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Can community health workers increase coverage of reproductive health services?
  1. Kavitha Viswanathan1,
  2. Peter M Hansen2,
  3. M Hafizur Rahman3,
  4. Laura Steinhardt1,
  5. Anbrasi Edward3,
  6. Said Habib Arwal4,
  7. David H Peters3,
  8. Gilbert Burnham3
  1. 1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  2. 2Policy and Performance Department, The GAVI Alliance, Geneva, Switzerland
  3. 3Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  4. 4Department of Community Based Health Care of the Ministry of Public Health of the Islamic Republic of Afghanistan
  1. Correspondence to Dr Kavitha Viswanathan, Route de la Gare 6, 1271 Givrins, Switzerland; kviswana{at}


Background Health services were severely affected during the many years of instability and conflict in Afghanistan. In recent years, substantial increases in the coverage of reproductive health services have been achieved, yet absolute levels of coverage remain very low, especially in rural areas. One strategy for increasing use of reproductive health services is deploying community health workers (CHWs) to promote the use of services within the community and at health facilities.

Methods Using a multilevel model employing data from a cross-sectional survey of 8320 households in 29 provinces of Afghanistan conducted in 2006, this study determines whether presence of a CHW in the community leads to an increase in use of modern contraceptives, skilled antenatal care and skilled birth attendance. This study further examines whether the effect varies by the sex of the CHW.

Results Results show that presence of a female CHW in the community is associated with higher use of modern contraception, antenatal care services and skilled birth attendants but presence of a male CHW is not. Community-level random effects were also significant.

Conclusions This study provides evidence that indicates that CHWs can contribute to increased use of reproductive health services and that context and CHW sex are important factors that need to be addressed in programme design.

  • Community health worker
  • multilevel analysis
  • Afghanistan
  • reproductive health
  • health impact assessment
  • measurement
  • international health
  • access to healthcare
  • environmental health
  • epidemiology
  • primary healthcare
  • public health

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  • Funding This work was supported by the Third Party Evaluation Contract (MoPH/AFG/GCMU/19/04) between the government of Afghanistan and the Johns Hopkins Bloomberg School of Public Health with the Indian Institute of Health Management Research. The Ministry of Public Health of Afghanistan contracted Johns Hopkins Bloomberg School of Public Health with the Indian Institute of Health Management Research as independent third party evaluators of the Afghanistan health sector.

  • Competing interests None.

  • Patient consent This paper does not contain any personal medical information about an identifiable living or dead individual.

  • Ethics approval Ethical approval was obtained from both the Ethical Review Board at the Afghanistan Ministry of Public Health and the Committee for Human Subjects Research at the Johns Hopkins Bloomberg School of Public Health.

  • Provenance and peer review Not commissioned; externally peer reviewed.