Overview of Community Health Worker Programmes in Afghanistan, Egypt, and Pakistan

"All three of the programmes reviewed have effected positive change in their respective countries, and have advanced women's engagement in local communities."

Although there is variation in the characteristics and duties of community health workers (CHWs) globally, they can serve not only as a bridge to reduce unmet healthcare needs in rural populations but also as advocates for community engagement and education in health. CHW programmes are especially important in the World Health Organization (WHO) Eastern Mediterranean Region, with its high illiteracy rates, poor infrastructure in some areas, and tight-knit communities that may lack trust in governments and non-governmental organisations (NGOs). The objectives of the study were to give an overview of the characteristics of CHW programmes in Egypt, Pakistan, and Afghanistan, and to review their strengths, weaknesses, and challenges.

A search of scientific databases and grey literature conducted from June 1 to September 30 2017 led to 23 articles for inclusion in this study. Some highlights from the findings:

• Selection and demographics of CHWs: In all programmes, CHWs must be members of the community they serve. The importance of this is highlighted by interviews with community members who said they were more likely to trust CHWs from the same sociocultural background as their own. In Egypt and Pakistan, CHWs must be female. In order for women to be CHWs in both Egypt and Afghanistan, they need permission from their husband or the male head of their household.
• Services delivered: CHWs in all 3 programmes are responsible for providing information about family planning (FP), writing referrals to other health workers, providing either ante- or postnatal health care, promoting vaccination, and providing disease prevention and other general healthcare information. Promoting community engagement of women is also an important feature of these CHW programmes.

Some of the challenges and recommendations related to communication:

• In Egypt, there is a lack of clear job description and community awareness about the existence and role of the CHWs (in this country called "raedats"). Many villagers wished that the raedats were more knowledgeable in issues beyond FP. Two selected recommendations: training should more effectively teach communication skills for promoting FP; and incentives should not be linked to FP acceptors, but instead should be standardised and based on factors such as client satisfaction, quality of home visits, and degree of raedat motivation.
• In Pakistan, concerns have been raised about community push-back against lady health worker (LHW) initiatives, such as polio vaccination, in some areas. In situations like these, where safety can be compromised, LHWs feel they should receive higher remuneration. The lack of provisions at health facilities reduces LHW credibility in communities. Another challenge is insufficient numbers of LHWs in economically poor and underserved areas due to the high educational level needed for entry into the CHW programme. Many LHWs feel that their training could be improved and advocate the inclusion of more skills. One selected recommendation: improve training to include emergency obstetric care and more communication skills.
• In Afghanistan, one theme to emerge from interviews is a lack of respect and trust for CHWs due to their volunteer status and potentially low level of education. A lack of female supervisors or managers presents a barrier, so one recommendation is: ensure that women are in leadership positions for the empowerment of women in Afghanistan, and because many families will not allow women to become CHWs if they must interact with nonrelated men.

Among the issues discussed in the article's conclusion section is the importance of CHW visibility in communities. Visibility increases access of community members to health care and fosters CHW accountability, in that CHWs who are known to their community are less likely to reserve resources for only friends and relatives. One practice in Afghanistan to improve visibility has been the development of village health councils that disseminate CHW announcements to the community. Afghanistan has also set an example with communication and collaboration between CHWs and religious leaders who help relay messages through announcements in the community mosque. LHWs in Pakistan are government workers, which improves their visibility and status in communities.

It is recommended that CHWs be continuously consulted with regard to their satisfaction with training, and that their feedback be taken seriously. Having some type of review process could increase the CHWs' feeling of investment in and responsibility and pride for the programme. The inclusion of pictorial training manuals in Afghanistan has reportedly increased accessibility of the CHW job to more candidates.

In conclusion, these findings highlight to policymakers "the need to review CHWs' scope of practice, update education curricula, and prioritize in-service training modules and improved working conditions. The effectiveness and impact of CHW programmes has been shown countless times, demonstrating that task sharing in healthcare is a successful strategy with which to approach global health goals."