Addressing Tuberculosis in a High-Burden Country: A Conversation with MSH Afghanistan Country Representative Dr. Mohammad Khakerah Rashidi

{Photo credit: MSH staff/Afghanistan}Photo credit: MSH staff/Afghanistan

Dr. Mohammad Khakerah Rashidi is Country Representative of Management Sciences for Health (MSH) Afghanistan and Project Director of US Agency for International Development (USAID)'s Challenge TB in Afghanistan. Rashidi also serves as First Vice Chair of the Country Coordinating Mechanism (CCM) Afghanistan (Global Fund) and is a Senior Lecturer at Zawul Institute of Higher Education. Earlier in his career, Rashidi says he was the “only medical doctor for more than a million people” in part of Afghanistan. He spoke with MSH about the ongoing work of supporting the Afghanistan's tuberculosis (TB) care and control efforts, despite the country's violence and fragility.

How long have you worked in Afghanistan with MSH?

I joined MSH in 2004. I had just completed a Master of Science (MSc) in Public Health in Developing Countries from the London School of Hygiene & Tropical Medicine. When I returned home from school in 2004, I was the only Afghan with an MSc Public Health in the country. I was asked by many international agencies to work with them.

How did you choose MSH?

I chose MSH Afghanistan because I wanted to closely work with the Ministry of Public Health (MoPH) and support them in policy and strategy development. I joined MSH as a public health management advisor supporting different departments, and since 2004 have continued my career in different positions. I currently serve as MSH’s country representative of Afghanistan and project director of USAID's five-year Challenge TB project, which follows the completion of TB CARE I in September 2014. MSH is a major partner of the Tuberculosis Coalition for Technical Assistance, an international team led by the KNCV Tuberculosis Foundation which implements Challenge TB.

MSH has supported Afghanistan’s national and local tuberculosis (TB) care and control efforts since 2004. 

What are some of the key elements in building resilience in Afghanistan when it comes to delivering TB services? 

Building resilience starts at the grassroots.

One essential element is finding experts from local communities and selecting experienced implementing NGOs which have good cultural understanding and strong links with community elders and even members of the opposition. They have to be able to communicate well with both the opposition and the government about the importance and necessity of TB interventions.

It is also important to use community elders, religious leaders, or teachers to provide or facilitate services to their communities. They live in the villages and are known and respected by the local residents.

TB CARE I facilitated the National TB Control Program (NTP) to decentralize the training and supervision, empower the frontline health care providers, focus on the community health workers and community health supervisors, and link the community to the health facility.

We have trained three to five facilitators from the NGOs and MoPH staff from each province. Whenever we want to conduct training we communicate with the MoPH and NGOs and they facilitate the training by inviting the trainees and trainers.

[TB CARE I/Afghanistan Provincial Quarterly Review Meeting.] {Photo credit: TB CARE I/Afghanistan}TB CARE I/Afghanistan Provincial Quarterly Review Meeting.Photo credit: TB CARE I/Afghanistan

Can you describe the conditions and challenges in the provinces where TB CARE I has been working? 

Through TB CARE I, MSH covered 13 out of 34 provinces in Afghanistan. Of those, seven were extremely insecure. Some parts of these provinces were very dangerous and the team had to cross the opposition territories to reach the districts where we worked. Through local nongovernmental organizations (NGOs) and communities we managed to provide services.

The biggest challenge of the TB program is increasing community access to TB services and providing them with quality service. Despite all of the efforts for the past 12 years we are missing around 48 percent of TB cases countrywide.

The general challenges of the NTP include difficulty reaching communities and health facilities due to insecurity, harsh seasons, rugged terrain, and the scattered nature of the rural population. Regular supervision and monitoring, sending supplies and medicine, and crossing insecure roads controlled by opposition forces have been among the biggest challenges to the implementing local and international NGOs, which provide service delivery.

Insecurity often prevents the frontline health care workers from attending training. As a result, we have decentralized the training approach and conduct the training in local settings, such as in the capitals or main cities of the provinces and districts.

[Bamayan, Afghanistan.] Bamayan, Afghanistan.

What advice would you give to any health care project in terms of building resilience in a fragile state? 

The easiest and best strategy to reach to the community is to empower and involve them in all aspects of health service provision to their own communities, provision of standard operating procedures and guidelines in the local language, finding local focal points for easy access in the community, and understanding their needs.

[TB CARE I Afghanistan World TB Day 2014 banner  TB CARE I Afghanistan WTD 2014 posters.] TB CARE I Afghanistan World TB Day 2014 banner TB CARE I Afghanistan WTD 2014 posters.

How might the idea of resilience be different in the context of TB CARE I compared to other health care interventions? 

Implementing a TB program such as TB CARE I is the best example of building resilience in the delivery of any kind of health service. These experiences can be used for immunization programs, integrated management of childhood illness, and any other interventions needed to be applied at the community level. 

What kind of TB work will MSH be doing moving forward in Afghanistan? 

MSH, through the new project, Challenge TB, will scale up community-based directly observed treatment–short course (CB-DOTS) to 13 provinces and increase the number of local experts to facilitate the TB strategies implemented in the countryside. CB-DOTS involves training community health workers to increase awareness, detection, and treatment of TB. It brings services directly to the homes of those at risk for infection and is among the most cost-effective approaches to TB control.

We will focus more on the needy communities in the insecure areas and densely populated cities to increase access and improve the quality of services provided in the assigned areas for Challenge TB. Our strategies address prisoners, internally displaced people, diabetics, and many other vulnerable populations. We will involve the cured TB patients to detect others infected with TB and provide services to their communities. We are building on a solid foundation. The number of suspected TB cases identified in 2009 was less than 70,000 while it increased to more than 200,000 in 2014.

Is there anything else that you would like to add regarding MSH, Afghanistan, and addressing TB?

As vice chair for CCM in Afghanistan, MSH provides strategic support to the MoPH in fundraising, capacity-building, and strengthening MoPH’s stewarding role. Through MSH projects we facilitated the collaboration among the implementing NGOs and MoPH departments that resulted in better coordination and understanding among MoPH and NGOs. TB CARE I has shared its findings through face-to-face or NGO monthly meetings and developed the action plan to bridge the gap, increase access, and improve the health care workers’ knowledge if needed.

We also mobilized and generated additional funds for TB services by advocating the need for TB program support and involving different stakeholders.

What are you most proud of in your work at MSH?

My biggest achievement is being beside my people and supporting in redesigning and structuring the health system. We have supported the MoPH in developing and applying more than 100 policies, strategies, protocols, and standard operating procedures and we learned together by doing, and training other health professionals. There has been a huge reduction in child and maternal mortality due to the past 10 years’ interventions and I am proud being part of such a team.

This interview was edited for the MSH website. Portions of this text originally appeared on the London School of Hygiene and Tropical Medicine website.