Dr Sediqa Hofiani is the Community Health Worker (CHW) Training Manager on the REACH Program. The following e-interview with Rachael Woloszyn describes Sediqa's unique experience as a CHW Training Manager and provides insight into the role of a Community Health Worker in Afghanistan. Dr Sediqa Hofiani is a native of Afghanistan. She was born in 1965 in Parwan province. Dr. Hofiani graduated from Kabul Medical University. She lives with her husband and four children in Kabul province.

RW: Do clients accept the work Community Health Workers are doing?

The community is also involved in the process of selecting CHWs. Community Health Worker candidates are identified by community members. Guidance and criteria for selection are explained to the community. Once the community identifies potential CHWs, the relevant health authorities will make the final selection. The selected CHWs then undergo training and receive regular supervision.

RW: What are the biggest challenges faced by Community Health Workers?

RW: How far must they travel in order to reach clients in the rural areas?

SH: Actually the coverage area for one CHW is 100-150 families. The geographical area of this coverage varies. Walking can take 15 minutes to 1 hour. By bicycle it may take 10 minutes and this bicycle is just used by males. According to Afghan culture, women are not allowed to use bicycles.

RW: What does a typical day for a Community Health Worker look like?

SH: CHWs are volunteers, so they don't have any specific schedule. They do their CHW work when they have completed their own work as a housewife, farmer, teacher or businessman. The female CHWs make home visits and visit client families in their houses. The male CHWs spend more time inspecting the mosque, bazar and butcher shop to make sure they are kept clean.

RW: How has the Community Mapping Tool enabled Community Health Workers (CHWs) to identify the health needs of villagers?

SH: By looking at the community map, the Community Health Workers can easily identify individual clients and their service needs. The community map contains status boxes of all BPHS clients of the catchment area. For example, if a client has one child under age one, and if that child did not receive any immunization services, then the CHWs can determine that that particular child needs to be immunized immediately. Similarly, by looking on the map at the colors designated for family planning the CHWs can determine who needs what type of contraceptive services, when and where.

RW: What are the challenges you face in training Community Health Workers?

SH: One of the biggest challenges is the selection of female health workers. It is a cultural and security problem. Women are not authorized to make decisions by themselves. Their decision is dependant on their families and whether their families allow them to work outside [their homes]. Otherwise, they won't participate. Another challenge is the different levels of education among CHWs, as well as different age ranges. The majority of CHWs are illiterate, especially women. We have to select them and enroll them in classes. Also the ages of CHWs, according to MOPH selection criteria, can range anywhere between 20- 50 years.

Unprofessional behavior among CHW trainers in remote areas like Badakhashan province and Bamyan province is a challenge.

Other challenges include CHWs dropping out of NGOs and shortages of teaching aids (for example flip charts) during last year's training.

CHWs are volunteers and should be remunerated for services based on locally determined policies and procedures governing regular payments. But still they are not totally supported by their communities in that sense. Lack of remuneration makes CHWs discouraged to actively take part in these activities.

RW: How have the men and women in provinces responded to the Basic Package of Health Services (for example, are there items that are included in the BPHS that are not part of Afghan culture)?

SH: The BPHS fulfills a community's need for health services. All the items that are included in the BPHS are acceptable to Afghan culture and in accordance with national policy. The services are acceptable to men and women in the community.

RW: Have Community Health Workers seen any improvements in their clients' lives?

SH: Actually there are lots of improvements seen in all communities where REACH has activities. The existing CHW program has already been effective in the community.

RW: What kinds of improvements have they noticed?

SH: According to the health facility reports, significant increases have been made in the cases referred by CHWs

CHWs actively participate in vaccination campaigns and advocate for community members to become vaccinated. During the polio campaign, they promote the advantages of vaccinations to families. As a result, families and women have grown increasingly interested in bringing their children to health facilities for vaccinations.

It is worth mentioning that CHWs were volunteers during the vaccine campaign and received a small amount of money for transportation. Although they weren't paid for the work they did, CHWs were very interested in taking part in this campaign.

CHWs promote hygiene, sanitation, and safe drinking water. They make sure the community knows how to prepare safe drinking water.

I had a mission for conducting a workshop at Herat Province. The majority of the NGO CHW trainers participated. I asked them about the impact of CHWS in the community. Here are some of their stories:

One CHW trainer named Mohmmad Azim working with NPO explained the following: In one village in a district of Herat province, there was a lot of pollution, which collected over long periods of time. Children played in it and got illnesses such as diarrhea and various skin diseases. When this district's CHW found the cause of these illnesses the CHW discussed it with the local health committee. They agreed to carry the children from the village to a safe place, where they could be treated. The CHWs helped to reduce the incidence of disease.

In another instance, I visited one female CHW named Sohila from IMC Qarabagh district in Kabul province. She encouraged pregnant females and their families to visit the health facility in their village. The family and women agreed to go with the CHW to the health facility and received antenatal care and the tetanus toxoid vaccine, a measure that prevented the baby from having tetanus.

Mirwis is a CHW and works in the Bagh Araq Qarabagh district. During one of his visits to his catchment area, he found a three year old child with polio paralysis. Mirwis brought him to the health facility, which was greatly appreciated by the health facility staff that encouraged him to work more.

One female CHW named Parigul works in Shakerdara district. She found a woman with a snake bite. Through CHW training, Parigul learned first aid and was able to treat the patient and refer her to a nearby health facility for follow up treatment.

CHWs promote the use of Oral Rehydration Salts (ORS) and other home-made re-hydration fluids. According to the division of CHW training phases, they learn about diarrhea in the first phase of their training so that, when they become active, they are able to distribute ORS packets and teach mothers to prepare ORS.

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