Toward universal coverage in Afghanistan: A multi-stakeholder assessment of capacity investments in the community health worker system.

Global efforts to scale-up the community health workforce have accelerated as a result of the growing evidence of their effectiveness to enhance coverage and health outcomes. Reconstruction efforts in Afghanistan integrated capacity investments for community based service delivery, including the deployment of over 28,000 community health workers (CHWs) to ensure access to basic preventive and curative services. The study aimed to conduct capacity assessments of the CHW system and determine stakeholder perspectives of CHW performance. Structured interviews were conducted on a national sample from 33 provinces and included supervisors, facility providers, patients, and CHWs. Formative assessments were also conducted with national policymakers, community members and health councils in two provinces. Results indicate that more than 70% of the NGO's provide comprehensive training for CHWs, 95% CHWs reported regular supervision, and more than 60% of the health posts had adequate infrastructure and essential commodities. Innovative strategies of paired male and female CHWs, institution of a special cadre of community health supervisors, and community health councils were introduced as systems strengthening mechanisms. Reported barriers included unrealistic and expanding task expectations (14%), unsatisfactory compensation mechanisms (75%), inadequate transport (69%), and lack of commodities (40%). Formative assessments evidenced that CHWs were highly valued as they provided equitable, accessible and affordable 24-h care. Their loyalty, dedication and the ability for women to access care without male family escorts was appreciated by communities. With rising concerns of workforce deficits, insecurity and budget constraints, the health system must enhance the capacity of these frontline workers to improve the continuum of care. The study provides critical insight into the strengths and constraints of Afghanistan's CHW system, warranting further efforts to contextualize service delivery and mechanisms for their support and motivation.