Learning from fragile states: CHWs in Afghanistan and South Sudan

In 2002, shortly after the Taliban were driven from Kabul, the Afghan Ministry of Public Health together with donor partners made 3 key decisions—to focus primarily on reducing maternal and child mortality, to provide PHC through NGOs rather than government, and to depend on volunteer CHWs for most service delivery. By 2011 Afghanistan had more than 22,000 CHWs (50% women) in all 34 provinces providing a standardized approach to promotion, prevention, and treatment. Non-literate CHWs treat pneumonia in under-5s, give first injections of DMPA, educate fellow villagers regarding exclusive breastfeeding, etc. An important lesson learned has been that in remote areas of conflict and insecurity, once villagers have basic skills, access to medicines, and at least occasional supervision, they can carry on even when health facilities have shut down. South Sudan now faces some of the same challenges that Afghanistan faced in 2002. Both are “fragile states” in that government is unable to provide most basic services, and with large insecure areas. In both countries the health infrastructure had been destroyed, few health professionals remained, and health services were practically non-existent. South Sudan is developing its own CHW program, but it is being implemented by NGOs with each NGO carrying out the program in its own way. South Sudan can learn from the Afghan experience and standardize its approach in order to ensure that as much of the population as possible has access to basic lifesaving interventions even if the worst should happen and civil war begin again.