues of concern to communities were drinking water supply, sanitation and health facility or school infrastructure. The need for clean drinking water was raised in most discussions. Some of the members in one of the Badakhshan focus groups were reluctant to cooperate with the team. Further, language limitations with some focus group participants led to disruptions as they jeered at the team and requested them to leave. This was a problem in Badakhshan, where many of the community members spoke only Uzbeki. In these cases, the FGD had to be conducted through one or two women in the community who spoke both Uzbeki and Dari, but in many cases they were reluctant to facilitate translation. In Baghlan, although the participants were friendly, a few were concerned that the CHW would receive the information from their discussions and refuse to provide services. The teams reassured the participants about the confidentiality of their discussions. In Walikhi village, there was only one male CHW who provided services as it was culturally unacceptable for females to work. However their services were still appreciated.


Some participants in one of the female health post shura-e-sehie in Logar expressed their dissatisfaction with participating in such discussions without any tangible change in outcomes based on their previous recommendations or feedback and were indignant to spend their time engaged in discussions and away from work.

Perceived Value and Attitude to CHW services It was common for community members to exclaim that CHW had done more than doctors in the community. In Jawhar Tapa village in Baghlan, they exclaimed that they “love the CHW so much and protect him”. Some participants said they pray for the well-being of the CHW and in Bulkmardad village they enthusiastically exclaimed that the CHW had brought a lot of change to their village. The CHW was considered a kind and loving person who saved the lives of children. They reported that without the CHW services many children would have died due to diarrhea. Most of the female community members stated that they were very happy with the services and the attitude of the CHW as she was helpful, behaved well, was kind, respectful and always available when they needed her anytime of the day. Her services were considered to be particularly valuable for poor people. Since literacy levels are low in the communities, the opportunity to learn new methods and gain knowledge about illness prevention and cure was appreciated by all community and shura-e-sehie members. Prevention of deaths due to measles was attributed to the information provided by the CHW on the importance of vaccination. A female focus group participant from Noorabay village in Balkh summed up the performance of the CHW by stating that the CHW had improved the community health status through free medicines and health education and was joined by another participant who added “we pretend that the CHW is God’s angel for the weak and poor people in our village since we are illiterate, and she is kind and informs and educates the women on several issues.” The willingness of the CHW to work at all hours and seasons was valued highly by many participants and illustrated by the demands for additional trained CHWs in the community.

Positive attitudes toward CHW

“We are pleased with the CHW in our community, there is no such word to commend him and we cannot praise him enough using any word. He helps and has a kind heart” 42 year old woman, Logar

“We are very happy with the government to send us the CHW for dispensing drugs to take care of sick people. CHW

are a gift from God for poor people; no one knew how to make safe water but now all know and stress on that” Members of a remote village, Balkh

“I swear to God there is no one in our village to solve our problems except the CHW” Female community member,

Balkh

“They are particularly good for poor people” Badakhshan

“Doctors treat the patients with our money, but CHW prevent diseases” Health post female shura member

“In fact they do a great job for the community’s well being and have proved to be more effective than a doctor” 80 and 75 year old Shura members, Logar

“He is not a doctor, but in fact he really does a great job for the community’s well being especially in giving first aid. He

has proved to be more effective than a doctor. When we face health problems he comes to our door in person and


provides education to prevent disease” 48 year old male Shura member, Baghlan

“It is said the teacher is the guide of the society, the CHW teaches us everything, if not for the CHW, nothing would be done as people are illiterate” Logar

“The messages about vaccinations have been very helpful. Four years ago when we did not vaccinate children, many

people died. Now all people vaccinate their children against measles”. Male community member, Balkh.

“We are happy with the CHW as they solve our problems; they help us anytime whether it’s summer or winter, night or day” 38 year old woman, Balkh

“Any organization that has trained them, Allah bless them, they did a very good job” 20 year old woman, Logar

There were a few negative responses about the value of CHW services as some participants felt that though the government had established CHW services they had not provided adequate infrastructure or effective drugs for them to perform optimally. While some considered the CHW knowledgeable and effective, there were a few community members who felt the drugs were ineffective and the CHW was of no use to them as she was illiterate, especially in Badakhshan. Participants in three of the five focus groups conducted in Badakhshan reported dissatisfaction with the CHW services, stating that they were not aware of their services or they were ineffective. However, participants in these groups reported positive perceptions of the effectiveness of the CHW as the health conditions in the community were worse before the establishment of the health post.

Negative Attitude toward CHW services in Badakhshan

“We have not received any services from CHW, we do not even know them” woman, Badakhshan

“The health education and awareness about vaccination and disease prevention is good but useless” female community member, Badakhshan

“The CHW have not offered any service, they are illiterate and cannot give proper treatment as they do not know what

medicine to give for each disease” Community Female, Badakhshan

Types of CHW Health Services and Reasons for Utilization

Type of heath services offered by CHW FGD participants in all groups reported that health education is the most important service provided by the CHW, followed by treatment with medicines and referral services. In the female focus groups, support during pregnancy, delivery and new born care were appreciated. Female members reported that they were appreciative of the emotional support provided by the CHW and her reassurance that they would recover from the illness. FGD participants reported that other services provided by CHW include overall reduction in disease burden in the community, increased knowledge on prevention of some communicable illnesses, water purification, environmental cleanliness, bed net use, and treatment of common illnesses. Some male participants spoke with strong conviction that their children are now vaccinated, so they will never fall sick with measles or polio and even if they did the illness would not be so severe.


Participants reported being impressed by the impact of the CHW on preventing diarrheal deaths. Participants were knowledgeable about the risks of bloody diarrhea and dehydration as signs to avoid or seek care from the health center. All six participants in Aliabad village, Balkh, claimed that the services were “100% useful” as in the previous year there were no CHW and medicines and many children died due to diarrhea. One of the participants remarked that if there had been a CHW in their village the previous year the children would not have died as the women could have sought care from the CHW even if the men were busy. In Haggoi village, Balkh, the participants felt they could not categorize which services were most useful as they considered all to be equally valuable. However, members from Badakhshan complained about ineffective services, especially stock outs of drugs for diarrhea.

Home Visits and Health Education

“The CHW goes to everyone’s home and asks about the health of the people. If anyone is sick she gives medicines, if a pregnant woman is weak or has anemia she gives pills, and contraceptives for women who want to prevent

pregnancy, helps women during delivery, gives medicine for children with diarrhea and lots of useful services 24h of the day”. 30 year old participant, Balkh

“CHW provides medicines for eyes, mouth, earache, and vitamins for weak women, she goes from door to door

providing education and medicines” 28 year old woman, Baghlan

[The CHW] “convinces people to wash their hands after using the bathroom and before meals and teaches us to keep ourselves and children clean and convinces parents to take children for immunization …. since our people are illiterate, the CHW provides health education and everyone is happy. The CHW informed us that mosquitoes cause malaria” 30

year old woman, Balkh

“CHW have educated us on how to improve sanitation. My daughter-in-law has never paid attention to personal hygiene but since the CHW came here we know how to take care of our family and personal hygiene” Male Participant,

Badakhshan

“ He goes to houses in remote areas and advises them about clean water, even the doctor does not do this, when there is a new born baby he advices vaccination” Male community member from Badakhshan”

“All poor people use the services, even barbers can use the service. I even brought my hen to be treated” 50 year old

woman, Logar

Female participants also reported changed behavior in personal hygiene and cleanliness and bathing more often and keeping themselves clean. A 45 year old woman from Noorabay village in Balkh was very appreciative of services provided during pregnancy and in her opinion fewer women died from pregnancy-related causes after the CHW came to the community. Other women agreed with this observation and endorsed the usefulness of the CHW service. Medications for headache, intestinal disorders, pain, tongue burn, treatment of wounds, injections, health education on personal and environmental hygiene, and sanitation were mentioned frequently in almost all the FGD. Prevention of diseases including vaccines for children were mentioned frequently as services provided by the CHW. Several participants mentioned the risks of drinking contaminated water and the importance of purifying water. Washing fruits and vegetables, minimizing mosquito breeding by draining stagnant water and using bed nets were stated as valuable messages provided by the CHW. Participants in several focus groups mentioned the importance of accessing care immediately for sick children with danger signs. In the female FGD, childcare, ORS for children with diarrhea, assistance during pregnancy and delivery, including vaccination, provision of contraceptives, birth spacing, antenatal care, first aid, medication for complaints like nausea, vomiting, headaches, body pain, eye conditions, snake


bites and other animal bites were also mentioned. A few participants also remarked on the CHW’s kindness and attention to widows. There was a strong belief that the health condition of the community improved after the CHW were trained. Services for safe delivery and new born care were also mentioned and valued and a few participants reported changes from traditional practices. Health education apparently was highly valued as many of the women in the focus groups mentioned the priority given to hygiene by improved handwashing practices with soap before meals and after defecation to reduce the illness incidence of diarrhea. The importance of boiling water, avoiding contaminated food, chlorinating wells, washing fruits and vegetables before consumption were apparently emphasized by CHW as these were stated most frequently by participants. The importance of vaccination was understood by most participants as they stated this to be one of the primary services provided by the CHW. Referrals and 24-hour emergency services were considered very essential services by most participants. A 30-year-old female participant from Walikhil village, Baghlan, stated that even when drugs were not available she utilized the services so she can learn from the ideas and messages of the CHW. In Walikhil village a male shura-e-sehie member exclaimed “before we were blind and knew nothing to do to prevent illness, but now we know what to do when we get sick.” For the male shura-e-sehie members the knowledge on latrine construction, safe water, acquisition of mosquito nets and vaccinations were prioritized as the most important CHW services. The availability and provision of medications for minor ailments was mentioned next and referrals were mentioned less frequently. Despite the stock outs and limited equipment at the health post they remarked that the services were appreciated. Health education and provision of medicines were also most frequently mentioned by female shura-e-sehie members. Most male shura-e-sehie participants, except those in Badakhshan, expressed high levels of appreciation for the work of the CHW. Complaints were usually due to the ineffectiveness and non availability of medicines, lack of environmental cleanliness, lack of improved water supply and poor quality of treatment. Female shura-e-sehie members from the facility were cognizant of the importance of preventive services and felt that the CHW should focus more on health promotion and disease prevention. At the community level the responses of the male and female shura-e-sehie members were similar to those of the health facility shura-e-sehie participants, who also emphasized the importance of preventive care.

Specific Service Interventions

Malaria Prevention and Treatment: “CHW advises community to dry ditches, by removing stagnant water and filling them with sand. He also instructs us to use mosquito net on the windows. Last year there were too many cases of

malaria, not this year.” Male Community Members, Badakhshan

Treatment of diarrhea: “My child had diarrhea, I take him to CHW, he gave me ORS and instructed me how to prepare it, he said if child does not get better, bring him back to me and I will refer him to clinic. He also instructed on how to

boil water and to breastfeed infants” 46 year old man, Balkh

Education on TB symptoms: “CHW explains the signs and symptoms of TB and convinces us to go to the doctor when we have signs of TB” Female community members, Balkh

Diet Counseling: “Increase consumption of vegetables and fruits, Avoid fat in the diet.” Male HP Shura members, Logar

Emergency Care: “During the day we usually go to the clinic, during the night (non-official time) we go to the CHW if we

have a problem” 38 year old man

Referral services were mentioned by the community members, especially when the CHW could not treat the illness or the drugs were not effective to cure the illness. Referrals for malaria and


typhoid were mentioned occasionally by the male members, and kidney problems, ‘black jaundice’, difficulty in breathing, ‘wound in stomach’ or ulcers, ‘bleeding in the brain’, obstetric complications, vaccination and anemia were mentioned by female participants. Shura-e-sehie reports on CHW referrals for severe illness were similar to the community reports. Responses of the participants from the four provinces varied based on their experiences of services provided by the CHW. Some emphasized hygiene while others focused on malaria prevention and TB treatment.

Pregnancy & New Born Care

“If anyone is pregnant the CHW helps during delivery and if the patient has post partum hemorrhage or any other complication, the CHW refers her to the clinic” Female participant, Balkh

“The CHW gives contraceptive pills to those who want, gives the vaccination schedules and diet for pregnant women”

30 year old woman, Balkh

“Our village condition is even better than before as deliveries are done in clean place with clean instruments, the amount of diseases has decreased. In the past new born babies were not washed till they were a year and a half old,

now they are washed shortly after delivery” female community member, Baghlan

“The CHW instructs the women to prepare food for our children by mixing flour, rice and peas” 30y old woman, Balkh

Services considered least useful When the focus group informants were asked about the services they considered least useful, a majority of them said all services were useful. Some participants, however, were concerned about the lack of effective drugs at the health post and some also mentioned that illiterate CHW were not qualified to dispense medicines. Others felt that the CHW did not have the capacity or training to address other health concerns like treating snake and scorpion bites. However they agreed that some service was better than nothing; as one participant stated: “having a CHW was like being offered a glass of water in the desert”. A different participant from Baghlan felt that the CHW does not pray and therefore his services are not effective.

CHW as Preferred First Provider In Logar and Balkh provinces, all participants stated that the CHW was their first choice of care and they were later referred to the health center if the CHW could not treat them. With the exception of participants whose homes were located in close proximity to the health center or a resident family physician, most participants reported using the services of the CHW for their first level of care. The reports were similar in Badakhshan and Baghlan, with the exception of three participants who reported that they used services in the city. The majority of the focus group discussants reported that all community members utilized the CHW services. In some focus groups, participants reported that the rich people used the CHW services more often as they did not want to waste money going to the health facilities. However, in a majority of the focus groups all community members were reported to use the services except in communities where there were only male CHW. Most reported that male members did not use services from female CHW and likewise female members did not access services from male CHW as they could not be examined by a member of the opposite sex. In a few focus groups, male participants reported that the services were used most frequently by women and children as they have more health problems and men tended to ‘cope’ more easily than women. Women also reported that males could utilize their services anytime whereas females required


permission from males if they used her services at night. In one of the villages in Badakhshan, the CHW was an older female and the participants did not feel she was as competent in providing services as TBAs trained in Pakistan. The gender of the CHW was a strong determinant of health service utilization and had serious negative consequences, which sometimes resulted in domestic violence. A number of women reported negative consequences of being seen by male CHW. In most cases where there were only male CHW, the female patients were accompanied by male family members who reported the presenting complaints. This was not acceptable to the women as they could not explain the presenting symptoms, especially if they related to gynecological problems. In other instances, they suffered abuse from their husbands if they utilized the services of male CHW. In Badakhshan the women pointed out that male CHW did not have experience in giving birth and therefore could not fully understand the problems of women during childbirth. Similarly they felt a female CHW could not understand male problems like hernia and therefore could not treat male patients.

Utilization of Male CHW Services by Female Patients

“When I was sick during my pregnancy I went to a male provider accompanied by my brother. When he asked about the complaints my brother responded, and the provider angrily said to me “you are the patient, not your brother” 22

year old woman, Logar

“I have gonorrhea, I can’t discuss with a male provider, it is not good and is shameful” 5 5year old woman, Logar

“My husband is very strict, does not allow me to talk to his brothers, let alone to a male CHW. One day I was sick with Jaundice and went to Mullah for treatment, when I came back I did not tell him, but my daughter told him and he beat

me and burnt the papers the mullah gave me for treatment” 45 year old woman, Logar

“We need both male and female providers but female CHW are more useful as our society is traditional and we cannot share our secrets and feminine problems with male providers” 32 year old woman, Balkh

“It is a shame for a man to instruct a woman how to use condom but if it is a female CHW we will listen”. 30 year old

woman, Balkh.

“CHW must not be male. If I am pregnant I can’t see him, I would prefer death” 26 year old woman, Baghlan

Male shura-e-sehie members from the health facility reported a higher level of utilization of services by women and children at the health post as women fall ill most often and are primarily responsible for child care. This observation was affirmed by the female shura-e-sehie members, but they also added that pregnant women would “rather die” than see a male CHW. At the health post level, the shura-e-sehie members observed that male community members utilized the services only if their condition was severe. Differential service provision was mentioned by a few male community members in Logar, who felt that the rich, those that owned buildings or the Mullah received better services or more medicines. Many FGD participants felt that the services were most valuable to those living in remote areas and the poorer members of the community, especially the Kuchi population, and even those of menial profession like the barbers. However, other male focus group participants reported under-utilization of the CHW services by marginalized populations like the Kuchis, as they lived in remote areas. There were also reports of CHW providing treatment for livestock, especially when cows and chickens fell sick. Most FGD participants preferred the proximity of the health post CHW services to the health center services. Many participants reported that the overall cost of utilizing CHW services is more affordable, since they did not have to pay for transportation to health facilities. Visiting the health


clinic during the hot season was reported to be infeasible, and this influenced their decision to seek care from CHW. In Baghlan, women remarked that they save on expenses for transport and buying costly medicines at the health clinic now that they have the services available in their villages. Others added that they do not have to wait long to receive treatment or medicines from the CHW, like they do in the health center. The services were most valued by the poor as they could not afford services at the health center.

Reasons for Choosing CHW Health Post as 1st Line of care

“If we take patient to the clinic we wait for 2-4 hours to see a doctor and may not even see a doctor. In the hot season people get sick more frequently and need to see a provider more often” 35 year old mother, Baghlan

“The weather is hot and frequently we have patient at home, before we went to clinic for minor illness, now our problem

is solved, free access and free treatment has eased our difficulties” community women, Baghlan

“In the past there was no CHW and we faced a lot of problems. We walked to the clinic for one hour, when we arrived there, we found the doctor did not come that day. It was really frustrating. Sometimes after waiting for two hours we go

back home without a chance to see the doctor. But now the CHW helps us and provides for most of our needs and works hard and gives information about tetanus”

45 year old man, Logar

“In the late night if we fall sick they give us medicine and if our disease is severe they refer us to the clinic. Even if transportation is not available they take us to the clinic by their own cars”

Male participant, Logar

“Our health is the most important thing and we think the CHW works hard for our health, when you are healthy everyday is Eid” 40-year-old woman, Logar

“CHW are a gift from God. If they were not located in our village we would have to take our patients to the city and pay

150 Afghanis for taxi, even though we are poor” 62 year old woman, Balkh.

“Our village is poor and we cannot go to the clinic and CHW are good to us” 30 year woman, Balkh

“The services are effective and we can take our children and adult patients to them for treatment as soon as possible” Participants from Logar

“I’m grateful for all CHW services; when I fall sick my husband cannot meet the expense of 100 Afghanis to pay the

doctor fee, so it is a golden chance for me to go to the CHW and receive free medicine; besides her service is good for all, as most village residents are poor” – 25y old woman, Balkh

“Yesterday I sold wood for 500, but I bought medicines for 600, but here medicine and treatment are free and it is a

good facility for the people of Badakhshan”, Male Shura, Badakhshan

Reasons for seeking care from CHW The most common reasons for seeking care from the CHW were accessibility, 24 hour service, home visits by CHW to those in distant households, referral, and availability of free services. Many participants commented on the advantages of receiving immediate care from an accessible CHW without enduring long waiting times and incurring high transport costs. Some participants mentioned that the advantage of having CHW services in their village in comparison to seeking


care at the health facility was not incurring the opportunity costs of lost work days if they travel long distances and waiting times at the clinic. “People are not missing work as a result of health problems as we receive care from CHW,” remarked a male community member. Some participants expressed their satisfaction with referrals from CHW as doctors provided the appropriate care and check up when referred by a CHW. Interpersonal relations and behavior of the CHW were often mentioned as one of the primary reasons for continued utilization of CHW services as they were polite, honest, kind, respectful and helpful. Some participants also mentioned the opportunity to trust and confide their personal problems with the CHW. In Noorabaay village in Logar, the male participants were glad that the CHW was from their village and therefore they did not feel inhibited to access services as she was familiar to the women in the village. The ease of purchasing essential drugs from the CHW was also considered more convenient than purchasing in the bazaar, which may be far away and more expensive. The CHW services were valued more during emergencies and in winter when the roads were impassable as they felt the patient would die on the way to the clinic if they had to walk for two hours.

Reasons for Seeking Care from CHW

“We go to CHW, then he advises us to go to the clinic. We knock on the door of the CHW during the day, even during the late night 12 or 1 am; we are satisfied with what he has done, God bless them” 45-year-old housewife, Logar

“When I fall sick, I don’t inform anyone about my illness, not even my husband, but I go to CHW and explain everything

to her and she gives me medicine.” 40 year old housewife, Logar

“The CHW gives useful and effective medicine to my children, especially for diarrhea. We don’t go to the clinic, she comes to our home to give the medicines” 30 year old mother, Balkh

“The CHW serves the community well. They distribute the medicines and behave properly with the people” Male Shura

members, Badakhshan

“When our patients get treated in their houses, what could be better than this service?” Male Shura Member at Health Post, Badakhshan

“I had difficulty breathing, and did not know about CHW or trust them; I approached the Mullah and he said evil has

captivated you. But later my husband took me to go to the CHW and he referred me to the hospital. For 6 months I’ve no health problem and now I trust CHW more than Mullah [regarding health issues]” 30-year-old woman, Logar

Preventive services of health education, especially related to diarrhea prevention, hygiene promotion, antenatal care, immunization, malaria prevention through promotion of bet nets and removal of stagnant water, were considered equally valuable as the curative services offered by CHW. Some community members reported that CHW provided supplemental food for malnourished children and conducted cooking demonstrations for preparing nutritious food for children. Another important aspect reported by participants was the opportunity to build community solidarity as the CHW post offered a place of socialization. Some female participants reported that they earlier sought care from the Mullah of the village if they could not access or afford the services of health clinics and were told their maladies had spiritual causes. Participants reported that they now use CHW services and find better cures for their illnesses. There were contradictory reports from Badakhshan from the same focus group. One participant remarked that she did not use CHW services, because the CHW never provided referral services as “she was an old woman and near to death,” whereas in the same village another woman interjected and reported that she was referred to the facility by the CHW during her illness. Nine of the ten participants in one focus group in Badakhshan complained about the lack of water and cleanliness in the village, and reported trying home remedies before accessing clinic services or a


private doctor as the CHW did not have drugs or they were perceived to be ineffective. Similarly, in Baghlan some of the participants complained about lack of effective medicines as a reason for not seeking care first from CHW. However, in the same province another 46 year old woman said that the village was too poor and since the clinic was far they used the services of the CHW, who was like an angel to them. The male members of the shura-e-sehie from all provinces except Badakhshan reported using the services of the CHW as the first source of care. In Badakhshan, some of the members did not seem to be aware of the responsibilities of the CHW. They believed CHW received a salary but felt they did not benefit the community with any service. Likewise the female shura-e-sehie members also reported seeking care from the CHW first, except in Badakhshan, where a few participants were skeptical about the quality of the CHW services as she did not have the knowledge of a doctor. A majority of the focus group participants reported using the CHW service for themselves or their family members in the past three months. Commonly reported reasons were minor ailments, intestinal disorders and injuries. In the female focus groups several women reported accessing services for themselves or their children, but also reported that CHW did not have the necessary medications to treat them. Many of the female facility-level shura-e-sehie members reported using the services several times in the past year, particularly for children. Others mentioned the effectiveness of the referral services. Frequent use of services was mentioned specifically for gastro intestinal disorders or for burns and injuries by male shura participants.

Health conditions for which treatment was sought from CHW in the past 3 months

Male community members: wound dressing for burns and injuries, headache, stomach pain, body or leg pain, diarrhea,

dysentery, sore throat, eye problem, pneumonia, flu, dryness of skin, gastro intestinal disorders, and malaria

Females community members: High blood pressure, pregnancy related conditions, diarrhea, vomiting, dehydration, headache and anemia

Non Users of CHW services According to the male community members, illness severity, wealth and land ownership were some of the reasons people preferred to use health services in the town rather than seek help from CHW. The female members felt that those who lived in remote areas did not participate in CHW meetings and those who believed that the medicines were ineffective did not utilize the CHW services. Others mentioned that for some families health was not a priority and therefore they did not feel the need for a CHW. Others who had negative experiences with side effects of drugs or worsening health conditions also felt that CHW were ineffective and did not access their services. In all FGD, commonly reported reasons for not seeking care from CHW were the non availability of female CHW and shortage of drugs or presence of ineffective or expired drugs. Non-availability of blood transfusions during obstetric emergencies was mentioned by some women as one of the obstacles for not utilizing CHW services. Community members with chronic conditions and disabilities were not satisfied with the service as the CHW could not treat their illness.


Competency of CHW and Perceived Quality of Care Participants in most focus groups reported that they perceived CHW services to be of high quality. Some community members acknowledged the value of vaccinations and reported reduced deaths due to vaccine-preventable causes. A few participants also said that in the past they were confused about drug dosages but now the CHW provides correct information on the prescriptions and instructions for their consumption. A 72-year-old man from Logar remarked that in his experience people used to run away from vaccination campaigns but now they take the children for vaccination. In some FGD, participants expressed their concern that illiterate CHW may wrongly prescribe drugs, resulting in adverse outcomes and death. However none of these participants reported actual incidents of such occurrences. One of the participants expressed her concern that the CHW provided the same drugs to three women with different presenting complaints. “Expired”, “ineffective”, and “wrong medicines” were quoted by some of the participants who were skeptical about the quality of the drugs provided by CHW. A few participants feared that the dispensing of expired or incorrect drugs by illiterate CHW could be fatal. In one of the FDG in Badakhshan a male participant shared that although he was satisfied with the services, the CHW did not perform complete physical examinations and dispensed the wrong medicines. In his opinion the CHW had effective medicines only for treating colds and he had to go to the clinic for treatment of other illnesses. Shura-e-sehie members at one of the health posts preferred that the CHW be replaced by a doctor, whereas members of a shura at a different health post preferred the CHW services but wanted further training to be provided. Literacy levels of the CHW were linked by participants to the CHW’s competence. As community members in Logar pointed out, “we are content, he has completed high school and knows a lot; during the middle of the night he provides services, we are delighted.” Poor road conditions and safety prohibited seeking care for health emergencies, but after the institution of CHW, community members declared how easily they could access health services from the CHW, saving many lives, especially women’s lives. At the community level, the responses from the shura-e-sehie members were similar to those of other groups on the types of services offered by the CHW and their value to community health, but they emphasized that CHW attitude and behavior were critical determinants for service utilization. There were both positive and negative reports about CHW behavior and their ability to respond immediately to the community’s needs. A few of the community shura-e-sehie members in Baghlan were not pleased with the CHW and recommended replacement with a knowledgeable CHW hired from outside the village. At the facility level most shura-e-sehie members who participated in the focus groups were very appreciative of the CHW services, particularly for malaria and first aid treatment as one of the members suffered burns due to the explosion of a steamer and was treated well by a CHW. Another 65-year-old male shura-e-sehie member from Balkh reported that in past years when children fell ill in the summer season they covered them in cool soil to recover but now they have realized the harm in this practice and they take them to the CHW.

Perceptions of Effectiveness of CHW services

“CHW offers everything he has available and solves all problems in the village” 20 year old student and 38 year old technician, Logar

“The drugs given by CHW are not available in the market but have the best quality and results” 60 year old farmer from

Balkh

“The treatment they provide really works and he always offers some refreshment like tea and bread at his house. The


CHW cures our patient at home” 35 year old shop keeper, Baghlan

“It is good that the CHW is a female and close to our houses and we can easily reach the health post and our problem is solved. Before we did not know how to take medicine and how many times a day, but since she provides information

everything is going well” 32 year old female, Baghlan.

“We get treatment on the spot, there is nothing more important than this” 72 year old male shura-e-sehie member, Baghlan

“People die due to malaria in our villages, but not anymore as CHW provides effective medicines to patients” 50 year

old male, Logar

“The CHW medicine is effective and has best quality” Male community member, Balkh

“The given medicine is helpful, and his knowledge and experience are good and he knows English, we are all delighted” Male community member, Baghlan

“It is very effective, there has not been a time when the treatment has not worked, we are so please with what the

CHW has done” 50 year old female, Logar

“I am both happy and unhappy, happy because we get treatment, unhappy because there is not enough medicine at the health post”

40 year old female, Logar

Cost and Willingness to Pay for CHW services The mention of payment seemed to evoke laughter in most discussants as most participants had not made any monetary or in kind contributions to the CHW. Many marveled at the fact that the CHW were not remunerated and yet continued to serve faithfully in the community and in many instances provided tea, yoghurt and bread for the patients. A few reported that they attempted to pay the CHW but he refused to receive any donations from the community. Some were of the misconception that the CHW were salaried government workers. In a few of the focus groups, participants reported making payments of 5-6 Afghanis to the CHW. In some instances they reported payments of 10-50 Afghanis for drugs which they felt was very reasonable as it was only 40% of the market value. Participants reported that certain drugs like paracetamol and ORS were provided free of charge but a nominal fee was charged for other tablets or syrups. In some communities they were willing to pay 2-5 Afghanis to the CHW but other communities felt they were too poor to make even minimal contributions. In Badakhshan they were willing to pay 3 Afghanis if the donors supplied the CHW with effective medicines. Another focus group participant from Baghlan reported that the CHW was from Pakistan and a qualified lab technician and therefore had unlimited drug supplies and sold them to the people according to their needs. In the female focus groups some women reported paying 100 afghani for delivery services while others said they paid 5 Afghanis for a visit if they could afford it or made in kind contributions like eggs or oil. Others felt that the CHW offered their services for the “sake of Allah”. The overall range of cash payments participants reported making was 1-100 Afghanis, depending on the type of service provided, but most participants who reported payments mentioned 3-5 Afghanis per visit. The widows in the female focus groups confessed that though they appreciated the services they could not afford to pay even one afghani to the CHW. Disagreements were evident in the focus groups as participants argued about the affordability and willingness to pay for services. A 30-year-old woman from Kunjak village, Logar was willing to pay if the CHW had effective drugs and she did not have to access referral services. She was soon interrupted by another 40-year-


old woman who objected and remarked that it was not the opinion of the group members as she could not even afford half the cost of the services and was joined by several others in the group. Some women were willing to pay more (50-100 Afghanis) if the CHW assisted during delivery (as a baby gift) or provided blood transfusions. More participants in the female focus groups reported payments to CHW than male participants, perhaps because they utilized the services more often. However many voiced their concern that if the CHW did not receive payment either from the village or government they would discontinue providing services. The opinion of the shura-e-sehie members was similar to the reports of the community members. They felt that it was not possible to support the CHW and the government should take full responsibility for a regular salary. Some, however, were willing to pay for the services as the CHW were poor and served willingly. In the female shura-e-sehie, most participants felt they could not afford payments but could consider small payments for medicines. Most participants were very sympathetic when they learned that the CHW provided voluntary services and expressed eagerness to support the CHW, but a majority strongly felt that the government should support the CHW with a regular salary. Although the majority of the participants in most focus groups felt they were financially incapable of paying for CHW services, they were willing to provide in-kind contributions of land for building a heath post, reconstruction of CHW homes, provision of clothes or free tailoring services. In one discussion group there were suggestions that every household provide one garment to the CHW and then they realized she would have more than 100 garments and resorted to other ideas to support the CHW. A number of women reported giving food such as milk, yoghurt, oil, hens, or allowing them to pick fruits in their garden. The custom of rewarding assistance during delivery was common where TBA or CHW were rewarded with chocolates, clothes, oil, hens or soap. A facility shura-e-sehie member from Badakhshan reported paying 50 Afghanis to the CHW for his motivation and support to the community following a bomb blast. In Badakhshan some community members felt that if they made cash payments when it was affordable, they would receive effective medicines, but they ought not to set precedence as the quality of service and medicine would decline if they could not afford the payment.

Payments and willingness to pay for CHW Services

“We cannot pay even one afghani, we are too poor” Male shura representative, Balkh “Either one can afford or can not, he/she would pay 5 Afghanis to CHW as the cost of CHW’s service, since if someone would go for treatment to the doctor in the city, he must pay for a taxi, to the doctor as the fee even for so many other needs of his trip to the city he/she must pay, so if you count all of these amounts it would become a very huge amount, therefore I imagine that giving 5 Afghanis to CHW is cheaper and more economical than going to the doctor.” Male community member, Balkh “We think the cost is not much as if I go to a doctor the fee will be 150 Afghani and CHW is only 5 afghani which we can afford” 45-year-old woman, Logar “We pay 1400 kg of wheat to Mullah and not give a single penny to the poor CHW who is serving us, it is a shame” Health Post Male Shura member, Baghlan “No we did not pay any fees, just one fee for 10 patients. I came to him several times and I did not pay and he dressed the wound of my son” Male, Badakhshan “All villagers get benefits from CHW, poor and rich. If a beggar or king comes to CHW none of them pay him/her or helps him/her. If CHW wants I’m ready to pay. Even the fixed 5 Afghanis no one pays, they serve us a lot, they are poor and no one helps them” Male, Shura Health post, Badakhshan


Community Support to CHW As described in the previous section, the evidence of community members supporting the performance and motivation of the CHW, especially through monetary contributions, was minimal. There were more reports of CHW support in Logar than the other provinces. General goodwill and altruistic feelings were expressed by several community members, which could be a powerful motivational factor for the performance and sustainability of the CHW. Specific recommendations for supporting male CHW included the team effort of the “Imam” and the cleaners in the mosque to help the CHW in environmental clean up activities and chlorinating water. The Mullah’s advocacy role was considered to be critical in introducing and establishing the credibility of the CHW and encouraging the community to utilize the services. Two participants in Balkh province felt strongly that the government should convince the richest people in the community who owned land to make salary contributions to the CHW. Other suggestions were for the provision of land and labor to build additional CHW health posts to increase access to CHW services for other community members. In Logar, community members reported incidents where they encouraged their neighbors or other community members to use the CHW services when they fell ill. There were a few accounts of helping the CHW with transport or providing land to construct the health post, but most groups reported that communities supported the CHW by advocating on their behalf to establish their credibility in the community and encourage utilization. A school teacher also demonstrated his support by educating the students and creating awareness about the services of the CHW and to encourage utilization of their services when someone in the family is ill. The advocacy role of male community members is powerful in leveraging support for CHW and their services.

Community Support to Male CHW

“We protect them, and educate the community that he is a good man. Also when he is busy with patients we water his land and maintain his land in good manner” 16 year old male, Logar “I myself have supplied a home for health post and it is open now. I have guided and convinced a lot of people to go to CHW” 50 year old male, Balkh “”I persuade the people to follow instruction for vaccination, and accompanied the CHW house to house for his safety and to introduce him to the people” male, Balkh “I have helped him by giving donkey to transport medicine” Badakhshan “I help transport patients by car to the health clinic” 32 year old male worker, Logar “For the sake of Allah I took 5 patients to the hospital” 43 year old teacher, Logar I have a tractor and can bring cement and stone to help build the health post” Driver, Logar “I help in the education of his children” Student, Baghlan In Balkh a male participant reported that they protect the CHW and do not allow anyone to bother him and gave him the freedom to function in their community without any limitations. This indicated the importance of community authority in facilitating the CHW’s work. Conflict resolution was mentioned by a few participants in Logar, where they intervened on behalf of the CHW and when there were disagreements in the community. Another male community member from Balkh province reported that he walked around the village announcing the vaccination campaign and requested women to keep their children at home so they could be vaccinated. Two middle aged participants from Logar expressed the need for ‘controlling’ or supervising the work of the CHW


so he does not engage in illegal activity. Another participant from the same village suggested buying shoes so the CHW could conduct the household visits. Participants reported that they were willing in the future to continue to support the CHW with land, construction of health posts and providing financial assistance and building a private residential room for the CHW. In Balkh, they promised to ensure the security of the CHW and protect them from troublemakers in the community. Others in Balkh offered to provide the CHW with lunch, help in constructing a well in his backyard, and provide free tailoring services. Carpenters, painters, mud plasterers and builders said they were willing to provide services for free to the CHW, including mud and cement for the health post. They expressed shame and remorse for not helping the CHW, especially when they learned he was not a salaried worker, and were willing to provide any physical help even if they could not afford cash payments. They were more willing to help if the CHW expressed his need for assistance. The women were very sympathetic to the issue of supporting the CHW but a few participants felt that their poverty precluded them from providing any monetary support. Some reported that their husbands assisted the CHW in transporting patients to the clinic by carrying them to the clinic even if transport was not available. A few participants mentioned offering gifts of food items, assistance during vaccination campaigns and hosting the CHW in their homes during emergencies or ailments. In Baghlan women reported an unusual incident of a poor CHW being abused by the Mullah, who took over her house and ‘kicked’ her and her family out. They also reported that she now lived in a stable with cattle. Her husband was apparently disabled during a bomb blast. Participants expressed their sympathy for the CHW, who could not provide effective services due to her domestic problems. The need for support groups for female CHW is evident as it is a risk to function independently in a community. Widows in one group in Logar felt that they were too poor in their village to consider supporting the CHW as only two households had an adult male present. They felt that the government should prioritize vulnerable communities and support the CHW. As in the male focus groups, women, despite their poverty, were very eager to provide more support to the CHW in the future with food, land, assisting in the construction of a room for her to live in the heath post and providing a donkey for transport. In comparison to the costs of renting a vehicle to transport patients and pay 200 Afghanis for care in a clinic, they expressed a preference for supporting the CHW.

Community Support to Female CHW

“We are satisfied with what she provides in our village and pray for her well being and are thankful that the government provided the CHW system in our village” 35 year old woman, Logar “We give small amount of money and food and men help carry the patients” Women, Baghlan “We provide food during the season and gave our house and land during vaccination campaign and health education” Badakhshan “Once it was winter, and we heard CHW had frost bite. We went and brought her to our house” Female community member, Badakhshan “We help CHW a lot. I let her use my house for health education for three days and provided food and tea and other items” 25 year old woman, Logar If a car is not available we will take emergency patient by donkey, otherwise men in our village are brave, we will take the patient on our hands, since helping each other is one of our customs” 28 and 30 year old women, Balkh


Shura-e-sehie Support to CHW Female shura-e-sehie members reported similar strategies for supporting CHW through advocacy, vaccination campaigns, health education and providing a room for the health post. Some members reported introducing the CHW at the mosque to provide health education to the men in the village. In Badakhshan and Logar, women reported providing minimal support for facilitating the work of the CHW and encouraging them but no monetary assistance. Likewise, the facility female shura-e-sehie also reported some support for health education and giving tea or milk during the CHW visit but no monetary help. In the future they were willing to seek opportunities to acquire land or construct a room although they could not promise any cash assistance. Two women reported providing cash assistance to a poor CHW, so she could prolong her stay in the community. The male shura-e-sehie members described incidences of assisting CHW by engaging in advocacy within the community on behalf of the CHW and their services, providing a donkey for transporting patients (Badakhshan), and protecting his house and health post from burglary (Logar). Others shared that they encouraged the community to be kind and friendly to the CHW as they are providing voluntary service and to motivate the CHW to continue in the village in the hope that they may be paid a salary by the government soon. This raises concerns as the CHW may have false expectations and it may result in a higher drop out rate if salaries are not provided in the future. Some reported that they advocate for their credibility in the mosques and demonstrate how they are providing voluntary services without remuneration as some community members believed that the CHW utilized the financial aid for themselves. All groups were willing to make greater efforts to support the CHW in the future. One shura-e-sehie member offered to gift him with vegetables if he passed by his farm.

Feedback on Performance of Shura-e-sehie Health post shura-e-sehie were reported to be present by community focus group members in Logar, Baghlan, and Badakhshan. The community members felt that the shura-e-sehie had a significant role in communicating and requesting regular salary support for the CHW from the government. The response of the community members regarding the shura-e-sehie was quite positive in one village in Logar as they reported that the female shura-e-sehie was very intelligent and was composed of great women. Participants from other groups were not aware of the term and some said they were curious and enquired about it from their husbands but were told not to discuss these issues. In one village in Logar a woman said she enquired from her husband and was told to shut up. However those who were aware of shura-e-sehie felt that their primary responsibility was to meet the minimum basic needs of the community. The male community members seemed to be more aware and appreciative of the shura-e-sehie. They reported that the shura informed them about vaccinations, introduced the CHW to the community, provided oversight to the work of the CHW (including drug availability), attended meetings at the clinic, shared issues related to disease incidence, supervised clinic construction, advised communities to drain water, and removed contaminated water. They also tried to motivate people to utilize the clinic services, solved disputes between community members, communicated the community problems to the authorities and provided general information on hygiene. Others reported that the shura-e-sehie was new and had not provided any services. In Badakhshan the community members were dissatisfied with the shura-e-sehie, as they had repeatedly requested safe drinking water and the shura was not compliant. Community members wanted tangible evidence of the shura’s performance and not just participation in meetings. Participants in Baghlan said that “if someone would die in front of them, they will not even move from their place”.


The most important perceived role of the shura-e-sehie was in ensuring the availability of clean water and maintaining environmental cleanliness to avoid infectious diseases. The community also felt that the shura-e-sehie could facilitate health education sessions, recommend building hospitals, be more aware of community problems, encourage the community to use CHW services and support their work, facilitate the construction of latrines, distribute bed nets, and advocate for the construction of schools in their villages. Their disposition was also important as the community felt they should be kind and approachable and have regular meetings with the community members. In Baghlan they also recommended that shura-e-sehie advocate for construction of roads. Some other community members felt they were a critical link with the government and ought to effectively convey their needs and demands to the government. Others felt that they should regulate the CHW and doctors in their villages, ensure adequate and effective drugs, and facilitate the transport of emergency patients to the clinic. In Badakhshan one participant remarked that there were a lot of mental problems in the community and therefore effective drugs must be available to treat these conditions. Overall the community felt that the shura-e-sehie must be more engaged with the concerns of the people in the community. Some community members recommended additional training for the shura-e-sehie and selection of only educated community members to the shura. Some also felt strongly that the present shura-e-sehie committee should be dissolved and other members recruited. Many members felt strongly about the shura-e-sehie role in promoting and supporting the work of the CHW, especially in addressing their financial difficulties and negotiating a salary with the government. They also felt that the shura-e-sehie could pay a small amount to the CHW in appreciation of their work to encourage them to continue services.

Participant Concerns and Recommendations for CHW services Although most participants shared their perspectives and experiences candidly with the discussion team, there were many incidences where they felt that any negative report about the ineffectiveness of services or drugs would lead to the termination of the CHW and were hesitant to share their opinions despite being reassured that their participation in the discussions was confidential. Women in one of the health post shura-e-sehie expressed their disapproval and futility of responding to these queries and making recommendations. They noted that they had been repeatedly subjected to surveys and witnessed very little evidence of their recommendations being carried out by the donors or the government. They felt it was a waste of time to discuss ideas for improvement. Participants’ responses on satisfaction of the CHW services were mostly positive as they valued the services offered and saw clear evidence of improved health in the community. Some gave mixed responses as they were appreciative of the efforts of the CHW but were dissatisfied with the effectiveness and availability of drugs. The participants reported that strengthening the CHW services should be the primary responsibility of the government and not the communities, who were willing to help in small ways. In addition to effective and adequate drugs, participants felt that the training and skills of the CHW should be improved and laboratory facilities should be included in the health post for diagnosing malaria, TB and other diseases. In Balkh, the female facility shura-e-sehie members recommended frequent CHW-physician interactions so the CHW knowledge on disease and medicine and diagnostic and treatment skills would be improved. Focus group participants, particularly those in Badakhshan, indicated a preference for literate and trained CHW. The male shura-e-sehie members from the health facility requested additional trained CHW, and training to enhance the skills of the CHW.


The provision of incentives, like monthly salary support, tailoring classes for income generation, free education for children of CHW and provision of bicycles for CHW to conduct home visits were mentioned in many focus groups both with the shura-e-sehie and the community. In one health post the female shura-e-sehie members felt that the children of the CHW must be given an opportunity to study medicine and become doctors so they can sustain the work in the community and provide better care. Improving the physical infrastructure of the health post was mentioned by a number of FGD participants as they prefer to use the services of the CHW to the health clinic. Reconstruction of the CHW home as a health post was seen as a priority by most participants to improve services, motivate the CHW and facilitate appropriate storage and dispensing of drugs. Another reason for revamping the health post was the added value of providing visibility of the services to the community as they felt it was difficult to find the CHW in the village. In some focus groups they requested that the government build additional health posts to make services more accessible. Cost sharing was mentioned in one focus group in Badakhshan, where participants reported that they would be willing to pay 5 Afghanis but the Government should pay 10 Afghanis per visit so the CHW would be encouraged and motivated to provide services. In some villages, community members requested replacement of the male CHW with a female as the males could not assist in deliveries. There continues to be high demand for female CHW by both male and female community members. On several occasions a number of female participants expressed a desire to be trained as a CHW so they could assist other women in the community, but were unable to do so because of objections from male family members.

Demand for volunteering to be a CHW “The only problem is deliveries, male CHW cannot help us. This is our fault as our men do not allow us to become CHW. My son who is a mullah refused to allow me to become a CHW” 38 year old woman, Baghlan Recruitment, training and introduction of CHW to the community were considered important for establishing the credibility of the CHW. In some focus groups in Badakhshan, participants complained that the CHW were recruited by the clinic staff and outside agencies and not selected by consensus of the community. Hence the CHW were unaccepted initially as they were not appropriately introduced to the community. However participants from the villages that were further away from the health facility were very appreciative of their service. In other focus groups, the introduction of the CHW and communication of the roles and responsibilities was considered to be the CHW’s task and not that of the donor or government. They also expressed the need for establishing some level of accountability to ensure that the CHW provided proper services and also behaved well with the patients. Participants in some community focus groups requested the provision of supplemental food by CHW for severely malnourished children. The female community shura-e-sehie members were satisfied with the current CHW services but felt that they should be offered 24 hours and that emergency patients should receive prompt care, including referral to the facility for blood transfusions during obstetric emergencies. Other disease prevention activities were recommended for inclusion in the CHW responsibilities like draining stagnant water and provision of bed nets to prevent malaria. There were several other recommendations for improving the CHW service which included health education in the Mosque or on prayer day (Friday), communication about vaccination campaigns, surveillance for illnesses, nutrition education, testing and purification of water, provision of equitable services without discrimination based on language or culture, and provision to the CHW of additional equipment like blood pressure apparatus and facilities for blood transfusion. Female community participants preferred that CHW had additional competency and skills for pregnancy related conditions and delivery assistance.


Community members in one group in Badakhshan felt that the CHW was too old and mentally stressed (she was reported to have snapped at the patients seeking care) and therefore recommended younger recruits. They had very high expectations of complete disease eradication and the ability of CHW to cure all diseases. During the discussions it was evident that the participants were particularly concerned about the ongoing support and sustainability of the CHW, particularly the male CHW. Fears about inadequate medicines, drug stock outs, lack of appropriate health post facilities for CHW to operate, the voluntary nature of CHW services and lack of community support were often voiced by the participants as factors that could contribute to the poor performance and attrition of CHW.

Sustainability of CHW services “CHW do not have salary and never asked for fee for services they provide, besides the community does not give the necessary support. How will they survive?” 75 year old retired officer, Logar Another major concern often voiced by the participants was the safety and security of the CHW who worked in remote areas with limited road access. They felt their ‘lives are in danger’ as they do not have car or money for transport and can be at risk. They felt that the government must guarantee their lives as they are perceived as health workers of the NGO, and regarded as employees of foreign committees or organizations. A few participants said that “although God is saving their (community) lives through the CHW, attention should be paid to protecting the lives of the CHW”. Some female participants reported being aware of the enormous contributions CHW had made without remuneration and felt it would be unfair to expect more of them. They also realized that they could not make unrealistic demands on the CHW, and that in case of obstetric emergencies they needed a female doctor who could respond immediately to their needs. One woman reported giving birth under a bridge on her way to the clinic as the CHW did not have the resources to help her. Another critical role that the community perceived for the CHW was to be a liaison to the government and communicate their concerns to the ministry for supplies and services.

Summary Conclusions of CHW Performance The institution of CHW services in the community has facilitated to some extent autonomous decision making for women to seek care for themselves or their children if the provider is female. As a result of CHW services, many community members perceive improved accessibility, reduced waiting time and costs, improved privacy, confidentiality and comfort in accessing care from a known community member, and improved access to social support networks. The CHW is often the preferred provider for first level of care and for emergency services. It is important to distinguish objective measures of technical quality of care from community perceptions, which may differ from a health provider or health system definition. Low quality, as perceived by community members, is often attributed to issues of access, convenience, costs, adverse incidents experienced, comfort related to interpersonal relationships and gender. Technical quality of care, including accuracy of diagnosis, availability and effectiveness of drugs and equipment, are factors that are important both to providers and clients utilizing the service. Perceived value of CHW Evidence from the discussions with community and shura-e-sehie members indicates that these workers are highly valued, even more than physicians in some villages as they provide equitable,


accessible and affordable services almost 24 hours of the day in all seasons. In comparison to accessing services in the health facility, which can entail high costs for transport, examination and drugs, long waiting times, and in some cases facilities that were closed before patients reached them, community members felt a CHW provided effective free services immediately and drugs were either free or subsidized. Moreover they also compared the opportunity cost of lost time from work when they had to access services from the doctors and now their women can go to the CHW without being escorted by the men. In most villages these community workers were appreciated for their personal dedication, integrity and loyal service to the community members, particularly the women and children who could in some cases access services without male family escorts. Gender differences in service preference and utilization Male community members were more appreciative of the preventive aspects of health education, which they saw evidenced by reduced deaths in the villages, particularly reductions in deaths due to malaria and vaccine preventable illnesses. The opportunity to access health care during pregnancy and assistance during delivery and new born care was highly valued by the female community members who felt comfortable to share even non-medical issues with the female CHW and reported reduced deaths due to pregnancy related causes and diarrhea in children, since the institution of the CHW in the community. Demand for skilled and female CHW The competency of the CHW was a critical factor in some villages as they felt they needed additional training or recruitment of literate CHW as they may make errors in drug prescriptions. The demand for additional female providers was universal in all villages. Introduction of CHW into community and relationship with existing authorities Although most focus group participants made no mention of the methods by which CHW were recruited or introduced in the community, some made recommendations that the process must be conducted in collaboration with community and shura-e-sehie members as they were not aware of the CHW in their villages or had not been informed about their role or services. Participants from different communities reported a high level of variation in the type of relationship the CHW has with existing authorities in the community, including Mullahs. In some communities, existing authorities in the village introduced the CHW to the community and facilitated the work of the CHW. In other communities, participants reported that the CHW did not have a positive relationship with existing authorities. The type of relationship the CHW has with existing authorities seemed to be a major determinant of CHW performance as reported by the community. Motivation and support of CHW Apparently the introduction of the CHW to the community as a non-salaried government worker was not evident to community members, as many participants considered them salaried workers and expressed surprise to discover that they had been demanding and utilizing free services from an unpaid health worker. Most participants felt it was primarily the responsibility of the government to provide salary, transportation (bicycle) and assistance in building the health post and ensuring the availability of effective drugs and equipment. The safety, security, moral support, assistance for building of health post and small in-kind contributions by those who could afford them were felt to be services the community was willing to provide. A nominal fee of 5 Afghanis was considered affordable in some communities, whereas this was considered too expensive in others, particularly where there were higher numbers of widowed households. In several instances community members claimed to support the CHW with labor and materials for construction, vegetables, fruits, yoghurt, oil, cloth material, and small rewards for delivering babies. Accountability and Regulation of CHW This issue was raised mostly by the male community and shura-e-sehie members who felt that there should be a mechanism to regulate the activities of a CHW. Although supervision is


conducted by the MOPH or NGO, other community structures need to be engaged in supporting and supervising the CHW, especially in services like vaccination campaigns, health education, delivery and management of drugs, and referral. Shura-e-sehie The concept was still new in some communities and very few provided evidence of shura-e-sehie support to the communities or the CHW. It is apparent that NGOs need to make additional efforts through the community health supervisor (CHS) or other mechanisms to clearly delineate the tasks and expectations of the shura-e-sehie and to train shura-e-sehie members in providing support and problem solving. The community also needs to be made aware of the CHW and role of the shura-e-sehie. Female shuras are few in number and female community members were not aware of the existence of the male shura-e-sehie in most villages.

Limitations Inherent in all qualitative research, the findings from the focus group discussions are likely to reflect the opinions of a few vocal participants. This was overcome to some extent by engaging quiet participants to agree, disagree or provide alternate perspectives through appropriate probing strategies. The findings must be interpreted with caution and cannot be extrapolated to all communities or all CHW programs, due to the study design and purposive sampling of the provinces and villages.

Program Recommendations for Strengthening CHW Capability As in all health systems that use an extensive capital of volunteer human resources, the ongoing performance and sustainability of CHW services face considerable challenges, though the community appreciates and demonstrates demand for these services. Increasing the number of female CHW The demand for female CHW far exceeds the demand for male CHW, whose services are currently limited to providing health education and first aid. Training additional female CHW particularly in reproductive and child health and limiting the responsibility to a smaller number of households would facilitate a more viable system that reduces the burden on CHW without diminishing their role and type of services provided. Availability of Drugs The issue of inadequate, ineffective drugs is a recurring complaint in all focus groups conducted as part of the National Health Services Performance Assessment over the past several years (2004-2006). Improving the availability of standard drugs would likely increase community satisfaction with and utilization of CHW services. CHW perceived expectations of monetary support Though they are aware of the voluntary nature of their services, CHW may have unspoken expectations that in the future they may receive a promotion or salary remunerations from the government. The initial enthusiasm is likely to wane gradually when the monetary rewards are not forthcoming. Other competitive forces in the community or district that engage salaried workers may also adversely affect the system, particularly the male CHW. Some vertical programs remunerate the CHW, which distorts the national system of promoting voluntary workers. Some NGO’s have developed innovative mechanisms to motivate and sustain the CHW through incentives. These approaches should be examined, and incentive mechanisms that are found to be effective and have a high likelihood of being sustainable should be nationally recognized and endorsed. This may include in-kind contributions, bicycles for transport, opportunities for school


education for the children of CHW, promotions, monetary contributions for referral, active case finding for TB, and other mechanisms. These innovative incentive systems should be further examined and evaluated for effectiveness, to inform the future development of a standardized national policy. Importance of support structures Increased demands from the health system and community for a wide range of preventive and curative services may result in overuse of the CHW and dilution of activities. This may overwhelm and diminish the quality of CHW performance in the long run. As reported in some focus groups, many CHW provide services on a 24 hour basis and also provide referral services and resolve disputes between community members. CHW are perceived as problem-solvers not just for health but for many community needs, such as ensuring water supply and road construction and serving as a liaison with the government. Different types of support structures need to be examined, such as those where the CHW is supported by a network of responsible community members. This is particularly critical in Afghanistan, where security and cultural factors impede the freedom of female CHW. Support structures may facilitate the equitable delivery of services to populations living in remote areas. In the future, if CHW utilization levels increase substantially, it is important to examine appropriate community support structures to sustain CHW operations. The Community Health Supervisor (CHS) was created as a new position within the BPHS shortly before the FGD for this study were conducted. It is important that the CHS provide support to the CHW, but it is imperative that the CHW also receive support from members of the community. Constructive engagement of community leaders There is an acute need to engage Mullahs and other community leaders in a constructive manner when introducing the CHW into the community, so that they support the CHW rather than compete with or hinder them. CHW are likely to have a much greater impact on the health of a community if their work is supported by the mullah, other traditional leaders, and new bodies with authority, like the shuras. NGOs and others who are training CHW and deploying them to communities should engage existing community leaders in a constructive dialogue to see how they can best work together to improve the health of the community and support CHW services. It is also important to equip the shura-e-sehie with training in problem solving and create awareness of community health needs.

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