Enhancing the CHW Model for Afghanistan:

Training Students as Household or Family Health Workers to Increase

Access to Community-Based Healthcare
Kayhan Natiq, MD, MPH 1
Johns Hopkins University, Afghanistan
Cor1espond1ng author: Kayhan Nat1q. Email: knatiq@jhsph.edu

Abstract
Despite extensive investments in the health sector in Afghanistan, many Afghan families still do not have access to basic preventive and thera­
peutic health services. The central role of community health workers (CHWs) is clearly defined in a Basic Package of Health Services (BPHS)
developed in 2003, and revised in 2005 and 2010, by the Afghanistan Ministry of Public Health (MoPH). However, the status quo reliance of
health service delivery on unpaid CHWs presents several challenges to a long-term viable strategic plan. To motivate a dialogue about alternative
, options to the provision of basic health services to communities, we compare three main options in this paper. These include (1) CHW "volunteer
model" in which CHWs receive no payment (status quo); (2) CHW "remuneration model" in which CHWs receive payments for their services;
and (3) "Family health worker (FHW) model" in which the demand for CHWs is offset by educating all children in school with progressive com­
ponents of the CHW training curriculum. We discuss these options in the context of several important attributes of decision making for health
policy. These include effectiveness, feasibility, efficiency, community solidarity, legality and ability to implement the strategy. Finally, we present
recommendations for policymakers and stakeholders.
Keywords: community health workers; community-based healthcare; family health worker; Basic Package of Health Services
1
_

Background
The Declaration of Alma-Ata from 1978 states that primary health­
care is essential to realize health for all and should provide promo­
tive, preventive and curative services to the community at "a cost
that the community and the counh:v can afford" (I), emphasizing
the role of community health workers (CHWs). Since then, the
CH \Vs have become a key component of primary healthcare pro­
gram, in developing countries, notably within the framework of the
strategy of Health for All. With a maternal mortality rate of 1,800
maternal deaths per 100,000 live births (2), an infant mortality rate
of 165 deaths per 1,000 live births (3), very low literacy rate, moun­
tainous terrain, poor roads, and scattered population, the potential
health benefits associated with a well-established network of CHWs
could be substantial in Afghanistan.
The role of CHWs is clearly defined in a Basic Package of Health
Services (BPHS) developed in 2003, and revised in 2005 and 2010,
by the Afghanistan Ministry of P ublic Health (MoPH) in collabo­
ration with the international community. The BPHS provides a
framework to restore a healthcare system ruined by more than two
decades of war, and classifies the health services to be provided at
each level of health facilities, namely district hospitals, comprehen­
sive health centres, basic health centers, health sub-centers, mobile
health units, and health posts. The health posts, run by one male
and one female CHW for approximately 1,000 population, form the
base of the primary healthcare pyramid (4).
Objectives
In this paper, we examine three general policy options for provision
of basic community-based health services in Afghanistan. These
include: (1) CHW "volunteer model" in which CHWs receive no
payment (status quo); (2) CHW "remuneration model" in which
CHWs receive payments for their services; and (3) "Family health
worker (FHW ) model" in which the demand for CHWs is offset by
educating all children in school, through grade 12, with progressive
components of the CHW training curriculum. Each option is first
described, and is then discussed in the context of several attributes
identified as important factors for decision making about health
policy. These attributes include effectiveness, feasibility, efficiency,
community solidarity, and legality (5).
Evaluation of Policy Options
Policy Option 1: CHW "volunteer model"
CHWs provide basic health services at the community level. CHWs
receive no payment (status quo).
Policy Option 2: CHW "remuneration model"
CHWs provide basic health services at the community level. CHWs
receive payments for their services.
Policy Option 3: "Family health worker (FHW) model"
The existing gap between CHW "supply and demand" is offset by
educating all children in school, grades 1-12, with progressive com­
ponents of the CHW training curriculum. An FHW workforce would
supply a substantial proportion of basic health services supported by
an existing network of more senior and more experienced CHWs.

In a country where 88% of the population lives in rural and re­
mote areas, the CHWs are seen as the cornerstone of the new Af­
ghan health system, providing basic health services at the commu­
nity level. Voluntary members of the communities are elected by
the local population, and then trained for a six-month period on pre­
vention of infectious diseases, promotion of mother and child health
and family planning, and treatment of simple childhood illnesses.
Policy Option 1: CHW "volunteer model"
In the status quo model, CHWs provide basic health services at the
community level, as described above. Volunteers are selected from
communities, trained for six months, and provided with CHW kits
on a regular basis. They are supervised by the community health
supervisors stationed in the BPHS health facilities, and are expected
to deliver services without salary or remuneration.

7 AFJPH Vol. 01 Issue 01 February 2012

Natiq
While the CHWs have produced impressive results (6) in Af­
ghanistan, including a substantial increase in family planning and
the contraceptive prevalence rate, a considerable proportion of the
population does not have access to their services for various rea­
sons. While the number of CHWs trained since 2003 is uncertain,
it may be as high as 40,000. However, according to the officials
from the Afghanistan MoPH (7), there are approximately 22,000
active CHWs and 11,000 health posts, leaving more than half of the
population without any access to basic community health services.
Even those who are living in the villages with trained CHWs may
not directly benefit from CHW services due to physical distance. In
addition, cultural sensitivities may preclude CHWs, particularly if
they are male, from visiting households in conservative communi­
ties. Finally, CHWs do not receive remuneration for their services
and are expected-to allocate their time to help the families in their
neighbourhoods voluntarily. This presents a major concern for in­
stitutions committed to the delivery of health services, such as
the MoPH. W hile the dropout rate among CHWs has been esti­
mated at 10%, attrition rates as high as 70-80% are unfortunately
realized in some settings. The problem of CHW retention, when
individuals are not paid and services rely on volunteer efforts, has
been well described in other countries as well (8).
Policy Option 2: CHW "remuneration model"
In this model, CHWs provide basic health services at the community
level and receive payments for their services.
There are several factors that motivate the consideration of this
policy. First, in most developing countries, CHWs face increasing
expectations from both communities and national authorities. In
Afghanistan, CHW expectations a decade ago ranged from preven­
tive services such as family planning and nutrition to the diagnosis
and treatment of malaria, Acute Respiratory Infection (ARI) and se­
vere diarrhoea. In contrast, in 2005, the revised BPHS added a host
of more complex responsibilities and expectations, ranging from
mental health promotion and case detection to disability awareness.
Second, in addition to the heavy workload, the catchment area
of CHWs is quite large (100-150 households for two CHWs, one
male and one female). This makes it difficult to visit all households
in sparsely populated areas, in particular those that lack road infra­
structure and access to transportation.
Third, while the concepts of accessibility and affordability of
healthcare are valued by both communities and the MoPH, the
expectation that CHWs will be available 24 hours a day and seven
days a week to provide free basic health services is likely unreal­
istic. In essence, meeting their responsibilities in the community
as CHWs equates to the loss of other opportunities to generate
income required to sustain their own families. Without financial
security, provision of CHW services is unlikely to be sustain­
able-the attrition rate will undoubtedly increase and the long­
term result will be a breakdown of trust between communities
and CHWs, and more broadly, loss of trust in the public sector
leadership to provide health services. Additional consequences
of attrition include the economic costs associated with training
new cohorts of replacement CHWs, and the lost opportunity to
leverage accumulated experience of seasoned CHWs (8).
AFJPH Vol. 01 Issue 01 February 2012
Fourth, the recommendation from Afghanistan policymakers
to build a two-room edifice as a health post is likely to change
the perception of CHWs about their volunteer "status" as the
recommendation essentially institutionalizes their position.
Further, the addition of new requirements, such as assurance of
fi xed opening hours, makes it difficult to justify the continued
absence of remuneration.
A formal income in exchange for service provision is likely to
enhance CHW motivation and commitment, and lower attrition
rates. For example, a program in Ethiopia showed that the attrition
rate decreased from 83% a year to zero after the establishment of a
small stipend for CHWs (9). Furthermore, CHWs who are paid can
be more easily held accountable, their performance can be assessed
against specific objectives, and their work hours and routines can be
standardized (I 0).
Nevertheless, paying salaries to CHWs puts forward the cru­
cial issue of financial sustainability, a recurrent concern in many
developing countries relying on international assistance. In fact,
many donors are reluctant to finance CHW salaries because of
this concern (11). In Afghanistan, where more than 80% of pub­
lic spending is reliant on international aid, long-term affordability
and financial sustainability are critical considerations. According
to officials from Afghanistan MoPH, if 35,000 villages require
70,000 CHWs, and each is to be paid $50 a month, the budget
implications are substantial. This scenario would equate to ap­
proximately $42 million out of an annual budget of $105 million
for BPHS in 2005 (12).
Soon after the fall ofTaleban, foreign aid flooded into the country,
offering a unique chance to dramatically improve health indicators
and health behaviours through national programs financed by the
international community. The contracting-out of BPHS to imple­
menting agencies follows that argument; as such, it is essentially de­
pendent on international funding. Since the financial support from
foreign countries is still growing (13), there could be an opportunity
to finance the salaries of CHWs, provided that good management,
rigorous evaluation, and positive outcomes are attainable. However,
it is unlikely that the Afghan government will generate sufficient
domestic revenue to ensure the continuous remuneration of CHWs
once foreign aid ends. Although evidence is sparse about the con­
sequences of abrupt termination of remuneration to CHWs, there is
every indication from the experience of other countries that there
would be negative consequences.
While providing salaries to CHWs may potentially address
some challenges related to CHW attrition and performance, ex­
perience in developing countries also supports the possibility of
negative outcomes. For example, monetary incentives can destroy
the spirit of volunteerism and work against the volunteer philoso­
phy and a sense of community. It can create a gap between the
community and CHWs. Given the role of NGOs as vehicles for
government programs, the community may develop feelings of
distrust toward CHWs who arc essentially employed by NGOs.
Similarly, CH Ws may feel more accountable to their employers, as
opposed to communities. Considering the large number ofNGOs,
the chance of inequitable standards and variation in employ­
ment terms may complicate matters further. Just as discrepancies

between paid and unpaid groups may cause strained relationships
within communities, discrepancies between the payment amounts
and terms of employment may have similar results.
Policy Option 3: "Family health worker (FHW) model"
In this model, the existing gap between CHW "supply and de­
mand" would be offset by educating all children in school, through
grade 12, with progressive components of the CHW training cur­
riculum. A� F HW workforce would supply a substantial propor­
tion of basic health services supported by an existing network of
more senior and more experienced CHWs.
According to the statistics from the Ministry of Education of Af­
ghanistan, there are roughly 8 million students enrolled in around
14,000 schools across the country. Almost 40% of the students
;ire females and 5% of them are in the higher secondary level (i.e.,
grades 10-12) (14). A subset of CHW supervisors and trainers could
be hired as teachers in the schools to integrate the knowledge, skills
and values included in the CHW training program into the student
curriculum. There would need to be a graduated approach such that
material included would be age- and grade-appropriate as children
proceed through their studies. With this approach, approximately
300,000 students could be trained as F HWs over a 3-year period.
In 10-15 years, over 7.5 million students would graduate with an
enhanced basic health education. As a result, the majority of fami­
lies in the country would have at least one member who would
theoretically be knowledgeable and capable of providing the most
basic of community-based health services. W hile there is virtually
no literature documenting the feasibility or effectiveness of such an
approach, the general benefits of community health education and
"health literacy" have certainly been well described.
The long-term affordability and financial sustainability of this op­
tion, in which most basic health services needed at the community
Table 1. Attributes of Policy Options and Projected or Expected Outcomes
Effectiveness•
Policy Option 1: ++
CHW "volunteer model"
Policy Option 2:
+++
CHW "remuneration model"
Policy Option 3:
"Family health worker unknown
{FHW) model"
--- - - - - - - ----·-··--------- - ----------
' Effectiveness refers to the probability or l1kel1hood of ach1ev1ng the desired health impact
' Efficiency refers to whether the policy option, as implemented, would provide good value compared to alternative uses of scarce monetary resources
' Feacibil1ty refers to whether the policy option is realistic and reasonable to actually deliver 1n the current context of Afghanistan, given current and anticipated political support, financial resources
requ11ed or "affordability," infrastruc ture needs and technical capacity requirements
'' Community solidarity refers to the likelihood that the policy option would contribute to community solidarity and community trust
' Legality refers to whether the policy option is implementable 111 the context of the current const1tut1onal, statutory, and common law status in Afghanistan
Natiq
level would be provided by FHWs, could potentially be attractive.
However, it is important to emphasize that both the costs of integrating
basic health education into schools, and the effectiveness of such an ap­
proach, are uncertain. That being said, if this approach would make it
feasible for a smaller cadre of CHWs to receive remuneration, thereby
limiting attrition and building up a senior cadre of CHWs to supervise
FHWs and provide referral support, this model may present an interest­
ing hybrid of previously suggested approaches to community care. For
example, an estimated $42 million (out of an annual budget of $105
million for BPHS) is required for the salary support of70,000 CHWs in
35,000 villages as discussed above in the second policy option. If most
basic health services could be provided by FHWs, providing payment
for experienced CHW trainers and supervisors becomes more feasible.
For example, assuming 1 CHW per 2-5 villages would require only
4%- 10% of the annual budget of $105 million estimated for the BPHS.
When one considers that the upfront costs of integrating the training
into the school curriculum rl1ight be supported by international sup­
port, and that it would not require the same degree of ongoing costs in
the future once the initial investment is made, this option becomes even
more potentially feasible.
Discussion
Each policy option (Table 1) can be considered in the context of
several attributes identified as important factors for decision mak­
ing about health policy. These attributes include effectiveness,
feasibility, efficiency, community solidarity, and legality (5).
In terms of effectiveness, the second policy option is likely to
be the most effective based on currently available evidence. The
third policy option could potentially be as effective, in that massive
numbers of FHWs would likely reach a greater number of individ­
ual households, and effectiveness is a function of both efficacy and
Efficiencyb Feasibility' Community" Legality"
++ ++ +++ +++
+
++ + +
potentially high +++ +++ +++
- ·- - - - - -
-
- -- - - - - - - -
�-- ---
9 AFJPH Vol. 01 Issue 01 February 2012
Natiq
coverage. However, it is i mportant to point out that this approach
has not yet been empirically evaluated.
Feasibility refers to whether the policy option is realistic and
reasonable to actually deliver in the current context of Afghani­
stan, given current and anticipated political support, financial
resources required (i.e., affordability, infrastructure needs and
technical capacity requi rements). Largely driven by concerns
about affordability, we assess the second option to be the least
feasible. Giving salaries to CHWs will consume a large propor­
tion of the health budget, making th is option unl i kely to be sus­
tainable. Although C HWs are not paid in the first option (status
quo), the process of C H W selection, training, supply, and super­
vision is resource i ntensive, rendering the scale-up to achieve
the numbers required for population coverage to be less feasible.
The third option may be the most feasible, given the constraints
in the country and the anticipated future situation, but it is not
yet tested.
To comparatively assess efficiency, information on the effective­
ness and costs associated with each policy option is required. The
efficiency of a strategy can be equated to provision of "good value"
compared to alternative uses of scarce monetary resources. Even
costly strategies may prove to be of"high value" if they are very ef­
fective. Since there is uncertainty about both the resources required
and the effectiveness of option 3, it is hard to assess the "value" at
this point- but it certainly would be predicted to be high.
The spirit of volunteerism associated with the first and thi rd
options concurs with the sense of community, cohesiveness and
equality. Furthermore, according to current MoPH policies, the
institutions involved in community-based healthcare are not cur­
rently allowed to pay salaries to CHWs. Although the training of
CHWs as volunteers (option I) and the training of all students (op­
tion 3) to augment senior-level CH Ws are similar i n terms of com­
munity solidarity and legality attributes, the latter is expected to
be more feasible.
If we place the uncertainty of option 3 aside, training of the
students in the higher secondary level to serve as FHWs could po­
tentially dominate the other alternatives in terms of the attributes
we have identified as important.
Integrating health education and components of the CH W cur­
riculum into the main educational curriculum of students through
grade 1 2 in Afghanistan could be a worthwhile option to explore
to increase access to promotive, preventive and curative health ser­
vices. The availability of hundreds ofCHW supervisors and CHW
trainers across the country adds to the feasibility of this approach.
With the massive graduation of the students equipped with the
knowledge and skills of the CHWs, the supply gap in the provi­
sion of the community-based healthcare will be more likely to be
filled than if the status quo continues. Over a 10 to 1 5 year period,
nearly all households would have a family member who has re­
ceived education about the basic health services their family might
otherwise look solely to a CHW to provide. Perhaps the most criti­
cal component of this policy option is that the transfer of preven­
tive and promotive health messages to other family members will
be more direct and likely more effective, compared to the diluted
AFJPH Vol. 01 Issue 01 February 2012
provision of services by overworked CHWs and lack of services in
villages without any CH Ws. Finally, the FH Ws wi 11 be well-in formed
parents taking care of their own families and communities.
Recommendation
The target audience of our comparative evaluation is primarily the
senior officials of the MoPH, M i nistry of Education, and Ministry
of Finance. Other important stakeholders include the parliamen­
tarians, donor agencies, non-governmental organizations, and the
general public.
While we may not be able to provide long-term financing of
CHWs for all families in Afghanistan under the current status
quo, we can explore, identify and attempt to empirically evalu­
ate alternatives in the coming years. We believe that i ntegrating
health education and components of the CHW curriculum into
the main educational curriculum of students through grade 1 2
i n Afghanistan i s a promising option to seriously explore and
rigorously pilot test to i ncrease access to promotive, preventive
and curative health services for the majority of households in our
largely rural country.
We recommend that a process needs to be initiated to engage
all stakeholders in a deliberative dialogue about the merits of each
policy approach. This message can be delivered to the officials
from the MoPH, Ministry of Education, Ministry of Finance,
donor agencies, and non-governmental organizations through
presentations in coordination meetings held in the MoPH. Par­
liamentarians can be engaged in the discussion through the par­
l iament's subcommittees responsible for health and education .
The publ ic can be engaged via broadcasting a round table via
popular local TV channels, as well as via publishing articles on
the proposed policy options in national newspapers.
Conflict of Interest
The author expressed no conflict of i nterest.
Acknowledgment
None.
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