Said Habib Arwal – Director of Community Based Health Care Department, Ministry of Public Health, Afghanistan
As a doctor, you only ever get to practice medicine by treating one person at a time. Public health, on the other hand, is about taking care of a community. It is this community-based approach that drew me to my work when I first started at the Ministry of Public Health. Under former President Karzai, Afghanistan started to rehabilitate its health system and address the shortage of health staff in rural provinces. We soon established the Community Based Health Care Department in 2005, with the goal of having the government work in partnership with the communities it serves as well as with non-governmental organisations (NGOs) that are providing healthcare services. The Ministry of Public Health strived to engage with community members and researchers to identify and invest in interventions that were consistent with government priorities.
As a result, the community scorecard project was launched, with support from the Future Health Systems Consortium, in two provinces in rural Afghanistan. The scorecard provided community members with a mechanism for involvement and engagement with the quality improvement process of healthcare. The project served as a link between local authorities, both governmental and non-governmental health providers, and the community members receiving the services. The results were shared with a technical advisory group, which encouraged us to expand the pilot programme to another province. The next round of results was then presented to the Ministry of Public Health for approval. With the support of the Ministry, we are hoping to continue to expand implementation to additional provinces and scale up nationwide.
The objective of the scorecard was to bring about a change in community behaviour and solicit their perspective on how to improve the current health system. As the government took steps to move away from a reliance on international donor support, we turned to the community for guidance regarding priorities for improvement. We did this by getting the patients themselves interested in the health system. The scorecards gave them the opportunity to think critically and reflect on how to make changes. Some communities wanted waiting areas at the clinics while other communities wanted latrines made available at their local health facilities.
The act of using the scorecard empowered the community not only to suggest changes but also ensured accountability from the health system so that the necessary steps were taken to implement these changes. In one community, patients expressed concerns about the lack of female staff. Both the health facility staff and the community members worked to identify the barriers preventing female staff from joining the clinic, such as the lack of housing for female staff. They worked together to come up with a multi-pronged solution with the community, opening a home for female health workers, the NGO agreeing to provide for the salary of a new staff member and the local government agreeing to provide security to ensure the safety of the new female staff.
This three-way partnership is essential for the sustainability of this scorecard programme and the health system at large. The implementation of community scorecards, with the support of Future Health Systems, helped to facilitate this partnership. With the government, local NGOs, and communities all coordinating together, we now have a stronger investment in the system. This cooperation is a key element of health services in Afghanistan, a country where close to 30,000 CHWs work closely with community stakeholders to address health promotion and education. In times of conflict and instability, it is difficult to convince people of the benefit of a health programme or of seeking care at a clinic. With our CHWs, we strive to work with the community, by the community and for the community.
There are many challenges when it comes to this work. Political insecurity and rampant poverty are major issues in Afghanistan. CHWs are all young volunteers, many of them women, who are working in insecure areas with support from both the government and NGOs. Even in an insecure area with no government, our volunteer health workers are able to provide a service because they are from that community. Despite Taliban rule, CHWs can keep health facilities open and functioning.
Working with the Future Health Systems project, we have been able to implement the community scorecards – a monitoring tool that can be used to engage the public and service providers in quality assurance and accountability. The opportunity for providers to interface with the community for feedback serves to empower both patients and physicians. The technical quality of services is better assessed, utilisation rates have increased and we are better able to understand the barriers that exist with regards to seeking care. The community is telling us directly what they need and what works for them, thus working with the data collected from the community scorecards has helped our health system grow and adapt to the needs of the community and better serve our people.