Community Based Health (CBH)

A fghanistan health system and basic packages of health services is being expanded throughout Afghanistan . The BPHS is an important element in the redevelopment of the health system because it deals the priority health problems of the country. The physical infrastructure, institutional capacity and human resources of the health systems required to form an integrated referral system providing a range of needed services: from health promotion to disease prevention to basic treatment to disability care to specialized inpatient care. Still today, Health conditions in Afghanistan were/are among the worst in the world.

Therefore, the Ministry of Public Health of Afghanistan focused on policy making rather than implementing the programs, and contracted-out the implementation of these policies (Basic Package of Health Services) to Non Governmental Organizations (NGOs).

BRAC is one of the implementing partners of the Ministry of Public Health in different areas in Afghanistan and providing basic health care services to an estimated population of 2.4 million in 36 districts of 6 provinces through 4312 CHWs in 2207 Health Posts, 44 Sub-health Centers, 66 Basic Health Centers (BHCs), 21 Comprehensive Health Centers (CHCs), 7 District Hospitals and providing support to develop the capacity of provincial 300 bed hospital.

Abed Vai Visiting one Clinic

After 30 years of working experience in Bangladesh . BRAC-Afghanistan started to work in July 2002 with 2 fixed health centers in Balkh and Parwan provinces. Later BRAC was operating 7 fixed health centers in May 2003. During 2003-2004, BRAC started implementation of USAID/REACH Project in Paghman district; Kabul Province and Performance based Partnership Agreement (PPA) in Balkh and Badghis provinces. BRAC is also responsible for selection and training of the Community Health Workers in Three MoPH SM provinces (Parwan,Panjshir and Kapisa) with collaboration of MoPH since 2005. At present BRAC have been running more than 76 different health facilities through out Afghanistan .It has started to provide health care services in two ways:

• Community based care
• Facility based care in collaboration with the public sector and other agencies in Afghanistan

•  Parwan province has been covered both by CBHP and CHW Training & Development programme

Performance and Management Indicators for Community Based Health Program

The health programme staff carries out door-to-door baseline surveys at the community level to learn the present health condition of the communities. They also hold discussions with the local people and ethnic leaders and community members. Indicators used for gathering information are: ratio of latrines, tube wells / piped water, hygiene practice, household garbage disposal, availability of contraceptives, immunization, pregnancy care, number of couples eligible for family planning methods, common diseases, tuberculosis treatment and number of children and pregnant women requiring immunization, disability and its care. Whole health programme is based on the guideline of Basic Package of health Services (BPHS).

Component of the Basic Package of Health Services

• •  Maternal and Newborn Health
• •  Child Health and Immunization
• •  Public Nutrition
• •  Communicable Diseases
• •  Mental Health
• •  Disability
• •  Supply of Essential Drugs

Role of Community Health Volunteer and Community Health Worker in health service delivery

Community Health Volunteers and Community Health Workers play a very important role in service delivery at the field level. Community Health Volunteers are selected from the community and undergoes a 6 months theoretical and practical training on family planning, reproductive health, identifying and treatment of common illnesses. In addition, they participate in a one-day monthly refresher's training at the BRAC static health centers on regular basis. In BRAC Community based Health Programme, under each Micro finance office, there are 10 CHVs. Each CHV are responsible for 150 to 200 households in her catchments area. Every working day she visits 15-20 households. The CHVs work six days a week, from Saturday to Thursday. They visit the households according to their convenient time. She participates in the monthly meeting of health programme. During household visit, the CHV provides basic curative care for common diseases, promote and provide contraceptives, identify pregnant women and provide support for pregnancy related care, mobilize children for immunization and ensure Directly Observed Therapy (DOTS) for tuberculosis patients. They also provide health education to the family members, raise awareness in the community on health care and assist in compiling records of births, deaths and migratory movement of people. Community Health Workers are developed to support and supervise the health volunteers. Each health worker supervises the works of Community Health Volunteers. They are to visit 15 households everyday together and both work during 9 AM to 1 PM . In USAID/REACH Project,PPA Project and MoPH SM Provinces , Community Health Workers works at field level and they work like community health volunteer elsewhere. The Medical Doctors provide training and refreshers to community health worker and volunteers. In order to motivate the community to support and use health services, the CHW arrange male and female group meetings (health forums) within the community. During these meetings people from various professions (religious leaders, teachers, Shura member etc.) participate. A community plan is then developed to ensure that the community members thoroughly know about the health services and are willing to avail these health services. The community health workers along with community health volunteer organize mobile clinics per month in the catchments area. According to her prefixed schedule, doctor, paramedics, and vaccinator to be present in the fixed venue and provide services from the mobile clinic. Mobile clinics are operated in afternoon.

Meeting with Shura Members in Balkh to orient about Community Health Workers

PROGRAMME COMPONENTS

Behavior Change Communication (BCC)

The conventional public health measures or interventions have not been successful in making inroads into lifestyle reforms.The action of prevention in this case, is one of individual and community responsibility for health, the physician and in fact each health worker acting as an educator than a therapist.Health education is a basic element of all health activity.It is of paramount importance in changing the views, behaviour and habits of people. Since health promotion comprises a broad spectrum of activities, a well-conceived health promotion programme would first attempt to identify the “target groups” or at-risk individuals in a population and then direct more appropriate message to them. Community Health Volunteers are the main resources for the IEC activities at the household. The health programme staffs including CHV, CHW, paramedics and midwives are provided with training on communication, especially in IPC activities so that they can perform their communication skills effectively.

Immunization

One effective way of controlling the spread of infection is to strengthen the host defenses. Under certain circumstances this may be accomplished by active immunization, which is one of the most powerful and cost-effective weapons of modern medicine. Immunization is a mass means of protecting the greatest number of people. By reducing the number of susceptible in the community, it augments “herd immunity” making the infection more difficult to spread. It also reduces the risk for those individuals who have escaped vaccination or those who have not developed satisfactory protection. Afghanistan has recorded recent successes in the area of childhood immunization, extending polio vaccination widely throughout the country and making measurable progress through the implementation of measles mortality reduction strategy consisting largely of mass vaccination campaigns. According to some, it is unlikely, at the time of this report that many Afghan children remain unvaccinated against Polio, and the number of cases detected, even in light of intensified surveillance, has been decreasing. BRAC is actively participating in National Immunization Days and conducting mobile outreach vaccination centers for hard to reach areas to provide vaccination in the remotest parts of its catchments area. BRAC is also utilizing Community Health workers and Community Health Volunteers to motivate and aware the community about immunization.

Pregnancy Related Care

BRAC felt the need of undertaking an effective health care programme for pregnant women. To do this and to reduce maternal and neonatal mortality and morbidity BRAC is providing antenatal and postnatal care services. In the case of pregnancy related care, pregnant mothers are given advice on what precautions and care to take and what problems and danger signs may occur during pregnancy. They also receive advice on birth planning/spacing and delivery. The CHVs also increase awareness among family members like the spouse and in-laws on how they can assist the pregnant mother and also where she should be taken in case of pregnancy related complications.

Antenatal Care

Care of the woman during pregnancy is known as antenatal care. The primary aim of antenatal care is to achieve at the end of a pregnancy a healthy mother and a healthy baby. The objectives of the antenatal care are:

• To promote, protect and maintain the health of the mother during pregnancy.
• To detect “ high risk” cases and give them special attention
• To foresee complications and prevent them
• To remove anxiety and dread associated with delivery
• To reduce maternal and infant mortality and morbidity
• To teach mother elements of child care, nutrition, personal hygiene and environmental sanitation
• To sensitize the mother to the need for family planning, including advice to cases seeking medical termination of pregnancy and
• To attend to the under-fives accompanying the mother

The health programme provides antenatal care services both at the community and static level. The volunteers identify pregnant women in their working areas. They are responsible for motivating these pregnant women to obtain antenatal care services at the community mobile clinic. The midwife provides services at the mobile clinic examine the pregnant women and also fills out and antenatal card for every woman. The antenatal card remains with the client, she brings the card on each visit. Pregnant women are provided with healthy and nutrition education on: nutrition and care for women, breast feeding, infant care and nutrition, immunization danger signs of pregnancy. They are provided with iron and folic acid tablets in the mobile clinics and in various other forums. High-risk pregnancies are identified and referred to the health facilities. BRAC ensures, through the volunteers and health workers, that every pregnant woman receives at least three antenatal care check ups and receives Tetanus toxoid vaccine. The Antenatal care package covers:

• •  Mother's height
• •  Weight
• •  Urine examination (for sugar and albumin)
• •  Foetal heart sound examination and foetal height measurement
• •  Physical check up for blood pressure, jaundice and anemia

Other services include screening and referral of the complicated cases to the static health facilities, promotion of family planning, advice about breast feeding, infant care and immunization.

Postnatal Care

Care of the mother (and the newborn) after delivery is known as postnatal care. The objectives of the postnatal care are:

• •  To prevent complications of the postpartal period.
• •  To provide care for the rapid restoration of the mother to optimum health
• •  To check adequacy of breast feeding
• •  To provide family planning services
• •  To provide basic health education to mother/ family

The CHVs are to deliver postnatal care at the household level through three visits. Problems faced by mother and/or newborn are identified in these visits so that they can be treated at the initial stage. The identified patients are referred to health facilities,if required. Advice on colostrums, breast-feeding, immunization and other infant care education are also given to the mothers.

Family Planning

In Afghanistan family planning devices are inadequate and people have little knowledge about contraception. Social norms are not conducive to the practice of family planning. Therefore, the contraceptive prevalence rate is very low. Through BCC the CHVs inform the community members of the benefits of using contraception and spacing needed between childbirths. Females as well as males are targeted. In addition to education for couples, family planning information is also disseminated to parent-in-laws. Non-clinical contraceptives are provided through the CHV, CHW and midwives. The CHV during her household visit educate couples and motivate them to use contraceptives. The mothers are educated about family planning, both during antenatal care and postnatal care.

Facility Based Care

Fixed Clinics

At present Health programme has 76 fixed clinics . The government of Afghanistan owns three static clinics in Nanagarhar province,but the clinic is supported by BRAC Afghanistan's health programme. BRAC is also providing technical support to Balkh provincial hospital. The function of the health centers is important for the health programme and provides a backup to the community-based health interventions. The patients with comparatively serious condition are referred to the appropriate health facility by community health volunteer. In addition, the fixed clinics treat the outpatient and also have facility for vaccination. These clinics provide need-based essential services to the rural people. It also establishes and maintains an effective referral mechanism with the government, other NGOs and private clinics.The common services provided at the fixed clinics are as follows:

• •  Basic Curative care to outpatients and referred patients
• •  Pregnancy related care (antenatal care, postnatal care)
• •  Family planning services
• •  Supply of essential drugs
• •  Vaccination
• •  Treatment of tuberculosis patients

Health care services provided in the clinics are in accordance with the WHO guideline of rational use of drugs and essential drug policy. The fixed clinics are equipped with outpatient and laboratory facilities, essential drugs and vaccines. Poor Afghan people are receiving health services free of cost in the centers however the better off people are charged for services. People usually receive treatment for diarrhea, dysentery, ARI/common cold, peptic ulcer, scabies, worm infestation, anaemia, malaria, fever, UTI, asthma, hypertension, allergic, fungal infection and eye infection etc. in the outpatient department of the fixed clinics. A substantial proportion of patients are also referred to specialists at the provincial level hospitals for further treatment.

Mobile Clinic

The health programme aims to take health services to people's doorsteps. To take health services to people's doorstep mobile clinics are usually operated in the afternoon so that it is easier for the women to attend it. The common services provided at the mobile clinics are:

• Basic Curative care
• Pregnancy related care (antenatal care, postnatal care)
• Family planning services
• Supply of essential drugs
• Health and nutrition education
• Behavior change communication (BCC) through proper counseling

At the mobile clinic a physician treats the patients and if necessary, refers patients with special attention to the fixed clinic at District level. For complicated cases, the midwives also consult with physicians and ensure treatment at the static level. Pregnant from the village receive antenatal care services from this mobile clinic. The CHVs ensure that all pregnant women in the respective area attend this clinic. They discuss the important and appropriate health issues with pregnant women, newlywed couples and women in children. The midwives guide pregnant women throughout their pregnancy period. They also provide antenatal and postnatal care services as needed.

BRAC TB Control Programme

Tuberculosis (TB) is generally considered to be an important cause of adult mortality in Afghanistan . Mortality is felt to be disproportionately high in women because of their relative lack of access to care, especially for chronic conditions such as TB. Although the globally accepted Directly Observed Therapy Short-Course (DOTS) strategy is widely recommended in Afghanistan, and has been successful under the watchful eye of the NGOs in some parts of the country, it will be a challenge to implement it widely.As with so many disease control programmes, success depends on accurate diagnosis of a large proportion of cases, an adequate and regular supply of effective drugs, and appropriate action at the community level. Regular monitoring and periodic evaluation are indispensable. BRAC has gradually expanded its TB Control programme in 19 districts of Afghanistan under the auspices of the National TB Control Programme and additional technical assistance of UN agencies with provision of food. The community health workers and volunteers help the program in terms of referring the suspected cases to the BRAC diagnostic center and community mobilization, which has an important role in the success of the program.

Community Health Workers Training and Development Programme in SM (Strengthening Management) Provinces ( Parwan, Kapisa, Panjshir)

BRAC has started working for training and capacity building of the Community Health Workers in three provinces under a approved project of the Ministry of Public Health in three SM Provinces. Project started on April 2005 and the duration of the project is 18 months. This training is divided into theoretical and practical follow-up session and the training is divided into three phases. 1 st phase ? 3 weeks, 2 nd phase ? 2 weeks and 3 rd phase- 3 weeks in theoretical training and practical follow up training of 2 months. After completion of basic training every month there will be one day refesher's training. To establish BPHS in the community level , this project has been taken jointly by the Ministry of Public Health and BRAC.

* As of November 2005. Third phase of training will start at the end of November 2005

Training completed during 2005

• •  Training on Basic Package of Health Services
• •  Training on HMIS
• •  Training on Malaria & Leishmaniasis
• •  Training on Basic Curative Diseases
• •  Refresher Training on EPI
• •  Integrated Management of Childhood Illness
• •  Development Management Course
• •  TB Training
• •  Training for Lab Technician
• •  Training on Reproductive Health
• •  Training on Emergency Obstetric Care
• •  Training on Wound Management & Infection prevention
• •  Training on Health Care financing

BRAC doctors presenting their group work during Development Management course in BRAC Training & Resource Centre in Kabul .

“………….I am Sayed Bibi, husbands name is Baba, working as a community Health volunteers for last one and half year in a village of Paghman district of Kabul province. I never went to school. I have 11 children. When BRAC started working in this area I showed my interest to work as CHV. I received 6 months training and now working in the community. At first I faced some problems as women are not allowed to work like this, but when our community realized that we are helping the people then they accepted us and now I am working with comfort…………”

“……..I am Dr. Arefa Haidari, have been working with BRAC Afghanistan in Bar Arghandy Comprehensive Health Centre in Kabul province. I joined BRAC on 8 th August 2005 . I am single. I have studied in Peshwar of Pakistan in a medical institute and worked there in a private hospital as Medical Officer. While my parents had shifted from Pakistan to Kabul city of Afghanistan , I joined BRAC. After long political and military conflict, Afghanistan needs people like us to reconstruct the country. I am very much satisfied to serve my country and thank BRAC for giving me opportunity to serve my country people. Life is getting better gradually for us here. I look forward for a bright future in Afghanistan ..…….”

Perspective of a BRAC Midwife:

“………..My name is Shahla. I am a midwife. I am not married yet though I have been engaged for marriage. I have studied Midwifery in Kabul . I am aware that the maternal mortality is a crucial public health problem in Afghanistan . We need more midwives to improve the poor maternal health condition and ensure safe motherhood in our country. I have joined BRAC since March 2004 to work in Paghman district of Kabul. I wish I can serve peoples properly through my knowledge and sincere services……”

Major Achievements of BRAC Health Program

• Running of four programs (PPA, USAID-REACH ,Community Based Health Program and CHW Training and Development programme)
• Membership of national HRD, HMIS, Health Care Financing taskforces and TB National Board
• Recruitment of qualified staff
• Implementation of BPHS
• Capacity building of the staff
• Introduction of cost recovery system
• Selection and training of Community Health Workers in SM Provinces
• Provincial Hospital received Hospital Management Consultant as Pilot Project
• Provision of technical Assistance to establish HMIS in Provincial Health Directorate
• Provision of USD 2000 as running cost for Balkh Provincial Hospital
• Established HMIS System in Provincial Health Directorate, Balkh
• Developed different training modules.
• Established standard HMIS system in all health facilities.
• Established central HMIS unit.
• Developed the partnership with local NGOs (BDF).
• Active participation in the PCC meetings and act as member secretary.
• Set monthly/ yearly target plan to achieve the performance indicators.

Lessons learned

• •  Capacity Building is essential to get good quality of services.
• •  Close supervision and regular contact is important to achieve good staff productivity.
• •  Close contact with the government and community is helpful for the running of program and for the good quality of services.
• •  Organizing Mobile Clinic in remote outreach area.
• •  To send Medical Doctors to these outreach area.
• •  To introduce the family planning methods in religiously conservative atmosphere.
• •  Medicine cost sharing.

Future Challenges

• Improvement of 350 bed Provincial Hospital Management
• To establish 2097 health post through community health volunteers.
• To achieve the set targets for local partner NGO “Bakhtar Development Foundation”
• To implement BPHS through partner NGO (BDF)
• To establish TB DOT in the community through trained Community Health Volunteers
• To continue cost recovery in health facility level from community
• Retention of Midwives and female community health workers and volunteers
• To ensure regular supervision and monitoring in the context of bad security situation and winter season in Badghis province.