This blog post is part of a content series published by UNICEF in the lead-up to the Global Conference on Primary Health Care, which will take place from 25-26 October in Astana, Kazakhstan. Learn more about the conference.
Nestled in the mountains of northern Afghanistan, the village of Charkent is both beautiful and remote. Like much of Afghanistan, it is difficult to access – even more so during the rainy season when the narrow road to Mazari Sharif some 80 kilometres away, is cut off by flood water, and in winter, when snow makes the journey impossible.
In the past, to fall ill in Charkent was a serious affair. Access to quality health care was virtually non-existent. And health issues like diarrhoea, pneumonia and complications around the time of birth often proved fatal, leading to extremely high newborn, child and maternal mortality rates.
But today, that picture has changed, as I discovered during a recent visit to Charkent, and the remote mountain community is at the forefront of Afghanistan’s efforts to expand primary health care, starting with the hardest-to-reach communities.
These efforts are being led by dedicated, empowered women like Nadia and Hakimah, two community health workers whom I met during my visit. When I first saw Nadia and Hakimah, they were providing antenatal care to a heavily pregnant woman, checking her blood pressure and listening to her baby’s heartbeat. Confident and professional, they provided advice and reassurance, taking time to answer questions and address concerns.
Nadia and Hakimah work for Bakhtar Development Network, an NGO contracted by the Government of Afghanistan to run health services in Balkh, the province where Charkent is located. The NGO delivers services through an integrated system, with community health workers linked to local health facilities which, in turn, are connected to primary health care facilities.
In this part of Afghanistan, many of the 1800 health workers employed by the Bakhtar Development Network are women. They are trained and equipped to address the major causes of child and maternal mortality, including diarrhoeal diseases, respiratory tract diseases like pneumonia, and complications around the time of birth. And while community health workers like Nadia and Hakimah can resolve most health complaints themselves, they are also empowered to refer those needing more specialised care for treatment at the local primary health care facility, 18 km away.
As members of the community they serve, Nadia and Hakimah possess an in-depth understanding of their patients’ needs and challenges and can provide joined-up basic care to the most vulnerable. In addition to treating illness, they can provide preventive services such as antenatal care, nutrition counselling, and advice on sanitation and hygiene, reducing the likelihood of illness and promoting community health and well-being.
What is also clear is that effective service delivery at community level requires investment — financial, institutional and political
This is a lesson that has been learned in many places around the world – that services delivered in a decentralized manner at the community level by frontline professionals like Nadia and Hakimah are an essential component of primary health care, and are key to improving the reach and quality of services. They are essential both in fragile settings like rural Afghanistan and in middle- and high-income settings, where overly centralized health systems often fail to reach the most vulnerable and marginalized – groups that generally bear the highest burden of disease and mortality.
But what is also clear is that effective service delivery at community level requires investment. It requires financial investment – sustainable funding for recruitment, training, salaries and equipment for community health workers, and, ideally, subsidised transport for sick patients who cannot afford to travel when referred.
It requires investment in institutions – the systems and structures needed to coordinate and manage community-level services and personnel, and to connect these services to more specialised, higher-level health services.
And it requires political investment – commitment from senior leadership to strengthening community-level services and to true decentralization of services. This is a challenge in many places. Indeed, even in Balkh, there are opportunities for further decentralization of services, including treatment for severe acute malnutrition and immunization.
As world leaders and health policy makers gather in Astana, Kazakhstan in October for the Global Conference on Primary Health Care, the value of investing in communities is something they should keep firmly in mind. Investment in service delivery at the community level – by people like Nadia and Hakimah – represents a strategic investment in the health, well-being and future prosperity of communities and nations. It is key to achieving the third Sustainable Development Goal on “health for all, at all ages”.
Ted Chaiban is Director, Programme Division, UNICEF