The community based health care policy and strategy 2009-13 of the ministry of public health of Afghanistan authorizes community health workers, majority of whom are illiterate, to administer the injectable contraceptive, Depo Provera, first and following dose to women in communities, which poses critical risks to women’s health.
According to Afghanistan’s health system and its basic package of health services, health posts (HPs) are the first level of basic health care provision point. One male and one female community health worker (CHW), based on a job description issued by the ministry of public health, run the health post. The health post is established in the house of CHWs and the ministry of public assigns a formal code number to each. As unpaid community volunteers, CHWs are trained for three months in provision of health education about a small group of health topics and basic therapeutic care for a specific group of diseases for 100-150 families under the health post’s catchment area. Based on the community based health care policy of the ministry of public health of Afghanistan, they are engaged in community collaboration and health promotion activities, provision of basic services, and activities related to the management of the HPs including the monthly activities and supply distribution reporting.
CHWs are providing life-saving services to the families who do not have immediate access to higher level of health care facilities; however their engagement in administration of injectable medications is not a safe practice. Despite they are trained in some specific services, they lack knowledge and skills to ensure injections infection prevention standards. Unsafe injections cause local and systematic infectious diseases and nerve injures, which results in disabilities and even death. No evaluation or studies have been conducted to assess level of competency of CHWs in administration of injectable contraceptives, however some observations indicate that many CHWs inject Depo Provera with out respecting the infection prevention measures and even some CHWs cannot locate the designated site of body for the injection.
To properly administer injectable contraceptive, CHWs need to be regularly supervised by community health supervisors (CHSs). Based on the CHWs capacity building mechanism, they need to receive quarterly refresher trainings on different subjects to maintain their knowledge and improve their skills. Due to financial constraints, the refresher training is not conducted and even contracted NGOs’ cut this activity from their implementation plan. Additionally, the CHS-CHWs monthly meeting, which is the only forum where CHWs are presenting their monthly activity reports, discuss the related issues with their supervisor and receive their monthly supplies, is not conducted regularly. Further, CHS as supervisor of CHWs cannot visit all HPs to regularly supervise performance of CHWs. With out having a fully functioning monitoring and supervision mechanism, CHWs’ competency in administration and follow up of injectable are questionable.
High turn over of CHWs is another factor that poses a critical challenge for keeping the HPs functional. As far as CHWs are volunteers, some percentage of them quit the job every year and new CHWs replace them. Due to financial limitations, it is very difficult for contracted NGOs to conduct CHW training programs every 3 months, which is required by the community based health care policy. Based on their job description, a CHW is engaged in a long list of tasks and activities, which overloaded them. Injections add up another daunting task in their tasks list.
Misuse of the medication is also a concern. There is not a close monitoring system to prevent misuse of injectable contraceptives in the HPs. It is likely that CHWs sell the medication or charge a fee on injecting the medication.
Research-based evidence is not available to show CHWs performance about the injectable contraceptives, although some programs reported that CHWs are capable to administer injectable. Looking into all compelling reasons, I would propose that the ministry of public health of Afghanistan revise the related section in its community based health care policy to exclude CHW’s task of administering injectable contraceptive from their job profile. This policy change on one hand alleviate the workload on CHWs, who consistently complained of being overburdened by their wide scope of work, and on the other hand we prevent a burden of disease on health system caused by unprofessional injections.
Health Policy 