HRH dimensions of community health workers: a case study of rural Afghanistan

Most countries deploy community health workers (CHWs) to address a shortage or maldistribution of professional and regulated human resources for health (HRH) such as physicians, nurses, and midwives [1, 2]. CHWs are members of a community who are trained and supported by the health system to provide basic services in the communities in which they live [3], and are a valuable cadre in the health workforce in many countries across the globe [1, 4, 5, 6, 7]. The overall number of CHWs was reported to be around 700 000 in India [8], 100 000 in Bangladesh, 30 190 in Ethiopia, and around 240 000 in Brazil [9]. Yet, the shortage of HRH is not only about the number but also about the geographic distribution, skill mix, and career paths of the workforce. Despite a general agreement that CHWs are a valuable health workforce, they are often viewed as elements of health programs rather than standalone human resources for health. In fact, there is a hesitance among some policymakers to recognize CHWs as a formal HRH, which in turn positions them implicitly as second-grade health service providers [10].

Despite the extensive use of CHWs across the globe and a growing evidence base for their training and the types of services they provide [11], there is a lack of contextual evidence on the size and distribution of CHWs, their career path, and their relationship with the professionally regulated and recognized health workforce as well as to other unregulated and unrecognized health workers such as traditional birth attendants and traditional healers. This is perplexing as CHWs often interact frequently with both, and the interaction has impact on the tasks of CHWs. Understanding the size of CHWs within a geographic context implies the shortage of professional providers and refers to CHWs importance as service providers [6]. The distribution of CHWs can be associated with the geographic distribution of health services in a context. In this article, we focus on a single case-study of Afghanistan, where a large number of CHWs have been recruited, trained, and deployed to address a chronic shortage of HRH.

Afghanistan faces a chronic shortage of skilled health professionals (9.4 per 10 000 population). The country has only 1.9 physicians for 10 000 people distributed unequally across the country with a rate as high as 7.2 in urban areas, and as low as 0.6 in rural areas [2]. The rest of the skilled health workforce included in the report by Global Health Workforce Alliance and WHO is comprised of nurses, midwives, and dentists [2]. On average, there are four times more skilled health professionals in urban areas than in rural areas [12]. According to the Global Health Workforce Alliance and WHO (2013), the density threshold of 22.8 skilled health workers per 10 000 people is required for most countries in need to achieve relatively high coverage for essential health interventions. Afghanistan is one of the countries with a least likely chance of hitting the threshold of 22.8 skilled health workers in 2035 [2].

Despite this shortage, the Afghan health system claims to cover 60% of its population for basic health services [13], with CHWs as one of the key first points of contact with the health system, with a focus on maternal and child health. In 2003, the Afghan government with the support from international donors initiated a national initiative called the Basic Package of Health Services (BPHS), which included training volunteer CHWs in rural areas to expand basic health services. CHWs have taken on the task of providing health services to the rural communities, bringing community members closer to the formal health system to which they previously had little access. The BPHS policy does not recognize the categories of traditional birth attendants, healers, and Hakimjis,¹ and CHWs are not supposed to have any collaboration with them. The program was funded by the World Bank, the United States Agency for International Development, and the European Union, and contracted out to national and international non-governmental organization for implementation. By 2014, around 26 000 male and female CHWs were trained across the country. An earlier article from this study affords a detailed description of the Afghan CHW program, highlighting issues of training and recruitment, task, supervision, and compensation [14].

In-depth interviews were conducted with policymakers in Kabul, health managers of NGOs implementing the program in provinces, and CHWs and community members in villages. Policymakers were selected based on their knowledge of the CHW program through consultation with Ministry of Public Health officials and researchers in Afghanistan National Public Health Institute. Once a number of potential participants were identified, the solicitation email was sent to them. Upon their agreement, a date and place were set with the participants and interviews were conducted. Most potential participants agreed to the interview. Lack of time was the main reason for some policymakers not participating in the study.

Health managers were selected based on the three types of implementing organizations (international NGOs, national NGOs, and provincial government health departments). First, the lead researcher contacted the implementing organizations and met with the director of the organizations to identify potential health managers who had good knowledge of the program. Then, the researchers sent a solicitation letter to the managers to ask them for their participation. All managers agreed to participate except one who expressed his lack of in-depth knowledge on the subject. The lead researcher traveled to each province to interview health managers in their offices at their own availability.

Across all categories, participants were recruited until there was saturation in the corroboration of the descriptive findings. Interviews and focus group guides probed for a number of facets of the CHW program and included specific questions about the tasks of CHWs compared to other providers, the relationship of CHWs with other professional and traditional providers, and potential career paths for CHWs.

Augmenting the interviews, field notes were taken during site visits to document observations of health facilities for their structure, distance from villages, wards, patients, services, staff, and equipment, of the villages for the sources of drinking water and the location and the type of latrines, electricity availability, distance from clinic, and main source of income. The final field notes included a journal of what happened during these visits, relevant statements, and the two researchers’ initial analytical reflections.

Interviews, conducted by the lead researcher and his assistant, were audio-taped and extensive field notes documenting observations made. The field notes were used to crosscheck or complement the interview data and to assist in contextualizing the interview analysis. A preliminary data analysis was conducted after phase 1 before the lead researcher traveled back to the field for member checking in the second phase of fieldwork. In this second round of fieldwork, the lead researcher shared the preliminary findings with previous participants, as well as with new participants for comment, confirmation, and further data gathering. Member checking is a validation procedure in qualitative methods adding value to the analysis of the raw data, as the participant takes part not only in providing the data but also in the interpretation of them. This process also helps to clarify misunderstandings, wrong information, and misinterpretations [16]. The second round took place between September and October 2014.

Interviews and focus groups were translated and transcribed by the lead researcher. Initial analysis began during the fieldwork, consisting of the researchers’ initial reflections and field notes. Final thematic analysis was carried out by manually coding the transcripts into nodes, which were then put into sub-themes and then broader themes using a constant comparison technique [17]. Representative quotes were selected based on the way they resonated with most respondents. The context in which each quote was expressed and what participant group made the statements are explained to enrich the analysis. All quotes in this paper have been anonymized by giving a code number to the broader participant groups.

Ethical procedures of consent, safety, confidentiality, and privacy were considered during data collection. The ethics review board of the University of Ottawa and Afghanistan’s National Public Health Institute approved the study.

In this study, we found that volunteerism has played a major role in deploying a large number of CHWs in Afghanistan. CHWs undertake a variety of roles including tasks shifted from professional providers such as treating common illnesses such as headache, diarrhea, and pneumonia, making referrals within the health system, providing health education, and initiating community mobilization efforts. CHWs do not have a direct relationship with professional providers, and they negotiate relationships with traditional providers contextually. CHW’s lack of integration into the country’s education system of the human resources of health and a lack of a clear career path hinder their struggle towards a more recognized professional role within the health system.

CHWs are used all over the world to help address HRH shortages, particularly in underserved areas [1, 14, 20]. The addition of CHWs may increase the ratio of human workforce per population, but their inequitable distribution remains a problem [21, 22]. CHWs are inequitably distributed among the marginalized, the poor, and rural and remote populations [1, 23, 24, 25], with consequences for the workers and the populations the serve. Findings from our study largely affirm these outcomes from other studies. With 26 000 CHWs in Afghanistan, CHWs have been able to address the shortage of human resources, at least to some extent, and have become the health workforce for the poor. With the current CHW program in Afghanistan, the population reached by the program has received minimum health service, while the government claims a large coverage for CHW services.

With regard to their skills, CHWs are a unique type of human resources in comparison with other established cadres. The tasks of CHWs all over the world are numerous but it is their flexibility that gives them an advantage. In the case of Afghanistan, their tasks range from detection and treatment of prevalent diseases, to health education and awareness, to referral, and to administration of a Health Post, which were all based on the needs of the communities [14]. In the recent outbreak of Ebola virus in the West Africa and Nigeria, CHWs were the frontline workers to engage with communities limiting the spread of the virus [26]. With increasing new cases of polio in Uttar Pradesh, India, in 2011, CHWs contributed to the elimination of polio transmission there [26]. In Afghanistan, professional health providers, who are the main HRH of health systems, do not supervise CHWs, leaving CHWs with a feeling of isolation from the health system [14]. Their programmatic contributions can be best utilized when CHWs are made members of a primary health care team rather than left alone or isolated from other health workers.

Another characteristic that makes CHWs particularly useful within health systems is the unique location that CHWs occupy, navigating between formal and informal HRH systems and crossing boundaries between the two [27]. As volunteers, they are situated within the community and the informal health systems. As health workers, they are viewed as members of the health system. As a member of the health system, they attempt to gain a status within the health system, perhaps as a member of the health providers’ team [20, 27]. In Afghanistan, CHWs have been able to use their referral power and links with the formal system to bridge the western health care with traditional communities in the rural and remote areas.

One of the spillover effects of the CHW program in Afghanistan has been a disruption in the gender dynamics of communities they serve. Half of the 26 000 CHWs in Afghanistan are women. The large deployment of female CHWs has the potential to affect the distribution of health resources, division of health labor, gendered social norms, and decision making on health issues in local communities [10].

Researchers have long argued that CHWs should not be considered a panacea for weak health systems [28, 29]. Whereas CHWs may address a shortage of HRH to some extent, provide the skill mix necessary in complex settings, and navigate between the formal and informal heath systems, the bigger challenges of governance and management, financing, pharmaceuticals, and technological adoption in health systems must be addressed. In fact, strengthening weak health systems is more important for the better use of CHWs than the existence of CHWs to strengthen weak health systems. A stronger health system can pave a systematic career path for CHWs, which is the missing HRH dimension not only in Afghanistan but also in many other settings [30, 31]. A professional medical career path is not feasible and probably not necessary. CHWs can be promoted to positions of trainer, supervisor, and probably health managers.

Like all research, this study had some limitations. Professional providers and traditional healers were not interviewed as part of the research, and thus their perspectives on their relationship with CHWs were not investigated. The personal security of the researcher, assistant, and key informants was a key concern, limiting the places to which site visits could be made and limiting the range of interviewees, notably at the community level. Finally, participants’ responses may have been subject to social desirability or other biases, an issue commonly encountered in qualitative research. In our study, the principal researcher is a male, an ethnic Hazara, and a physician with additional foreign-training which may have influenced data collection from participants who were female and/or had a different ethnicity and social status. The researchers were aware of these potential biases and took efforts to minimize them by hiring a female research assistant for data collection, striving for a balance of ethnic backgrounds among participants, and continually de-briefing with the local researcher and the research supervisors over any potential evidence of bias in the study process and interpretation of results.

CHWs in Afghanistan are a viable option to meet the basic health needs of the population, but their full integration into the health system as human resources for health is limited. The limitation to CHW integration and effectiveness comes partly from the fact that they are viewed as second-level providers. In places where professional providers are available; CHWs have the potential to extend the services to marginalized populations, provide community health services, and become a member of the health provider team. Most importantly, CHWs also have the capacity to assume new roles quickly, with the potential to help a complex health system adapt to changing contexts and needs. Attention to career progress is needed.