Sustaining CHW Programs When External Funding Ends: Global and Domestic Contexts
Laura Guzman-Corrales, MPH candidate
Improving Health in Afghanistan with the Help of CHWs
Improved access to basic health services can have dramatic effects on life expectancy and other health indicators in global and domestic contexts. In Afghanistan, the expansion of health care infrastructure in the past 10 years has led to significant improvements in life expectancy. Recent reports attribute most of these gains to reductions in infant and child mortality. These reductions have been achieved through large-scale vaccination campaigns and the establishment of more clinics and hospitals to provide primary care services, especially for women and children.
Along with the expansion of basic health services, Community Health Workers (CHWs) have been another critical resource in improving health, especially in the most rural areas of the country. CHWs help the Ministry of Public Health communicate messages about the benefits of using new clinic and hospital services, with special attention to pregnant women. Many women have unattended home births, but the CHW program hopes to teach women the benefits of prenatal care and delivering in clinics, hospitals, or with the help of a trained midwife. They also distribute neonatal kits for women to have safer at-home births. The health education they provide targets the entire household, especially mothers-in-law, to address harmful cultural practices, such as feeding infants tea instead of breastfeeding.
CHWs are a valuable informational resource for rural women who have limited knowledge of and experience with a formal health care system and the many services it can provide to them and their families. Despite the importance and effectiveness of CHW-provided health education programs, there is a growing concern about the long-term sustainability of these efforts. Foreign aid to Afghanistan is getting cut in the coming years as coalition troops are withdrawn from the region. Already, CHWs have lost the support of large NGOs like Save the Children. USAID, a major funder of health programs, is slated to halve their current level of aid to Afghanistan. While CHWs are continuing much of their educational work, they have fewer tangible resources, such as neonatal kits, to offer women beyond informational support.
Strategies for Sustaining Global Health Programs
So the question remains, how can these hard-won gains be sustained given limited long-term funding and technical support from international funders?
Below are some possible considerations in planning and implementing CHW programs, as well as other health programs, that may promote their sustainability.
Involve local stakeholders. Foreign donors have funded much of the improvements in the health care system of Afghanistan and the CHW program; however, much of this money has been funneled through the Afghani Ministry of Public Health and local NGOs. This ensures that local actors have contributed to the program process from the planning to the implementation phase with the goal of aligning programs with local values and systems.
Develop local technical capacity. A related benefit of involving local stakeholders is the sharing of knowledge between large international donor NGOs and local, community based organizations. This allows the smaller, local organizations to develop the technical capacity to provide services without the direct involvement of an international NGO. For example, the Ministry of Public Health has developed the capacity to plan and monitor the CHW program as a result of this partnership.
Empower CHWs to continue their work. In addition to content specific trainings about health, CHWs should receive training to develop professional capacities, like leadership and community organizing skills. Promoting leadership can empower CHWs to continue their work even without the formal support and funding of international NGOs.
Cross-cutting Implications for Domestic Contexts
These are just three considerations for sustaining global health programs. Many of these considerations are not exclusive to the global context. Sustaining CHW programs domestically presents similar challenges. Often, CHW programs are not reimbursable by insurance unlike other health services, so clinics, hospitals, and community organizations have to seek outside funding to support these efforts. Grants are often short-term, so programs struggle to plan for the medium and long-term future.
Some of the above steps can also be used to sustain these efforts. For example, similar to global programs, domestic programs should think about how to involve several local actors in program planning and implementation phases. This can help maximize resources and avoid duplication of CHW programs in the same community. For more information about the health programs in Afghanistan and issues of sustainability in a global context, refer to the resources listed below.