The female community health nursing initiative in Afghanistan: a situation analysis

This article shows the roles (actual and expected) of female community health nurses (CHNs) in health services in Afghanistan, taking stock of an education programme introduced in 2010.
WHO (2006) reported a health worker density in Afghanistan of 41 per 100,000 population. The nurse density was as low as 6.6 per 100,000 population (Ministry of Public Health, MoPH, 2007). (1)
The role of nurses in the management of diseases and in the con-text of task shifting has been the object of a number of studies and reviews. A study in Spain showed that nurses successfully addressed 86.3% of cases of acute disease of low complexity in primary care (2). A meta-analysis of 20 studies on task shifting from physicians to nurses showed that nurses provided more frequent and longer services than doctors with similar referrals, prescriptions, or investigation services (3). A Cochrane review of 16 intervention studies (25 articles) suggested, with some caution, that appropriately trained nurses can be as effective as doctors in providing health services (4).

In 2010, the Afghan MoPH introduced the Community Health Nursing Education (CHNE) programme, modelling the successful experience of community midwifery programmes elsewhere. CHNs are responsible for the provision of a wide range of services at peripheral health facilities. These services include health promotion, integrated management of neonatal and childhood illnesses (IMNCI), first-aid, referrals, immunization services, nutrition counselling, and certain tasks in tuberculosis, malaria and leishmaniasis control programmes. Furthermore, they are supporting disadvantaged and vulnerable individuals. The International Council of Nurses core competencies enable CHNs to support Afghanistan’s Basic Package of Health Services (5).

Methodology

With the aim of documenting the cur-rent situation of community nurses in Afghanistan, a study was conducted, using a mixed method approach of participatory task analysis, time-motion task study, key informant interviews and focus group discussions. Two peer-facilitated task analysis workshops were held to identify the type and frequency of tasks provided by CHNs. A diary was used to record the time that CHNs spent carrying out various tasks. To assess different viewpoints on CHNE programme strengths and weaknesses, lessons learned and the role CHNs should play in providing health services, qualitative data were collected from MoPH officials, donor agency representatives, individuals with key roles in the CHNE programme and policy and curriculum development, and from health service managers.

Findings

The programmes were funded by 10 different donors and implemented by 23 different NGOs using the national curriculum. The CHNE programmes had graduated 1487 students by April 2017. An additional 510 students were still studying at that time. Of the 791 students that had graduated from CHNE programmes by Febru-ary 2016, 469 (59.2%) were deployed to public health facilities. Deployment data for graduates of programmes after Feb 2016 are not yet available.

In November 2015, 166 CHNs were deployed, out of which 123 CHNs participated in a task analysis exercise. The CHNs reported performing several clinical tasks (Fig. 1), in particular: 1) administering injections, providing dressings and performing minor surgical procedures, 2) providing in-patient care, 3) providing health education, and 4) performing some non-clinical administrative tasks (all mentioned by more than 85% of the respondents). Preparing workstations and sterilizing equipment were also frequently reported (more than 80%).

More than 75% of participants performed these five tasks at least once per week.

The CHNs reported to have received most of their training in the form of pre-service education. They had learned clinical tasks performed at the outpatient department for a large part also through formal in-service training. On-the-job coaching was mentioned by few respondents as the most important channel of training. More than 50% of the respondents reported being confident to provide the services that were expected of them.

More than 50% of the respondents reported being confident to provide the services that were expected of them.

Most of the CHNs expressed their frus-tration with the lack of formal recogni-tion of CHN as a standard MoPH staff category. Also the low salary of CHNs compared to nurses and midwives was mentioned as a source of discontent.

The analysis of task diaries kept by 50 CHNs gave a median number of work-ing days of 16.5 (range 5-21) per month and an average length of a working day of seven hours. The tasks reported by 90% or more CHNs were health education and first-aid services. The three tasks performed most frequently were health education (65.6% of working days documented), adult and child first-aid (58.1% and 54.8% of days, respectively) and IMNCI (48.9% of days) (Table 1). Community outreach services were not reported during the task analysis workshop. Follow-up by phone with 21 of the task analysis workshop participants showed that community outreach was not part of the CHN job descriptions, although several CHNs did provide private services within their communities.

Interviews conducted with health facility managers and other key informants (MoPH managers, CHN school man-agers, and faculty members) revealed appreciation of the contribution of CHNs, with some of the interviewees suggesting that additional clinical tasks could be delegated to the CHNs. All of the 23 CHNE programme implementing agencies, however, were dissatisfied with the competency, recruitment and retention of faculty staff. They emphasized inadequate capacity building and salaries of the CHNE faculty. In some programmes, students were recruited who had completed only 8th grade while the recommended mini-mum prequalification level for recruiting community nursing students was 12th grade. Few programmes were happy with the deployment rate of graduates. They also complained of inadequate infrastructure and amenities in the schools. The health facility managers reported that the performance of their facilities had improved with CHNs, but they wanted them to provide more advanced nursing services.

Figure 1. Tasks performed by CHNS (N=123)
Figure 2. Type of training received for routine tasks performed by CHN

Discussion

The CHNE programme has been designed to address the shortage of human resources for nursing services at remote health facilities.
The findings of this study show that the additional health workforce of CHNs has actually alleviated this shortage. The community based selection and deployment strategy adopted from the community midwifery programme has been successfully implemented. The services currently provided by the CHNs are perceived as satisfactory by some of the study participants, although additional expectations documented in the study indicate that both the job profile and the curriculum of the programmes should be revised to address these needs.

Home visits that could be implied by the term “community” in CHN have not been part of the activities that are expected from CHNs. Community based services by the CHNs require more attention, during their pre-service education as well as at the health facilities themselves. An improved preservice curriculum, improved clinical practice opportunities and more accurate posting of the cadres are important for improvement of the skills and confidence of the CHNs and further success of the programme. Further-more, CHNs are not recognized as civil servants and are paid low salaries and most often further career development pathways are not defined. This research and other studies show that these are key aspects associated with low job satisfaction (6) (7). In order to improve the role of community health nurses these aspects should be addressed.

References

1. MoPH. Afghanistan National Health Workforce Plan. 2012:1-51, MOPH, Kabul, Afghanistan.
2. Iglesias B, Ramos F, Serrano B et al. A randomized controlled trial of nurses vs. doctors in the resolution of acute disease of low complexity in primary care. J Adv Nurs. 2013 Nov; 69 (11):2446-57. doi: 10.1111
3. Martínez-González NA, Rosemann T, Djalali S, Huber-Geismann F, Tandjung R. Task-shifting from physicians to nurses in primary care and its impact on resource utilization: a systematic review and meta-analysis of randomized controlled trials. Med Care Res Rev 2015; 72(4):395-418.
4. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database of Systematic Reviews 2005, Issue 2. Art no CD001271. Doi: 10.1002/14651858.CD001271.pub2
5. MOPH Afghanistan. A Basic Package of Health Services for Afghanistan 2010/1389. 2010. MOPH, Kabul, Afghanistan.
6. Ayalew F, Kibwana S, Shawula S et al. Under-standing job satisfaction and motivation among nurses in public health facilities of Ethiopia: a multilevel analysis. Unpublished.
7. Ayalew F, Ababa A. Factors affecting turn-over intention among nurses in Ethiopia. Heal Hum Resour 2015;62-74.