CommCare in Afghanistan

November 7, 2009

I’m in Herat province at the very start of a new project with World Vision, assessing the landscape for rolling out CommCare among the CHW community here. It’s been a fascinating trip so far. I’ve worked directly with CHWs in various different programs (in Africa) before, but as you can imagine, one of the things that makes Afghanistan and the surrounding countries unique is the extremely volatile security situation. Let me share with you just a bit about how that affects the programs here.

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One of those rooms is a health post.

First, of course, is the danger the CHWs bring upon themselves simply in the course of performing their regular duties. They work in pairs out of ‘health posts’ (their homes), where they keep a whole set of charts, information booklets, and materials. However, many of these materials are labelled ‘USAID’, and the ‘US’ in ‘USAID’ marks them as infidels – and hence targets. So they often hide them away. Similarly, they are supposed to place a blue signboard with their healthpost number on the door, so that people in the community can identify them, but the vast majority do not wish to attract such attention and hide the signboards.

Supervision is a challenge, not only because various health posts become inaccessible throughout the year, but also because of the difficulty of predicting/accounting for such variance. For example, in the district we are working in now, 2 out of 25 health posts are inaccessible, but only 2 months ago, 15 out of 25 were inaccessible due to the risk of local conflict. This exacerbates existing problems of monitoring and support, and intensifies the need for strong communication lines.

Because of the low literacy rates among CHWs, educational materials tend to have a strong visual component.

Because of the low literacy among CHWs, their trainings incorporate many visual aids.

For anyone, like us, looking to innovate in this space, this raises challenges with regards to scheduling and gaining access to people and resources. Depending on the political situation on any given day, field visits can be limited or out of the question entirely. We made plans to visit a few health post during the first two days we were here, but those had to be postponed because of the attacks in Kabul. One fact that surprised me was that the staff here find the living situations more stifling than any other place they’ve worked. And they’re a pretty remarkable team: some of them were doing humanitarian work in Sudan in ‘96, Somalia in ‘92, Rwanda during the genocide, Gulu in Uganda, Bosnia…

Even the technological infrastructure is held back by the political situation. GPRS was introduced in Herat several months ago by the biggest telecom provider in this region, Roshan (Telecom Development Company Afghanistan, whose majority shareholder is the Aga Khan Foundation) – but their radio tower was attacked the week before last, and so is non-functional in the near future. If you want to get your phone up and running on the GSM network here, it’s not just a matter of shelling out a dollar for a new SIM card on the street (as it is in most of the countries I’ve visited). Afghanistan has to be the hardest country in the world to get such a card. For a single card (4 bucks), you need to provide your passport, a picture of yourself, and paperwork on who you are, where you live, and who your father is. This information is used to trace your phone number back to you, ostensibly so that people can be held accountable for prank calls; you can imagine the kind of security/privacy considerations such a system raises.

Given all of these barriers – stigma against aid materials, inaccessibility of war-torn districts, destruction of infrastructure and restrictive communication policies – one wonders if any technological project can even hope to have its impact felt here. Perhaps we need to focus on political stability before we start thinking of ways in which technology can work for this community?

A CHW demonstrates the usage of the Talking Book

A CHW demonstrates the talking book

But even in the midst of such challenges, where power and literacy and political stability are scarce, I was astounded to come across one ‘ICT’ artefact which seems to have made its mark. It is a ‘talking book’ (USAID-sponsored, Ministry-distributed) which has been given to most posts throughout Afghanistan. Basically, it’s a booklet with pages dealing with family planning, hygiene, nutrition, etc. and it comes with batteries installed and a little magnet. The supervisors who visit once a month bring new batteries with them. Touch the magnet to the page and it ‘speaks’ salient health information.

I sat down with a group of community trainers who felt this was one of their most effective training tools, especially for the high number of low-literate CHWs who have difficulty reading refresher material. They stressed that the success of this booklet can be attributed to availability in the local language, use of very basic grammar and vocabulary, good illustrations, and ‘appropriate voices for all the different actors’. What’s more, as I watched the male and female CHWs use this tool to promote health education, it became clear that they were not just passive listeners. The talking book is the perfect medium for interactive learning – as they explained each lesson to a client, they seamlessly supplemented each of the short electronic phrases with their own understanding, the local context, and the experiences of others in the community.  The book was just a starting framework around which they could weave a rich and more complete conversation about health. Yet at the same time, it provided an undercurrent of authority and a touch of novelty which kept the lessons interesting.

Great example of low-cost, participatory technology helping people do what they do best.

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