Health Shura Guidelines
SY 1392
CBHC Department
General Directorate of Primary Health Care
Ministry of Public Health
1
Table of contents
Introduction ..................................................................................................................................... 4
Shura in the light of Islam ............................................................................................................... 8
Shura in the Qur'an .................................................................................................................. 9
Shura in the light of sayings of the Prophet (‫ )صلی هللا علیه وسلم‬............................................... 10
Shura principles in Islam ....................................................................................................... 10
Shura method ......................................................................................................................... 11
Benefits of shura and consultation......................................................................................... 11
Purpose of these guidelines ........................................................................................................... 13
Afghanistan Health System........................................................................................................... 14
Basic Package of Health Services (BPHS) ............................................................................... 17
Community-based health care (CBHC) .................................................................................... 18
Importance of health post shuras and health facility shuras ......................................................... 22
Mission of health shuras ............................................................................................................ 24
Responsibilities of health shuras ............................................................................................... 25
Accountability of health shura ...................................................................................................... 28
Accountability of health workers .............................................................................................. 30
Coordinating and collaborating with community and health workers .......................................... 31
Building trust ............................................................................................................................. 33
Providing feedback to health workers ....................................................................................... 36
Motivating health workers ........................................................................................................ 38
Persuading community members .............................................................................................. 40
Health communication with community members ................................................................... 41
Health education of the community .......................................................................................... 42
Community leadership .................................................................................................................. 43
Being a community leader......................................................................................................... 43
Managing health affairs of your community ............................................................................. 45
Conducting effective health shura meetings ............................................................................. 46
Responsibilities of head of health shura .................................................................................... 50
Strategic, annual, and monthly work planning .......................................................................... 52
Planning Forms and Formats .................................................................................................... 53
Strategic plan ............................................................................................................................. 53
Annual plan ............................................................................................................................... 53
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Mobilizing community .............................................................................................................. 54
Benefits of Community participation ........................................................................................ 56
Mobilizing resources ................................................................................................................. 57
Participatory rural appraisal ...................................................................................................... 58
Community decision-making and governance.............................................................................. 60
Cultivating accountability ......................................................................................................... 60
Engaging stakeholders............................................................................................................... 61
Setting a strategic direction ....................................................................................................... 61
Mobilizing and using resources in a responsible way ............................................................... 62
Conducting community health needs assessment ..................................................................... 63
Coordinating and collaborating with other shuras and authorities ............................................ 65
Interaction between health shura, health facility staff, health workers and community ........... 67
Developing shura capacity ........................................................................................................ 69
Selection of the head and members of health shura .................................................................. 71
Women’s health shuras ................................................................................................................. 73
Self-assessment ............................................................................................................................. 76
Community scorecard, shura checklist, map, tally sheet and health campaigns .......................... 80
Community scorecard ............................................................................................................... 80
National monitoring checklist for shura .................................................................................... 86
Community map ........................................................................................................................ 88
Pictorial tally sheet .................................................................................................................... 89
Community health campaigns ................................................................................................... 91
Annexes......................................................................................................................................... 92
Job description of Facility Shura-e-Sehie .............................................................................. 92
Job description of Health Post Shura-e-Sehie ....................................................................... 93
Job description of a community health worker ..................................................................... 94
Job description of a community health supervisor ................................................................ 96
ToR of Education shura ......................................................................................................... 98
ToR of CDC shura ................................................................................................................. 99
Other Shuras ........................................................................................................................ 101
Shura Success Story............................................................................................................. 102
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CHAPTER 1
Introduction
There are many different shuras in the provinces and districts in Afghanistan.
Community Development Council (CDC) shura, village shura, health shura,
education shura, ulema shura, youth shura, women’s shura, district shura, and
people’s shura are some of them.
Health shuras have been established at many different levels. The Provincial Public
Health Coordination Committee (PPHCC) is a provincial health shura. The
PPHCCs were established 7-8 years ago in all the 34 provinces. These committees
have been successfully functioning as a forum for coordination and information
sharing among various stakeholders of the provincial public health directorate and
the provincial health system. They coordinate delivery of the Basic Package of
Health Services (BPHS), Prison Package of Health Services, and Hospital Package
of Health Services (EPHS). They also perform a monitoring and supervision role.
Around the same time, community health shuras were established at health post
level. Health facility shuras were established at sub-center, basic health center,
comprehensive health center and district hospital level. Hospital community boards
have been established at provincial hospital level. A vast majority i.e. about 74%
of these community and facility shuras are active. They meet on a monthly basis.
Encouraged by the success of the PPHCCs and community health shuras, and with
availability of donor assistance for positioning District Public Health Officers in
about half the districts, the Ministry of Public Health has established District
Health Coordination Committees (DHCCs) in these districts during the last 3 years
to perform a role similar to that of PPHCC but at a district level.
More than 100,000 individuals who are members of various health shuras are
preforming a governing role in Afghanistan as of today. See the table below.
Performed more effectively, their work can make a difference to the care delivered
during 43 million patient visits to health facilities that take place every year in
Afghanistan (excluding patient care visits to national and specialty hospitals).
4
5
Active Health Shuras in Afghanistan as of September 2012
Source: October 2012 HMIS data
Level
Number of
jurisdictions
or facilities
that have
active
Shuras as of
September
2012
Type of the Shura
Average
number of
members
in a Shura
Total
number
of Health
Shura
members
in the
country
22
748
14
392
9
1674
14
994
Province
34
Provincial
Hospital
28
District
186
District Hospital
Comprehensive
Health Center
Sub- Health
Center
Basic Health
Center
71
Provincial
Public Health
Coordination
Committee
Hospital
Community Board
District Health
Coordination
Committee
Facility Shura
287
Facility Shura
14
4018
366
Facility Shura
14
5124
607
Facility Shura
14
8498
9536
Community
Health Shura
9
85824
Health Post
Grand Total number of Health Shura members in Afghanistan
107,272
Total patient visits in a year
43,000,000
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Health shuras have been facing many challenges. Some of these are:
1. Low level of awareness among shura members on their role and
responsibilities
2. Inadequate guidance on how to fulfill their responsibilities
3. Low level of coordination with other shuras, health shuras at higher levels,
and provincial and district health authorities
4. Inadequate communication with other shuras, health shuras at higher levels,
and provincial and district health authorities
5. Low level of motivation among shura members
6. Low level of interest in the community
7. Weak link between shura and the community
8. Low level of trust between shura members and health workers
9. Lack of resources, for example, finance and logistics
10.Insecurity in some areas
11.Shura members do not want to make health workers unhappy by raising
unpleasant issues
12. Low level of participation of youth and women due to social factors
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Shura in the light of Islam
Shuras or consultative assemblies have a long and well-established tradition of
conducting public affairs in Afghanistan. The word shūrā provides the title of the
42nd chapter of the Holy Qur’an. In this chapter on shuras, Great Allah advised the
Prophet (Peace be upon him) to exhort the believers to conduct their affairs by
mutual consultation.
Shura comes from an Arabic word shara whose original meaning, according to
classical Arabic dictionaries, is to extract honey from hives. The word then
acquired secondary meanings all of which are related to that original one. One of
these secondary meanings is consultation and deliberation. The way consultation
and deliberation bring forth ideas and opinions from peoples' minds must have
been seen to be analogous to the extracting of honey from hives. It might also have
been thought that good ideas and opinions were as sweet and precious as honey. It
also refers to the assembly that meets for this purpose. The rules of shura are used
to solve every problem that a group of individuals faces starting from within the
family, to the problems of the community and continuing even to the political
affairs of a country.
According to this purely linguistic meaning, Shura is no more than a procedure of
making decisions. It can thus be defined as the procedure of making decisions by
consultation and deliberation among those who have an interest in the matter on
which a decision is to be taken, or others who can help them to reach such a
decision.
The important matter on which Shura decision is made can be either a matter
which concerns an individual, or a matter which concerns a group of individuals,
or a matter that is of interest to the whole public.
Prophet Muhammad (PBUH) had an Advisory Council known as Majlis-Shura and
most wise men around him were the member of this Shura. He was making all his
decisions in consultation with his followers unless it was a matter in which God
had ordained something. It was common among Muhammad (PBUH)'s
companions to ask him if a certain advice was from God or from him. If it was
from Muhammad (PBUH), they felt free to give their opinion. Sometimes
Muhammad (PBUH) changed his opinion on the advice of his followers like his
decision to defend the city of Madinah by going out of the city in Uhad instead of
from within the city.
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Shura in the Qur'an
Shura, as a principle, is rooted in the Qur’an itself.
 The first mention of the Shura in the Qur'an comes in the 2nd chapter of
Qur'an. The 233rd verse of that chapter is in the matter of the collective
family decision regarding weaning the child from mother's milk. This verse
encourages that both parents decide by their mutual consultation about
weaning their child.
“And the mothers should suckle their children for two whole years for him
who desires to make complete the time of suckling; …. But if both desire
weaning by mutual consent and counsel, there is no blame on them.”

The second Sura of Qur'an is named as Shura. The 38th verse of that Sura
suggests that shura is praiseworthy life style of a successful believer. It also
suggests that people whose matter is being decided be consulted. It says:
"Those who hearken to their Lord, and establish regular Prayer; who
(conduct) their affairs by mutual consultation among themselves; who
spend out of what We bestow on them for Sustenance" [are praised].”

The 159th verse of 3rd Sura orders Muhammad to consult with believers.
The verse makes a direct reference to those (Muslims) who disobeyed
Muhammad, indicating that ordinary, fallible Muslims should be consulted.
It says: “Thus it is due to mercy from God that you deal with them gently,
and had you been rough, hard hearted, they would certainly have dispersed
from around you; pardon them therefore and ask pardon for them, and take
counsel with them in the affair; so when you have decided, then place your
trust in God; surely God loves those who trust.”
The first verse only deals with family matters. The second proposed a lifestyle of
people who will enter paradise and is considered the most comprehensive verse on
shura. The third verse advices on how mercy, forgiveness and mutual consultation
can win over people.
Shura is also a quality term used in the Qur’an in Sura Al-Shura (The
Consultation), Aya 88: “And their matters are attained by consultation between
them”. Shura emphasizes teamwork and cohesion among members of the group in
Islamic society, for the purpose of empowering groups and society.
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Shura in the light of sayings of the Prophet (‫)صلی هللا علیه وسلم‬
1. Narrated by H. Ali “May Allah (SWT) be pleased with him” to have asked the
Prophet (PBUH): “If there is any matter which is not clear with regard to doing
it or forbiddance, what shall we do,” said the Prophet (‫ )صلی هللا علیه وسلم‬consult
with scholars and devoted Muslims and do not take the opinion of one person as
special.”
2. Narrated Ayesha (‫“ )رضی هللا عنها‬I have not seen any person consulting people
more than the Prophet (‫ )صلی هللا علیه وسلم‬did.”
3. “Anyone who consults will not fail and anyone who avoids consultation will
not prosper.”
4. “Anyone who consults will not feel remorseful and anyone who offers Istikhara
will not suffer”.
Shura principles in Islam
1. Shura is predicated on three basic precepts:
1) All persons in any given society are equal in human and civil rights.
2) Public issues are best decided by majority view.
3) The three other principles of justice, equality and human dignity,
which constitute Islam's moral core, and from which all Islamic
conceptions of human and civil rights derive, are best realized, in
personal as well as public life, under shura governance.
2. Shura is a cardinal principle of governance in Islam. The Qur’an has
presented shura as a principle, and not as a system, of governance. The
distinction is important to note, because the Qur’an thereby has left it to
successive generations of Muslims to continue to strive toward a more
perfect realization of the shura principle.
3. Shura is a central issue in the on-going debate among Muslims over political
reform.
4. Authentic Islamic positions, stressing popular consent, collective
deliberation, shared responsibility, personal freedom, justice, equality, and
dignity of the human individual, are all conceived within the shura
framework of governance.
5. A Muslim society should run its affairs by a process of consultation that
involves all members of the society and covers all matters of public concern.
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6. The opinion of the majority of Muslim jurists is that Shura is part of
aza'im al-ahkam (commandments) which is obligatory on both the ruling
authority and the Muslim people. These words quite naturally suggest that
all Muslims be involved in the process of consultation within the
community.
7. People must express their views on how certain matters should or should
not be handled.
Shura method
Applying the principle of shura in any community obviously requires two
things. First, it requires that if members of the community have any views on
any matter of community concern, they should raise their voices and express
their ideas. Second, there must exist in the community a process whereby
various views found among the members of the community are translated into
a coherent policy consistent with Islamic teachings and then put into action. If
members of the community do not express their views or if various ideas
circulate in the community without producing any clear policy and definite
course of action, then the community obviously cannot be said to run its
affairs by shura.
Benefits of shura and consultation
It goes without saying that Shura and consultation have positive and valuable
impact and results some of which are briefly mentioned below:
1. Prevents despotism, selfishness and unfounded arrogance;
2. Ensures participation of all in making social decisions and expressing of
views by members of the society about their own destiny, blocking the way
for self-centeredness and despotic thinking and an individual can realize
flaws in his own thinking;
3. Identifies mistakes and corrects decisions and errors: It is natural that when
all have a chance to participate in vital social decisions, they can collectively
correct errors and mistakes;
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4. Invites people for participation and gets the society involved in decision
making and the oversight of implementation of law; organizing the affairs
gives them personal responsibility and they feel responsible, it strengthens
their sense of dignity and help them develops their personality dimensions
and they will have more active participation in various social activities;
5. Protects against errors and mistakes and helps the authorities feel safe when
taking any action and being excused in case of committing mistakes while
making decisions and acting upon them and protects from envy of others in
case of overriding of their thoughts and proposals;
6. Respects and ensures collective benefits;
Making decisions on the basis of taking and assessing of general opinions,
particularly those of the learned people will minimize the chance of
prevailing of the whim and focusing on personal and party interests, because
an individual is required to respect others’ opinion and ignore his personal
wishes and thinking and pay attention to the collective interests;
7. Reduces the possibility of failure in implementing decisions:
Consultation among concerned individuals leads to stronger decisions and
brings about more commitment and sympathy when performing and reduces
the chance of failure and in case of failure there will be no room for blaming
and reprimanding a specific individual;
8. Develops wisdom and talents;
Exchange of views, productivity of thoughts, and power of planning is a
proper means for expression of opinions and creativity and the surfacing of
hidden abilities and talents;
9. Creates an understanding and unity and consistency in thinking and action,
mutual respect, love and affection and removes misunderstandings and
misconceptions from decisions and actions and revives sense of cooperation
and empathy; and
10.Prevents suspicion and wards off any chance of suspicion and draws
people’s attention to the matters of importance to the society.
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Purpose of these guidelines
This health shura governance guideline is aimed to assist the health post shuras and
health facility shuras in successfully meeting their challenges. The purpose of this
guideline is to assist the health shura members in discharging their role and
responsibilities in effective, efficient, transparent and accountable manner.
The guideline describes salient features of Afghanistan’s Health System. It
provides guidance on the mission, role and responsibilities, authority,
accountability of the health shuras and health shura members. It also provides
guidance to health shura members on engaging with the community and the health
workers, motivating health workers and providing feedback to them, building trust,
persuading, educating and mobilizing the community, adopting effective
leadership, management and governance practices, conducting effective shura
meetings, conducting strategic and annual work planning, carrying out health
needs assessment, and working with other shuras and the authorities at higher
levels.
The guideline will help the health shuras identify community’s health needs, plan
to address these health needs, implement the plan, monitor progress and evaluate
the results.
The guideline has a chapter on competencies expected in the head and the
members of the health shura and procedure for their selection. The guideline
provides details of how the Community Based Health care (CBHC) Directorate of
the Ministry of Public Health will develop capacity of health shura members.
Finally, the guideline provides detailed guidance on how to conduct regular selfassessment of health shura as a whole, individual shura members, and shura
meetings.
Using this guide and practicing what it contains, health shūrā members will be able
to influence access to health care, quality of care, and overall health outcomes for
the people living in their area.
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CHAPTER 2
Afghanistan Health System
Afghanistan is making progress in improving health and quality of life of its
citizens. For example1, the death rate due to all causes has decreased for every age
range. Girls aged 1-4 years and women in reproductive age group experienced
substantial reductions in deaths due to all causes from 1990 to 2010. The disease
burden due to Tetanus declined steeply falling by 37% from 1990 to 2010. Use of
family planning has increased markedly in the past decade in Afghanistan.
However, much needs to be done.
Child mortality continues to be high in Afghanistan although there has been a
marked decline in the last decade. Lower respiratory infections, diarrheal diseases,
and preterm birth complications were the highest ranking causes of neonatal and
child deaths in 2010.2 One Afghan woman dies about every 2 hours from
pregnancy-related causes.3 For every 1,000 live births, about 3-5 women die during
pregnancy, in childbirth, or in the two months after delivery.4 Most of these deaths
can be prevented. The top five leading causes of years lived with disability in
Afghanistan in 2010 were major depression, iron-deficiency anemia, low back
pain, anxiety disorders, and tuberculosis. Much of this disability can also be
prevented or treated. About 35 percent of deaths in Afghanistan are due to noncommunicable diseases like cardiovascular diseases and cancers, while about three
in ten are due to communicable diseases and infections. The leading risk factors in
Afghanistan are household air pollution from solid fuels, childhood underweight,
dietary risks, suboptimal breastfeeding, smoking, and poor sanitation. Health
shuras can do a lot in this regard.
1
GLOBAL BURDEN OF DISEASES, INJURIES, AND RISK FACTORS STUDY 2010
GLOBAL BURDEN OF DISEASES, INJURIES, AND RISK FACTORS STUDY 2010
3
Afghanistan Mortality Survey 2010
4
Afghanistan Mortality Survey 2010
2
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The populations must have access to safe, effective, timely, efficient, affordable,
and patient-centered health services to surmount many of the health challenges.
Health services in Afghanistan operate at three levels:
1. At the community or village level as represented by health posts, community
health workers (CHWs), Health Sub-centers (HSCs), Basic Health Centers
(BHCs) and Mobile Health Teams (MHTs);
2. At the district level, as represented by Comprehensive Health Centers
(CHCs) and District Hospitals operating in the larger villages of a province;
and
3. At the provincial and national levels, as represented by provincial, regional,
national, and specialty hospitals.
Basic Package of Health Services (BPHS) is complemented by the Essential
Package of Hospital Services (EPHS) which defines essential elements of hospital
services and promotes a referral system.
Together, the BPHS and the EPHS are key elements of the health system in
Afghanistan.
15
The following health facilities provide the basic services.
1. Health Posts (HPs) are staffed by one female and one male CHW, cover a
catchments area of 1,000– 1,500 people, which is equivalent to 100–150
families.
2. Health Sub-centers (HSCs) are established for small pockets of population
that do not meet the criteria recommended for locating health facilities under
the BPHS.
3. Basic Health Centers (BHCs) cover a population of about 15,000–30,000,
depending on the local geographic conditions and the population density.
The minimal staffing requirements for a BHC are a nurse, a community
midwife, and two vaccinators.
4. Mobile Health Teams (MHTs) serve a cluster of districts in a province.
5. Comprehensive Health Centers (CHCs) cover a catchment area of about
30,000–60,000 people and offer a wider range of services than does the
BHC. In addition to assisting normal deliveries, the CHC can handle certain
complications, cases of childhood illness, treatment of complicated cases of
malaria, and outpatient care for mental health patients.
Persons with disabilities and persons requiring physiotherapy services are
screened, given advice and referred to appropriate services in the area. The
facility usually has limited space for inpatient care, but has a laboratory.
The staff of a CHC is larger than that of a BHC; it includes both male and
female doctors, male and female nurses, midwives, one (male or female)
psychosocial counselor when mental health activities are implemented, and
laboratory and pharmacy technicians.
6. District Hospitals (DHs) handle all services in the BPHS, including the most
complicated patients. Patients referred to the district hospital include those
requiring major surgery under general anesthesia, X-rays, and
comprehensive emergency obstetric care.
The district hospitals offer comprehensive outpatient and inpatient care for
mental health patients and rehabilitation for persons requiring physiotherapy
with referral for specialized treatment when needed.
16
The district hospital also provides a wider range of essential drugs, treatment
of severe malnutrition renewable supplies and laboratory services than do
the health centers.
The district hospital is staffed with a number of doctors, including female
obstetricians/gynecologists; a surgeon, an anesthetist, a pediatrician, a doctor
who serves as a focal point for mental health: psychosocial
counselors/supervisors; midwives; laboratory and X-ray technicians; a
pharmacist; a dentist and dental technician; and one to two physiotherapists
(male and female).
Each district hospital covers a population of about 100,000–300,000.
Basic Package of Health Services (BPHS)
The BPHS has seven elements.
No. Element
What is covered?
1
Maternal and Newborn Care 1) Antenatal care
2) Delivery care
3) Postpartum care
4) Family planning
5) Care of the newborn
2
Child Health and
1) Expanded Program on Immunization (EPI)
Immunization
2) Integrated Management of Childhood
Illness (IMCI)
3
Public Nutrition
1) Prevention of malnutrition
2) Assessment of malnutrition
4
Communicable Disease
1) Control of tuberculosis
Treatment and Control
2) Control of malaria
3) Prevention of HIV and AIDS
5
Mental Health
1) Mental health education and awareness
2) Case identification, diagnosis and treatment
6
Disability and Physical
1) Disability awareness, prevention, and
Rehabilitation Services
education
2) Provision of physical rehabilitation services
3) Case identification, referral and follow-up
7
Regular Supply of Essential Drugs based on the essential drugs list
17
Community-based health care (CBHC)
Community-based health care (CBHC) is the foundation of successful
implementation of the BPHS. Its success depends upon community participation
and a partnership between community and health staff. The CBHC recognizes first
that families and communities have always looked after their own health. Religion
and cultural norms and beliefs play an important part in health practices. Families
are making decisions to maintain health or care for illness every day. Most
importantly, community members understand and have better information on local
needs and priorities.
The partnership of health services with communities is important for two reasons.
It persuades families and communities to make appropriate use of health services,
and to change certain behaviors and social norms for more healthy behaviors and
norms. It seeks the guidance and collaboration of communities in the provision of
health care, and encourages them to identify and solve their own problems.
Community health worker (CHW), shura-e-sehie, community health supervisor
(CHS), Family health worker (FHW) and Family health action group (FHAG) are
five key elements of community-based health care.
18
Community Health Worker (CHW) is an important member of health system,
working with the community which needs health services. CHW provides basic
health services from his/her home recognized as health post. CHW is responsible
for supporting the community in identifying their health problems and addressing
these problems. CHW manages all community-based health programs.
Community Health Supervisor (CHS) is a member of the health facility staff. He
or she is the main link between the facility and the communities in the catchment
area of the facility. CHS supervises the CHWs and guides them in the
implementation of their plans. CHS conducts monthly supervisory meetings with
CHWs and ensures the regular replacement of materials in CHW kits. In addition,
CHS collects and processes all monthly reports from CHWs and helps them in
their training of practical work. CHS evaluates the performance of CHWs and
identifies their need for further training.
There are two types of Health Shuras in the Community-Based Health Care
Program: Health Shura at the health post level and Health Shura at the health
facility level. The Health Shura at the health post level supports the health related
activities in the community, selects and monitors Community Health Workers
(CHWs). They monitor the community map with CHWs to make sure that families
make full use of the health services, accept and promote healthy behavior. The
Health Shura at the health facility level works with CHWs to adapt the health
services to the community needs and ensure the better quality of services and
satisfaction of patients at the health facility.
Family Health Action Group is a group that supports female CHW in
encouraging healthy lifestyle and appropriate use of health services for reducing
deaths of mothers and children. Female CHW selects a group of 10-15 women
with young families and well-respected within their community, and shares with
them what they have learned. This is a family health action group. These 10-15
women promote adoption of healthy behaviors among the women in their
neighboring households. The group makes the work of the CHWs more effective
and more efficient. The group spreads health awareness and key health messages
among mothers. This results in healthy homes and healthy lifestyles and increases
the use of available health services. The group helps CHWs attend to pregnancies,
births, and illness.
School students become Family Health Workers when they receive health
education and in turn, take health messages to their families and play the role of
health educators.
19
CBHC (Community-based health care) was adopted by the Ministry of Public
Health in September 2002. The CBHC policy in Afghanistan has the following
provisions.
1. The community plays the prime role; its participation is required to ensure
sustainability of health services.
2. CBHC is a community-based and community-owned program.
3. The health services are monitored by health shuras.
4. The technical and material support comes from both the NGO and the
MOPH.
5. All levels of the health care system receive orientation to the principles of
CBHC. All health workers will be trained in being responsive to referrals.
6. The community agrees with the CHW job description.
7. CHW training takes place as close to the community as possible, using
locally determined methods.
8. Adequate and supportive supervision is provided to the community health
worker by the community health supervisor.
9. The health facility regularly provides CHWs with a drug kit adapted to the
local situation and approved for CHW activities.
10.Compensation is sustainable. Full-time work is paid and part-time work is
compensated by incentives.
11.Community assets include traditional and modern health providers in the
private-sector.
20
Principles of CBHC:
1. CBHC focuses on major health problems for which solutions exist.
2. Community health worker can provide the service at a reasonable standard
of quality.
3. Health workers are locally identified and recruited.
4. Health workers are trained incrementally, one skill at a time.
5. An established list of drugs and supplies is used.
6. Supervision is regular and supportive.
7. The health worker is accountable to the health shura and the community.
8. The community makes a financial or in-kind contribution for the services.
21
CHAPTER 3
Importance of health post shuras and health facility shuras
Health shuras have been playing several important roles. They have several
strengths.
1. The poor and the rich are at the same level in a shura. The knowledgeable
and the illiterate are also at the same level in a shura.
2. Health shuras play a vital role in referral of patients and health education of
the community. They persuade people to go to the health facility.
3. Shura members have contributed in reducing stigma associated with
tuberculosis, mental health and disability.
4. Health shuras have an important role in immunization and TB control.
5. Health shura provides regular feedback to the health facility staff every
month.
6. Health shura keeps a watch on supply, stock out, and any pilferage of
medicines.
7. Health shuras have an important role because they solve problems, for
example, staff members of a clinic were under threat from the insurgents.
The health shura resolved the issue by contacting their local commander. At
one place, the staff was hostile to the new head of the facility. The local
health shura resolved this issue.
8. Health shuras collect funds from the community to help pregnant women.
9. Shuras mitigate the damage done by rumors.
10.Health shuras resolve an issue arising out of misunderstandings in the
community, for example, a belief that immunization of a woman makes her
infertile or anti-tetanus injection ethically corrupts a woman. Shuras take
corrective steps.
22
Nevertheless, many health shuras have weaknesses.
1. Many shura members do not know their own job description, leave alone
that of a community health worker.
2. Shura members not well informed about health services provided by health
posts and health facilities.
3. Shura members do not conduct monthly meeting on a regular basis and they
don’t follow up the implementation of decisions they take in their monthly
meeting.
4. Many times the health shura does not want to displease the facility staff and
hence difficult issues are not brought up during the shura meeting. Shura
members do not want to make health workers unhappy by raising unpleasant
issues. They avoid real issues.
5. Health facility staff members do not give priority to the patients referred by
our health shura.
6. Shortage of medicines makes the community health worker less enthusiastic
to hold shura meeting.
7. The shura interacts with the head of the facility not with other health staff.
8. The shura members are often not taken into confidence while selecting a
community health worker.
9. Shura members are not selected according to the criteria. Some of them are
selected based on their relationship with NGO staff, head of health facility or
community health supervisor.
10.There is no motivation for shura members, for example, there is no provision
for refreshment, transportation, lunch, etc.
11. There is low level of leadership, management and governance skills among
health shura members and there is no training of shura members in this
regard.
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Mission of health shuras
The health shuras provide leadership and support to all health-related activities in
their communities. They select, support and supervise the CHWs in the
community. They encourage families to make full use of preventive and curative
health services. They provide leadership in the adoption and promotion of new
behaviors and social norms.
The mission of the health shuras is to improve the
health and nutritional status of the people living in
their area.
The health shuras achieve this mission by
1. working closely with the community and the health providers,
2. linking people to health services needed by them,
3. facilitating delivery of safe, timely, efficient, effective and patient-friendly
health service,
4. supporting the health of mothers and young children,
5. promoting healthy lifestyle among the community members,
6. mobilizing the community and the health workers to identify and solve the
health challenges the community is facing, and
7. advocating for sanitation, clean water, and clean air.
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Responsibilities of health shuras
1. Provide general direction and guidance for the management and operation of
the health post or the health facility
2. Set a strategic direction shaped by assessment of the needs of the community
3. Serve as the policy and strategy-setting body of the health post or the health
facility
4. Serve as a link between the community and the post or the facility
5. Ensure that the post or the facility fully and genuinely meets the needs of the
community
6. Ensure that high quality services are provided
7. Nurture relationship with the community and people
8. Generate community support for the health post or the facility
9. Work closely with representatives of other sectors (for example, counter
narcotics teams), and work closely with other shuras in the village and
manteqa
10.Support the leadership of the health post or the facility
11.Provide oversight to the health post or the facility, involve people especially
community elders in community health planning and monitoring of heath
post and health facility, monitor heath post and health facility, and
participate in joint monitoring visits heath post and health facility
12.Create a culture of accountability, honesty, transparency, ethics and
compliance with the Ministry of Public Health policies
13.Assess and monitor the community’s health status on regular basis
25
14.Identify health risks to the community and determine the community’s
health service needs, and be watchful regarding health hazards in the
community
15.Develop strategic, annual and monthly plans for the shura based on the
community health needs assessment
16.Identify community assets that can be useful in promoting health and
improving quality of life of the community members
17.Inform, educate, and empower people about health issues, convey health
messages given by health workers to the community, and share facts and
realities with community about ongoing health activities
18.Collaborate with the health workers and facility staff, and collaborate with
private health providers
19.Mobilize community partnerships to identify and solve health problems
20.Link people in the community to needed health services
21.Help solve the problem of the health post or the health facility
22.Review community satisfaction with the services provided by the health post
or the facility
23.Support high performance from the health worker sand the health staff
24.Ensure adequate resources for the health post or the health facility
25.Review and oversee the implementation of the work plan of the post or the
facility
26.Make sure the health workers are responsive to the community
27.Supervise, advise and counsel the head of the health facility or the health
workers, and appropriately reward and punish the health workers and CHWs
26
28.Bring health problems and health needs of the community to the attention of
head of health facility, district health officer and provincial public health
director
29.Inform health workers and health facility head in case of an outbreak, and
coordinate and participate in all stages of emergency response such as
epidemics
30.Participate in special activities such as immunization campaigns, national
immunization days, personal and environmental sanitation campaigns, and
other health campaigns
31.Mediate disputes that arise among stakeholders
32.Work for continuous improvement of the health shura’s governance.
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CHAPTER 4
Accountability of health shura
Accountability exists when there is a relationship between two parties, and the
performance of tasks or functions by one party is subject to the other’s oversight,
supervision, direction, or requests for information. Accountability means ensuring
that officials in public, private, and voluntary sector organizations are answerable
for their actions and that there is redress or remedy when duties and commitments
are not met.
Accountability means that institutions—ministries, organizations, and health posts
and health facilities—are responsible for meeting the needs of the people whom
the institutions were created to serve and protect. Openness and transparency are
key enabling factors of cultivating accountability.
Social accountability refers to actions that citizens, communities, independent
media, and civil society organizations can use to hold public officials and public
servants accountable. Social accountability is a means of improving service
delivery. Social accountability tools include citizen report cards, community score
cards, community monitoring, public hearings, and community radio.
When accountability is strengthened, the opportunity for corruption is diminished,
and there is improvement in health system performance.
28
Shura members are accountable to the communities they serve. To demonstrate
this, health shura and shura members must:
1. Be consistent in your public and private behavior. Practice what you preach.
2. Openly listen when the community members or the health workers offer
perspectives that are different from yours.
3. Interact openly and candidly with the community members and the health
workers. Share information with the community members and the health
workers. Use mobile phones for effective dissemination of information.
4. Accept responsibility for your actions as a shura member, and accept
ownership for the results of your decisions in the health shura.
5. Accept responsibility for the future direction and accomplishments of your
health shura.
6. Openly explain the reasons for your decisions in the shura.
7. Answer questions from the community members and health workers, and
welcome constructive feedback on your actions and decisions in the shura.
8. Demonstrate a sense of responsibility to the community and to the health
workers when making decisions.
9. Avoid making excuses and blaming others for mistakes, openly admit your
mistakes to the community and to the health workers, and take quick action
to deal with the consequences of a mistake.
10.Provide explanations to the community members for the underperformance
of your shura or the health workers without making excuses.
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Accountability of health workers
The head of the health facility and the health workers are accountable to the
community they serve. For developing their accountability, your health shura must:
1. Be willing to admit mistakes and learn from them. Set an example for the
health workers to follow.
2. Encourage the health workers and the head of the health facility to share
both successes and challenges.
3. Provide timely, clear, and specific performance expectations and feedback to
the health workers and the head of the health facility.
4. Regularly review performance of health workers in your shura meeting.
Assess performance of the health facility and the health post and explain
your findings to the community. Review utilization of medicines and drugs.
5. Discuss the underperformance with the concerned health worker and the
head of the health facility. Recognize and praise excellent performance of a
health worker.
6. Set the standards of behavior for the health workers. Encourage community
members to assess whether these standards are being met.
7. Establish a process for community members to ask questions to the health
workers, the head of the health facility, and the health shura members. In
response, the health workers, the head of the health facility, and the health
shura members must explain their decisions and actions to the community.
8. Establish a system of rewards for health workers who meet these standards.
Establish a process for dealing with the health workers who are not meeting
these standards.
9. Set clear goals for the health workers and the head of the health facility and
support them in achieving these goals.
10. Ensure the health workers and the head of the health facility have enough
resources to succeed.
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Chapter 5
Coordinating and collaborating with community and health
workers
There are five ways of working with the people in the community and the health
workers. Begin with informing and consulting with them, then gradually involve
them in shura’s decision making process, collaborate with them in finding
solutions, and finally empower them.
1. Inform
Keep the community members and health workers informed, and
educate the community members.
2. Consult
Listen to people’s and health workers’ concerns and provide feedback.
3. Involve
Coordinate with both community and health workers to make sure that
their concerns are directly reflected in the shura’s decisions.
4. Collaborate
Work with the people and the health workers to formulate solutions.
5. Empower
Do what people decide.
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You and your health shura should, in a significant and meaningful way as
described above, engage with the community and the health workers in order to
effectively fulfill the responsibilities of the shura.
1. Be proactive and go out into your community to seek out health opinions
and health concerns of the community members.
2. Give your time to the work of your health shura.
3. Provide the community and the health workers with the information and
time they need to participate in shura activities a meaningful way. Avoid
misunderstanding, miscommunication, and conflict.
4. Collect input from the community and the health workers before and during
a shura meeting.
5. Provide clear guidance on what the community and the health workers
should expect from each of the shura meetings.
6. Demonstrate to the community and the health workers how their
involvement can help shura perform better for protecting health of the
community members.
7. Announce the shura meetings widely and keep them open to the public.
People will participate when they view the health shura as open and
supportive of their right to have a voice in the shura decision making
process.
8. Respect cultural practices while consulting with the community members.
9. Have courage and humility.
10.Establish a 3-way trust i.e. trust between the health workers and the health
shura and vice versa, trust between the community and the health shura and
vice versa, and finally trust between the health workers and the community
and vice versa.
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Building trust
Facilitate establishment of trust in three relationships
1. Trust between the health workers and the health shura
2. Trust between the community and the health shura
3. Trust between the health workers and the community
BUILDING TRUST
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Building trust
Begin with yourself.
1. Tell the truth, even if it is difficult.
2. Do what is right sometimes even at personal risk.
3. Maintain consistency in what you say and how you act. Practice what you
preach.
4. Do not seek personal gain.
5. Keep promises and commitments. Make your promises and commitments
carefully. Make commitments to yourself and keep them.
6. Hold yourself accountable before holding others accountable.
7. Take responsibility for the results. Take responsibility for the decisions that
go wrong. Admit your mistakes and explain how you made that decision.
Learn from your mistakes.
8. Be a patient listener. Listen to your colleagues in the shura, and listen to the
health workers and the community members.
9. Be open-minded and consider ideas and points of view different from your
own.
10.Be a learner. Seek feedback from your colleagues in the shura, and from the
health workers, the community members and other influential leaders.
Establish mechanism for seeking this feedback on a regular basis. Act on the
feedback you receive from them. Broaden your knowledge and skills in
public health.
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Then, extend trust to the health workers and the community members.
1. Establish the shura’s vision of a healthy community closely working with
health workers, community members, other shuras in the community,
influential persons and organizations. Communicate this vision of healthy
community effectively and regularly.
2. Treat health workers, community members, and other shuras as equal
partners in achieving the vision of a healthier community. Seek opinions and
ideas from them.
3. Sincerely trust in health workers and the members of your community.
4. Respect the health workers and the members of your community, and show
your respect through words and actions.
5. Make your expectations from the health workers and the members of the
community very clear to them.
6. Recognize the good work of the health workers and contribution of the
community members. Give credit to them.
7. Do not withhold information. Be transparent.
8. Do not avoid difficult issues. Deal with them with courage before they turn
into major problems.
9. Be just and fair in our decisions. Treat the health workers and the
community members in a fair and just manner.
10.Have a strong sense of purpose. Involve the health workers and the
community so that they share and support that purpose. Create a culture in
which tolerance and cooperation are valued. Have many people participate
in making decisions.
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Providing feedback to health workers
1. Giving feedback becomes difficult when you and the health worker see the
facts differently or interpret the facts differently.
2. It is also difficult when emotions are strong.
3. When we see or hear something, we filter what we see or hear through our
past experiences and beliefs. We decide whether what we see or hear is a
threat or benefit. We think we know what is going on with the other person.
We decide that our own views are correct. We reinforce our old beliefs or
form new ones. We act or react. This is how we make an inference or draw
our conclusion.
4. When you give feedback to a health worker, the health worker may think if
you consider he or she is less knowledgeable or less experienced or less
skilled or not a good person or their intentions are not honest.
5. In these circumstances, re-establish that you care about them as a person and
you care about their best interests, and clarify what you want to achieve and
what you want to avoid.
6. Look for common purpose and common interest.
7. Do not avoid giving feedback. Give your candid opinion. Be clear about
what you want to say.
8. Give constructive feedback. Do not be aggressive while giving feedback. Do
not exaggerate your side of the argument. Never say things that might hurt
them personally.
9. Hear their side. Do not come to a conclusion before you hear their side.
10.Remember three golden rules of giving feedback.
One, share the facts.
Two, tell your version.
Three, ask them for their side of the story.
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11. Give participants an opportunity to respond to the feedback, while you
actively listen during this response.
12.Be timely in giving feedback. Give your feedback soon after the event.
13.Avoid embarrassment. Constructive feedback should be given in the form of
“what you can do differently next time,” rather than what you did wrong this
time.
14.Be specific. When feedback is specific, the health workers learn exactly
what they did that was effective and what they should do differently next
time.
Example of specific feedback:
“I was pleased to see that you asked each mother with a child older than 6
months what foods she was using to complement breastfeeding.”
15.Do not criticize. Describe the consequences of the behavior; do not judge the
person.
16. Take responsibility for your own feedback. Speak for yourself, not for
others.
17.Be encouraging. End your feedback with words of encouragement,
reaffirming approval of the performance and the expectation that
improvement will continue.
18.Convey positive feedback by facial expression and tone of voice along with
words, when appropriate. This type of feedback can be highly effective.
19. Refer to behavior in your feedback, especially behavior that can be
changed.
20. Always be respectful and polite when giving feedback.
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Motivating health workers
Motivation is the key to success of the health workers and the health shura.
Motivation is a foundation of success of health workers. Health workers can give
their best if they are motivated.
1. Constantly communicate your vision and goals. Focus your health workers
on the end result or the overall team goal.
2. Spell out specific targets, goals, and expectations for behavior and
performance, and measure performance. Identify obstacles and help in
removing them.
3. Give regular and timely feedback on how they are performing against those
goals. Give your feedback in a direct and supportive manner. Feedback is
vital to continuous improvement. It motivates and inspires people to use
their full potential.
4. Create a safe environment for health workers to do their job.
5. Let your health workers know you are willing to listen to them. This will
increase their morale. Be an active listener. Listen to their goals and dreams,
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their past achievement, their concerns and challenges. Listen with your
heart and mind. Respect their thoughts and opinions. They may have the
best answer for achieving the results the shura is trying to achieve.
6. Address their questions, concerns and complaints.
7. Involve the health workers in decision making.
8. Encourage them to undergo training, acquire new skills and grow in their
career.
9. Recognize good work done by the health workers. Praise them publicly.
Praise them four times as much as you criticize their performance. If you
need to criticize constructively, do it in a private manner.
10.Reward a health worker as soon as he or she performs excellently and gives
excellent results.
11. When appropriate, use monetary and non-monetary incentives. Give in-kind
rewards to CHWs and health workers. Mobilize resources from wealthy
individuals to support the CHWs and other health workers.
12. When rewarding a health worker, consider his or her need for career growth
and career advancement, and reward accordingly.
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Persuading community members
1. Focus on the needs of the community members. Take time to listen to them
carefully and find out about their needs and expectations. They are then
more likely to trust and respect you. It will also make it easier for you to
outline the benefits of what you want them to do in a way they understand.
2. Argue your case with logic, reason and conviction.
3. Use positive rather than negative language.
4. Be firm. Do not be passive or aggressive.
5. Do not undermine the argument of others. Show respect for views of others.
Do not impose your own views.
6. Build trust. Compliment the community for their positive contributions.
7. Understand any outside forces that may be affecting the problem.
8. Work together to come up with a solution to suit community’s best interests.
9. Decide on a course of action and come to an agreement though it may take a
lot of your time, effort and patience to achieve common understanding.
10.Remember to use ideas persuasively, gain support and develop strategies.
 To use ideas persuasively: Engage people’s attention, explain the benefits
of your argument, develop reasoned argument, make your points clearly
and concisely, and understand the concerns and needs of the people.
 To gain support: Emphasize how costs and problems can be minimized,
handle objections, challenge the points of view expressed by others, and
get other people to support your views.
 To develop strategies: Use many different approaches to gain support for
your ideas, give an example of when your idea has been used
successfully in some other context, make compromises when required to
reach agreement, work for solution which benefits the community.
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Health communication with community members
Health communication can promote awareness of a health issue. It can promote
changes in attitudes to health and health beliefs. It can also promote community
support for desirable behaviors. In addition, communication can bring about
changes in the community that encourage healthy behavior.
1. Accept into your own life the behavior you want community to adopt
2. Make a preliminary assessment of community’s attitudes towards the
desired behavior, and then keep track of changes in it
3. Expose community to your health message, adapt it based on educational
attainment, age, gender, and socioeconomic status
4. Make sure community members pay attention to the message and they
understand the message
5. Ensue that they find your health message is personally relevant to them
6. Confirm that they can personalize the desired health behavior to fit into
their life
7. Ensure that community members are able to make decisions based on the
message
8. Encourage community members to try out the behavior change, then
judge whether it suits them and is useful to them, and finally accept the
change
9. Ensure that community members remember the message and continue to
agree with it
10.Give positive reinforcement to community members for the healthy
behavior
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Health education of the community
The purpose of health education is to improve health-related knowledge, attitudes,
skills and behavior of the community members, and ultimately the health status
and the quality of life of individuals and families in your community. It reduces
premature deaths in the community. By focusing on prevention, health education
saves the money that families would spend on costly medical treatment. Working
with your health workers, you should:
1. Educate community on healthy practices and behaviors that will maintain or
improve the health of self and others.
2. Explain the importance of assuming responsibility for personal health
behaviors.
3. Inform community members so that they are able to make positive health
choices.
4. Give accurate information to community about health issues it is currently
facing.
5. Help community members and their families to set a health goal, and work
towards it.
6. Help them differentiate between situations when a health-related decision
can be made individually or when assistance of health workers is needed.
7. Help them identify characteristics of valid health information, health
products, and health services.
8. In coordination with other Shuras in the community, advocate use of
nonviolent strategies to manage or resolve conflict.
9. Advocate for healthy individuals, healthy families, and healthy schools.
10.Educate on how the family and culture influence personal health practices
and behaviors. Work with the school and help the teachers find out what the
school can do to support personal health practices and behaviors.
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CHAPTER 6
Community leadership
Being a community leader
Leadership relates to the ability of an individual to influence, inspire, motivate, and
enable others to contribute toward success of their community. Leading means
inspiring and mobilizing your fellow shura members, health workers and the
community members to dream of a healthy community and realize it. Leading also
means scanning challenges and opportunities, and focusing your attention on
critical challenges. Leaders provide mentoring, coaching and recognition. They
encourage and allow other leaders to emerge. Health leaders exert influence across
all sectors for better health of community members.
1. Scan challenges and opportunities in your community and in the
environment beyond your community. Do it as if a doctor reviews a patient’s
pulse to get a basic picture of his or her health. Try to recognize
opportunities, challenges, and trends to gain a sense of your whole situation.
Talk to as many community members and health workers as possible,
establish trust and relationships, learn from past experiences, and review the
current situation. Identify health needs of your community, and identify the
capacity of the community and health workers to meet these needs.
2. Focus your attention on critical challenges. Communicate these challenges
to your fellow shura members and health workers. Determine key priorities
for action. Work with them in a participatory way. Encourage them to think,
act, and take responsibility of meeting these challenges.
3. Align and mobilize your fellow shura members, the health workers and the
community members to the purpose of the shura. The purpose is to improve
health and nutritional status of people living in your community. Motivate
your fellow shura members, and health workers to address the health
challenges. Motivate the community to mobilize adequate resources to face
the health challenges in an effective way. Enable all three (shura members,
health workers and community members) to work together and overcome
these challenges. Facilitate teamwork.
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4. Inspire your fellow shura members, health workers and community
members. Set an example through your own attitudes, actions, commitment,
and behavior. Inspire them to think, learn, act, commit, and create effective
solutions. Be honest and practice what you preach.
Competency Application
To be an effective community leader, you must do eight things.
1 Master yourself
2 See the big
picture
3 Create a shared
vision
Reflect on yourself and be aware of your influence on your
fellow shura members, health workers and community
members. Manage your emotions. Use your strengths, and
work on your weaknesses.
Look beyond a narrow focus to take into account conditions
outside your own community and see the complete picture.
Work with your fellow shura members, health workers and
community members to envision a healthy community. Use
this vision to focus all your efforts.
Know your own values and what health goal is most
important to accomplish.
Hold conversations focused on results. Advocate and
enquire.
Clarify the purpose, and establish trust.
4 Clarify purpose
and priorities
5 Communicate
effectively
6 Motivate health
worker teams
7 Resolve conflict Reach agreements from which both community and health
workers can benefit.
8 Lead change in Enable your fellow shura members, health workers and
the face of
community members to meet challenges in face of uncertain
uncertainty
and adverse conditions.
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Managing health affairs of your community
Managing health affairs means planning and using resources efficiently to produce
a healthy community and monitoring and evaluating the results of your efforts.
Plan
1. Achieve a healthy community by assigning resources, accountabilities, and
timelines
2. Set short-term and long-term goals and objectives
3. Develop long-term and annual plans
4. Allocate and assign adequate resources (money, people, and materials)
5. Anticipate and reduce risks
Organize
1. Organize shura members, health workers, community members, health post
and health facility to implement the plan
2. Establish accountability and authority for implementation of the plan
3. Ensure that the health facility and health posts support the plan
4. Strengthen processes to implement the plan
5. Align health workforce with planned activities
Implement
1. Implement activities efficiently, effectively, and responsively
2. Coordinate and link health workers with the community, and balance
competing demands
3. Routinely use information and evidence for decision-making
4. Coordinate activities with other shuras
5. Adjust plans and resources as circumstances change
Monitor and evaluate
1. Monitor and reflect on progress against the plan
2. Observe, check, and keep a continuous record of what is going on
3. Provide feedback to health workers and community members
4. Assess the results, and assess what worked and what went wrong
5. Identify changes needed to be made to improve work processes
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Conducting effective health shura meetings
Criteria for effective health shura meetings
1. Use the community health improvement plan to guide dialogue and
discussions.
2. Focus discussion on strategic issues.
3. Relate decisions and action taken to community health improvement plan.
4. Exhibit courage when taking difficult decisions.
5. Prepare and actively participate in discussions. Keep the cellphones silent or
turned off.
6. Discuss all sides of an issue and encourage others to provide their
perspectives.
7. Consider what is best for the people of the community.
8. Respect different points of view.
9. Listen when others are speaking. Avoid side conversations and ask for
clarification if needed.
10.Leave meetings with clarity on what was discussed and what was decided.
Follow up the implementation of shura decisions.
Before the meeting
1. Meeting attendance is not optional. It is a public duty. When a member is
not able to attend a meeting, he or she should communicate so to the chair
with reason for not being able to attend the meeting, preferably before the
meeting begins. In case of a prolonged absence, the chair will communicate
with the member to enquire about the absence. The chair will bring
prolonged absence of a member without a substantial reason to the notice of
the shura meeting for appropriate decision.
2. Meeting should ordinarily be open to public and interested public should be
allowed to observe the meeting. A confidential session can only be held if
the majority of the voting members present so decide.
3. Except in emergencies, meeting must be announced at least 24 hours before
the meeting starts. The announcement should cover place, date and time, and
agenda items of the shura meeting.
46
4. The chair calls the meeting, asks for the agenda items, and sets the agenda.
The members may make a request to add an agenda item. The chair will
review the request and may allow the agenda item suggested by a member.
5. The facility health shuras will invite issues from the health post shuras. If
health post shuras think their issue needs the facility health shura’s attention,
they will send the issue to the facility health shura. The facility health shura
may invite a representative of the health post shura to make their case.
6. The number of meetings will depend on the amount of work that needs to be
accomplished.
During the meeting
7. Start the meeting with the recitation of the holy Quran and end with Dowa.
Review the implantation of decisions taken in the last meeting.
8. A record keeper and a time keeper are assigned. As shura meeting usually
lasts more than 3 hours, mobilize and provide local refreshment (for
example, tea and cookies).
9. A member should come prepared to meetings, ask questions, pay attention,
and make decisions according to his or her best judgment.
10.A member should enthusiastically volunteer for work assigned by the shura,
for example, taking part in facility visits.
11.A member should be prepared to hear and respect a point of view different
from his or her own. To be able to get to the heart of the matter of an agenda
item, members of the shura must be willing to listen to opinions presented
by fellow members. Everyone should have an opportunity to express his or
her opinion.
12.Decision making in the health shura meetings should be based on consensus.
When consensus cannot be reached, shura decisions will be based on a
simple majority of members present and voting. For a vote to be held, ¾ of
the voting members must be present. If fewer members are present,
discussion may take place, but voting must be postponed until the next
meeting when ¾ of the members are present. If there is no consensus on a
47
decision, the decision is put to vote. Decision is then taken by a majority
which means 51 percent of the voting members in favor of a decision.
13.The health post shura meeting should regularly review and monitor the
performance of the health post and the community health worker on their
core functions.
14.The facility health shura meeting should regularly review and monitor the
performance of the health facility and the health workers working at the
facility.
15.The health shura should invite community members to participate in the
shura meeting.
16.Date and time for the health post or health facility visit are determined.
17.The chair will ensure that the health shura meeting focuses on real,
important and relevant issues and time of the members is well utilized.
18.The chair will facilitate the health shura meetings in a way that the meetings
are productive and decisions are taken.
19.The health shura will have at least one self-assessment meeting every four
months.
20.The chair or the members will suggest nominees for vacant post and the
health shura will select the nominee to be member of the shura. The facility
health shura should also invite nominations for its membership from health
post shuras in its jurisdiction.
21.There should be an evaluation of the meeting by the members at the end of a
meeting. Sample format for such an evaluation is given in the table below.
After the meeting
22.Meetings will take place at least once a month. However in case of an
emergency, health shura members would need to meet more frequently.
23.The chair is responsible to follow up the decisions made in the health shura.
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24.The chair is also responsible for preparing the minutes of shura meetings,
and sharing the minutes with the facility health shura.
25.Issues discussed in health post shura meeting will be shared with the facility
health shuras and other shuras in the manteqa. Shura decisions will be
implemented in coordination with head of health facility, CHS, and CHWs.
26.The chair of the facility health shura is responsible to give timely feedback
on the health post shura minutes. A representative from a health post shura
may participate in the meeting of the health facility shura for the purposes of
problem solving and coordination.
Sample health shura meeting evaluation form
(To be distributed by the chair immediately after the shura meeting)
#
1
2
3
4
5
6
Issue
Meeting started and ended in time.
Meeting followed the agenda.
Agenda focused on real, important and relevant issues.
The quorum was present in the meeting.
All members participated actively.
The chair facilitated the meeting in a skilled way.
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Yes
No
Suggestion
7
The shura meeting covered all agenda items thoroughly and
objectively.
8 I could contribute my skill and expertise in the meeting.
9 Shura members demonstrated an understanding of the issues.
10 I left the meeting knowing what I need to do next.
Responsibilities of head of health shura
1. Lead and facilitate health shura meetings,
2. Lead development of a strong health shura,
3. Make health shura development a priority,
4. Set goals and expectations for health shura,
5. Encourage individual health shura members to take leadership,
6. Work with health shura members to recruit new members,
7. Ensure regular opportunities for health shura self-assessment,
8. Assess results of self-assessment and consider improvements in
consultation with shura members,
9. Oversee community health needs assessment every 3 years or sooner,
10.Solicit inputs from all health shura members,
11.Keep all health shura members engaged in the work of shura,
12.Speak on behalf of health shura regularly and especially when
controversy or conflict arises,
13.Guide health shura in approving plan and overseeing its implementation,
14.Facilitate health shura involvement in strategic planning,
15.Share appropriate information to keep health shura informed and
educated,
16.Coordinate overall resource mobilization effort,
17.Develop meeting agenda, and define the objectives and agenda for the
meeting ahead of time.
18.Resolve conflicts among health shura members,
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19.Coordinate and collaborate with other shuras,
20.Coordinate and collaborate with health facility staff, and authorities in
the district and the province,
21.Welcome participants in the meeting,
22.Start and end the meeting on time,
23.Set the rules of conduct for the meeting, for example, raising a hand to be
recognized,
24.Keeps the meeting moving forward by managing the discussion,
25.Encourage full participation of all attendees,
26.Encourage active discussion and expression of different viewpoints, and
teamwork,
27.Maintain order, courtesy, and spirit of mutual respect,
28.Clarify and summarize conclusions or actions to be taken,
29.Delegate responsibilities, make effective use of subcommittees to work
on activities before the next meeting, and follow up the implementation
of health shura decisions.
30.Establish the time, place, and agenda for the next meeting.
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Strategic, annual, and monthly work planning
1. Strategic planning is the process of defining strategy for the health shura for
longer term (5-7 years) using its knowledge of the community, and the
technical expertise of the health workers. Take a long-term view.
2. The 3-year community health improvement plan developed with intensive
involvement with the community (as discussed in the community health
needs assessment chapter) should guide the strategic planning process.
3. A strategic plan contains
1) mission statement (why we exist as a shura)
2) vision (what we want the community to be in the future)
3) vision priorities (how we will achieve the vision by focusing on the
critical few areas of importance)
4) goals & actions (how we will achieve each priority step-by-step), and
5) values (how we will treat each other, our community members and
health workers).
4. Strategic planning helps the health shura prepare for the future, and improve
its decision-making process.
5. Day-to-day decision-making and problem solving should be guided by the
long-term and short-term goals contained in the strategic plan.
6. Do strategic planning in phases: understand the situation, develop a
community health improvement plan, use it as a guide, set a direction, move
from vision to action, implement the strategic plan and monitor its progress.
7. The strategic plan is the backbone that supports the annual plans.
8. The annual plan is based on the strategic plan and is composed of the current
year’s priority goals and actions.
9. Once a year, the health shura and the health workers should come together to
focus on accomplishments of the year, and prioritize goals for next year.
10.The annual plan should guide monthly work planning.
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Planning Forms and Formats
Strategic plan
1.
2.
3.
4.
5.
Mission
Vision and vision priorities
Goals and strategies
Activities and tasks
Resource mobilization plan
Annual plan
Health
Problem
identified
Desired
outcome
Activities
Time
period
Responsible Results
persons
Resources Comments
to be
mobilized
Review of monthly work plan
No. Planned activity
Percentage Percentage
complete incomplete
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Mobilizing community
1. Build trust and rapport with the community. Build strong relationships with
members of your community, visit the families and households, attend social
functions and converse with the people on their health needs and what can
be done to meet these needs.
2. Frequently walk in the community. Systematically collect information about
health issues in the community that need immediate or long-term solutions
by talking with the people.
3. Build partnership with the well-respected and influential members of the
community. Involve them in the community health work.
4. In your health shura meeting, analyze the information collected by each of
the shura members, identify and rank community health problems according
to their importance and the urgency of solving them. Prioritize the problems.
5. Define solutions working with the health workers and the community
members.
6. Plan together with the community and the health workers what needs to be
achieved, how it will be achieved, who will be responsible for what, what
resources are available and what will be needed, when and where the
activities will be implemented, and how results and success will be
monitored.
7. Arrange a community meeting to arrive at an agreement on the actions that
need to be taken and to delineate responsibility of taking these actions.
Orient the community. Motivate people towards collective action. Raise
their motivation and the energy to a level that they are willing to take action.
8. After every community action, reflect on the lessons learned.
9. Engaging community to collectively generate a shared vision and action
plan, to work towards achieving it, and finally experiencing positive changes
in the community health takes time. Have patience and persist in your
efforts.
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10. Help the community maintain and sustain the positive change.
11.Learn these skills to effectively mobilize the community: public speaking,
planning, managing, observing, analyzing, organizing, and resolving
conflicts.
12.The best way to learn these skills is learning by doing or by practicing them.
13.Learn how to illustrate a point and make it interesting to the community.
14.Be honest, enthusiastic, positive, tolerant, patient and be motivated.
15.Your goal for your community is to strengthen it by promoting self-help
actions.
16.Explain that they have to solve their own problems and you can assist and
guide them, and not do it for them.
17.The community members may also assume that you will provide resources.
Explain that they must identify and contribute their resources.
18.No matter how poor the community is, it has the potential to solve its health
problems, and to become stronger.
19.Facilitate the community members in coming to their own decision. For
example, a clinic may help in treating diarrhea, but it is possible to reduce
diarrhea by: (1) hygiene education leading to behavior change, (2) using
clean potable water, and (3) effective sanitation that keeps human waste
away from the drinking water.
20.Pay particular attention to and involve people with disabilities, the youth, the
aged, the very poor, and the women.
21. Mobilize health providers in the private sector – both traditional and
modern.
22. Religious leaders can play a positive role, for example, they can speak to
community in Friday prayer, on Eid, and other religious days. Involve them
in the community mobilization process.
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Benefits of Community participation
1. Community’s commitment to health services and health increases.
2. Community members contribute additional financial and material resources.
3. Increased motivation and ownership of the community members. When
community performs an activity, community members will supervise and
maintain it.
4. Timely and efficient service provision
5. Motivates government to strengthen health services.
6. Better solutions to service delivery problems
7. More consistent demand and use of the health services
8. More effective planning, management, and use of resources
9. Members of the community can serve as a link to the hard to reach
populations.
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Mobilizing resources
1. Involve both formal and informal leaders in mobilizing community
resources.
2. Provide more information to community members before asking them to
contribute.
3. Seek community contributions about the activities affecting them directly
and immediately.
4. Encourage consensus in the community before taking a drive to mobilize
community funds.
5. Do not think of mobilizing financial resources only. Mobilize human,
organizational, and other community resources. There are many examples:
wood to keep the facility warm, labor to carry out the facility repairs, sand
and bricks for construction, land and space for the health post and the health
facility, food for families coming from far, medicine for the health post or
the facility especially during health emergencies, and private car as an
ambulance for the patients in need.
6. Elect or select a committee of 5 persons, who are considered honest by the
community, to mobilize the resources.
7. Health shura should establish a help box (Da Mrasto Sandooq) to help
eligible patients at a time of need. This help box cannot be kept at the health
post or the health facility because the constitution of Afghanistan provides
for free health services at public facilities. The box may be established at the
village mosque or other prominent place.
8. Work with local associations, institutions, businesses and shuras that exist in
the community. Create partnerships with them.
9. All shura members should take an active interest in mobilizing resources.
They should build relationships or use their existing relationships.
10.People want to help and give to people in need. Use this motivation.
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Participatory rural appraisal
The community faces many health problems and needs. Participatory problem
analysis is one of the participatory rural appraisal techniques. This is a method of
participatory community needs assessment and problem analysis.
1. Organize a community meeting to learn about the community’s perspective
on the health issues they are facing and what can be done to resolve them.
Briefly give an introduction to the purpose of the meeting.
2. Tell people that you would like to discuss two questions.
What health needs are the community members able to meet?
What health needs are the community members not able to meet?
Make sure that the two questions are understood by all members of the
community members present in the meeting. Involve young people in the
meeting. Hold separate meetings for women when community is prepared.
3. Ask the participants to divide in groups and give them group work. The
group task is to discuss the two questions above. Distribute a pile of pebbles
(smooth stones) and a pile of rough stones to each of the groups to represent
the result of their group discussion.
4. To represent each need that is met, a pebble should be used by the group.
For example, if three needs are met, they should have three pebbles. The
groups will use rough stone to represent an unmet need. Size of the stone
represents the importance of meeting the unmet health need from the group’s
point of view. The groups use bigger stones for the unmet needs which they
think are the most serious needs for the community. Each group should
therefore be given rough stones of different sizes. One rough stone
represents one problem.
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5. During group discussions, the shura member who is facilitating the meeting
moves around making sure that the task is understood, and free and frank
discussion is taking place. The facilitator shura member should not lead their
discussion.
6. After a good time of discussion, the groups get back together. Each group
gives its report.
In the first round, all groups report about the health needs that the
community is able to meet using pebbles arranged in a cluster.
Reflect briefly in the full meeting on why the community is able to meet
these health needs.
7. In the second round, have all groups report about the health needs the
community is not able to meet.
Each group will present on the unmet needs they discussed and the three
most critical needs.
Try to understand the different aspects of the three priority health needs. For
each to the three priority needs, the full meeting reflects briefly on:
Why these health needs are not met?
What can be done about meeting them?
8. Get insights on possible solutions from the participants of the meeting. Ask:
What have we tried in the past and what was the outcome?
What have we seen done elsewhere (in other communities, districts, or
provinces)?
Whether there has been any positive experience in coping with the problem?
9. Thank the people for sharing their thoughts. Stress that you have learnt a lot
from them and that you would like to continue the discussion started.
10.Fix a successive meeting to tell the community what the health shura has
done to facilitate meeting of the community’s unmet health needs.
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Chapter 7
Community decision-making and governance
Working with community, solving health challenges, and measuring results are
three core community skills you should acquire as a health shura member.
Adopt four effective governing practices while making decisions in your shura.
Cultivating accountability
1. Be open and transparent. Provide timely and accurate information to the
community and health workers in respect of decisions shura makes. Create a
culture of openness and transparency that serves interests of your
community.
2. Accept responsibility for your actions as a shura member, and accept
ownership for the results of your decisions in the health shura. Demonstrate
a sense of responsibility to the community and to health workers when
making decisions.
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3. Provide timely, clear, and specific performance expectations and feedback to
the health workers and head of the health facility.
4. Regularly review performance of health workers in your shura meeting.
Assess performance of the health facility and health post and explain your
findings to the community.
5. Establish a process for community members to ask questions to health
workers, head of the health facility, and health shura members.
Engaging stakeholders
1. Involve all community groups. Where possible, involve women and youth
by giving them a meaningful place and a meaningful role in shura decisionmaking process.
2. Hold open meetings, and encourage the health workers, facility staff, and
community members to share their ideas.
3. Resolve conflicts in a traditional way when they arise.
4. Seek feedback from the community members and health workers and
respond to it in a timely manner.
5. Establish partnerships for joint action with local associations and other
shuras in your areas. Involve private doctors, pharmacists and other
professionals.
Setting a strategic direction
1. Work with your fellow shura members, health workers and community
members to create a vision of a healthy community and use this vision to
focus all your efforts.
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2. Working with your fellow shura members, health workers and community
members, create and implement an action plan to achieve the vision.
3. Make sound decisions in your health shura to achieve this vision.
4. Set up accountability mechanism i.e. who is responsible for what.
Everybody should be assigned their responsibility.
5. Monitor and oversee the efforts of the community and the health workers to
achieve the vision. Hold conversations focused on results. Community is a
powerful organ. When community wants to do, it can do many things.
Mobilizing and using resources in a responsible way
1. Mobilize resources for achieving the vision and mission of your health
shura.
2. Use these resources carefully to serve the members of the community.
3. Involve public in monitoring the use of resources mobilized from the
community, and also in monitoring the working of the health post and health
facility.
4. Collect all relevant information and evidence, and use them for making
decisions in your shura. Use mobile phones for getting things done quickly
and in time.
5. For reviewing results, walk neighborhood by neighborhood and village by
village, see the result of the activities through your own eyes and hear
through your own ears.
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Conducting community health needs assessment
The purpose of the community health needs assessment is to collect information on
a broad range of issues that provide an aggregate picture of the health status and
quality of life among residents of your community. It also serves as a baseline to
monitor improvements associated with actions taken by your shura and the health
post and the health facility.
1. Conduct a community health needs assessment every three years or sooner if
needed and develop a community health improvement plan to meet needs
identified in the assessment.
2. Community health improvement process is the shared responsibility of the
community, heath shura and health workers.
3. The catchment area of your health post or health facility is your community.
The community may have many different ethnicities and neighborhoods.
4. Collect with the help of your health worker, health post and health facility
information on high prevalence health conditions in the community, and use
of the services provided by the health post and health facility.
5. Community members are a key resource in the assessment of community
health needs. Engage community members as partners in community health
assessment and community health improvement.
6. The best way of learning about community health needs is by speaking with
the members of the community. Convene community members to work
together with the health shura to define a problem, and to define solutions.
Make use of community’s problem-solving abilities.
7. Identify the community’s unmet health needs.
8. Identify high health-need neighborhoods and individuals. Pay special
attention to the health needs of the poor, people with mental health issues
and disability, women and children, widows and orphans, illiterate, and old
people.
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9. Collect information on income and unemployment, access to transportation,
and other issues that are creating a barrier to access health services or to be
healthy.
10.Schools are a rich resource for information as well and also a place for
action.
11.Select priority needs among a large number of unmet health needs in the
community. Focus on meeting these priority health needs.
12.Build consensus for mobilizing and allocating resources in areas most likely
to yield positive outcomes.
13.Establish timeline, and determine who is accountable for what.
14.Document how the health shura, the health facility and the community
working together plan to meet the unmet health needs prioritized by the
community.
15.Mobilize resources.
16.Implement the community health improvement plan.
17.The community health shura will have responsibility to monitor and oversee
implementation of the plan and to make sure that its implementation
improves the health of community members.
18.Health post shuras will work in partnership with its facility health shura, and
also in partnership with other shuras in the village and the manteqa.
19.Health post shura will conduct the community health needs assessment,
develop a community health improvement plan, mobilize resources and
implement it. The health facility shura will support the health post shuras in
its catchment area at all the stages of the community health assessment,
community health improvement planning and implementation of the plan.
20.Health post shuras will share their progress with the facility health shura,
head of the health facility, district health officer and CBHC officer in the
provincial public health office on a regular basis.
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Coordinating and collaborating with other shuras and authorities
1. Health shuras should actively work with other shuras because community
health is influenced by many factors. For example, social inequality,
stressful life, social exclusion, social support, work, unemployment,
addiction, early childhood development, food and transport influence health.
Clean air, clean water, and hygiene and sanitation protect health.
2. The shuras dealing with education, social protection, community
development, water and sanitation, roads and transportation, environmental
protection, agriculture, food, women’s affairs have an important role to play
in improving community health.
3. People’s shura includes representatives of different tribes and it has power to
solve political issues as well.
4. Coordination meetings between different shuras should be held at all levels,
i.e. in the community, at manteqa level and at district level.
5. Health shura leaders should take a lead in organizing these coordination
meetings.
6. Different shuras should network with each other.
7. A list of mobile telephone numbers of different shura members in the
manteqa should be prepared. Shura members can then remain in touch with
each other on mobile phones and can meet on telephone.
8. If there is fighting in the village, all shuras come together to discuss what
should be done. Similarly, all shuras should come together for improving
health and well-being of the community.
9. Establish a close link with different kinds of shura, especially with CDC
shura. In the communities where there is no health shura, CDC shura should
have a sub-committee designated for health-related activities.
10.There should be a meeting of health shuras with each other and also with
other shuras for sharing information and ideas. Health shura may have
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subcommittees, for example, one of them should be liaison committee to
have coordination with other shuras and programs.
11.A representative of shura-e-sehie will participate in different kinds of shuras
and also invite a representative of these different shuras to health shura.
12.The health post shuras should send their issues to the facility health shura,
and the facility health shuras should send their issues to the district health
coordination committees if the issues need attention from a higher level. A
representative from a health post shura may participate in the meeting of the
health facility shura for the purposes of problem solving and coordination.
13.District health officer is the chair of the district health coordination
committee. To make their case, the health post shura and the facility shura
members can participate in the meeting of the district health coordination
committee, with the prior permission of the chair of the committee.
14.Learning visits are necessary for experience sharing. The Ministry of
Agriculture and Livestock uses the training visits very effectively. They
organize visits of the farmers to model farms. Likewise, a health shura
should pay visit to other better-performing health shuras and other shuras
like education shura, shura-e-inkeshfi-mahali (CDC shura), youth shura and
other shuras in the area.
15.Health shura should invite officials to the shura meeting for better
coordination. For example, a health post shura may invite the head of the
health facility to the shura meeting. Similarly, a facility health shura may
invite the district health officer to the shura meeting.
16. The Provincial CBHC Officer should pay monitoring visits to health facility
shuras and health post shuras. If security situation does not allow a
monitoring visit, CBHC Officer can invite health shura representatives to
provincial center.
17.The Ministry of Public Health authorities in the district, province and center
may also pay monitoring visits to health facility shuras and health post
shuras.
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18. Provincial Public Health Director will conduct a general meeting of health
shuras every six months. Representatives of health shuras in the province
will attend this meeting at the provincial center.
Interaction between health shura, health facility staff, health workers and
community
1. Health shuras should meet regularly and the members should know their
responsibilities.
2. Health shura members should be aware of community health problems.
Shura members should know the needs of the people, the health facility and
its staff. They should take responsibility for the health of the community.
3. They should keep close contact with people. The health shuras need to work
more with the community. Without the support of the people in the
community, a health shura cannot do anything. The community should be at
the center of health shura’s and health workers’ attention.
4. Health shuras should help in eliminating discrimination against specific
ethnic groups. The health shuras should work with local associations, for
example, an association of artisans in the village.
5. Health shura members and health facility staff should meet with the
community on a regular basis.
6. Health shura ensures security of health workers.
7. Female staff, for example, midwives, vaccinators and female community
health workers should be supported by the community and the shura
members.
8. Health shura should help in providing land and building for locating
community health workers and health facilities.
9. The head of the health facility should involve the health shura in the annual
planning of the health post or facility.
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10.Health shura should have close coordination with the clinic staff. The clinic
staff should have close coordination with the health shura.
11.If shura members need some information regarding health issues, health
facility staff must provide it.
12.The health facility collects the reports from health posts. This information
should be shared with the facility shura.
13.When a health worker or a facility staff member is not behaving properly
with patients, the patients should be encouraged to call health shura through
mobile telephone. To resolve the problem, the health shura will have a
discussion with the head of the health facility.
14.In emergency situations, shura members can call the head of the health
facility on their mobile phone to help a patient.
15.Shura members can also call, using a mobile telephone, health facility staff,
community health supervisors, or community health workers to get guidance
on a health-related issue.
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Developing shura capacity
1. MOPH CBHC director will develop a strategy for capacity building of the
health shuras.
2. MOPH CBHC department will develop training manual for health shura
members. CBHC department will conduct training for health shura members
on a regular basis.
3. CBHC department will review and further develop the current ToRs of the
health shuras. The points not needed to be in ToR will be removed and
essential points but not currently in their ToR will be added. This will be
done once every two years in consultation with the health shuras all over the
country. Health shuras will be invited to give their inputs.
4. Central and provincial MOPH authorities, Provincial CBHC officer, District
health officer will make monitoring visits to the health shuras.
5. District health officer will organize meeting of the heads of health shuras in
the district.
6. Health post shura, facility health shura, district hospital shura, provincial
hospital community board, district health coordination committee, and
provincial public health coordination committee should work closely with
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each other. Shuras at higher levels should invite to their meeting health shura
chair or members in their area depending on the health issue involved.
7. The head of the health facility, director of the district hospital and the
director of the provincial hospital will be responsive to health shuras in their
catchment area. They will actively coordinate with health shuras.
8. Shura members will have an authority to supervise the health facility.
9. Identity cards will be issued to the health shura members. CBHC department
will design and distribute ID cards to health shura members through
provincial CBHC officers.
10.Health shuras will encourage young members of the community to join the
shura as a member.
11.Health shuras will orient the shura members on the responsibilities of shura
and also on the contents of this guide. New members when they join should
be given a similar orientation by a health shura.
12.Health shuras should carry-out their self-assessment at least once and if
possible two times in a year using the instrument given in this guide. This
has two parts: self-assessment of shura as a whole and self-assessment of
individual members. This should preferably be done in a special shura
meeting called for self-assessment purpose.
13.Health shuras should invite the community members to assess the working
of the shura and to suggest improvements.
14.Health shuras should recognize and celebrate excellent governing behavior
of a shura member.
15.Shura members should regularly reflect on how to improve the working and
the results of the shura.
16.Participation of others shura members in the health shura meetings and vice
versa is good for coordination and capacity development.
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Selection of the head and members of health shura
1. Shura members should be selected by the people of community in
coordination with CHW, CHS, and head of the health facility.
2. Selection of shura members should be according to criteria of truthfulness,
good background, professionalism, commitment, knows the value of the
community and health system, accountable and transparent in dealings with
the community, hardworking, and interested to serve the community on
voluntary basis.
3. The shura members should be honest and honorable. They should know
value of health and the role of health shura in it. They should have good
communication and counseling skills. They should be aware of people’s
health problems.
4. Committed people should be selected as health shura members and those
who are not committed should be removed from membership in the shura. A
person who cannot participate in the shura meetings and activities should not
be member of health shura.
5. A shura member, to the extent possible, should be literate and educated.
6. The Head of a health shura is like a father or a mother in the family. He or
she needs to have courage and decision making ability. He or she should be
able to persuade the community. He or she should be a good communicator
in the community. He or she should be an honorable and well-respected by
the community.
7. If the head and the members of a health shura are committed in fulfilling
their responsibilities, the shura recommendations will be accepted by the
community.
8. Shura members should be able to solve the problems of health facility and
health problems of the community. They should be able to motivate others.
9. Representatives of all ethnic groups should be selected in a health shura.
When each section of community sees their representative in health shura,
they are more likely to agree and comply with shura decisions.
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10.Dress and behavior of shura member should be in line with the local culture.
11.Religious leaders should be encouraged to be a member of the health shura.
Community elders should also be encouraged to serve on the health shura.
Teachers should be encouraged to be a member of the health shura. If
teachers are not a member of health shura, they should be invited to the
shura meeting as necessary.
12.Involve professional people in health shura. Encourage young people of the
community to serve on the health shura. Commanders however cannot be
head or a member of health shura.
13.Increase awareness of the community on importance of women’s
participation in health related activities especially through Friday khutba.
Where possible, convince community to allow participation of women as
shura members.
14.Women’s health shura should be established separately when community is
not prepared to have a mixed shura. Suitable and secure place should be
provided for women’s health shura meeting.
15.Female staff of the health facility should work with women in the
community to encourage them for participation as shura members in
women’s health shura.
72
Chapter 8
Women’s health shuras
Shuras have long played an important role in Afghan society. Traditionally
comprised of respected male elders, shuras are responsible for resolving conflicts,
deciding community issues, and taking action to meet community needs. Afghan
women are assuming leadership roles in women’s health shuras to improve the
health of their communities.
Many communities have women’s health shuras. Members of women's health
shuras are selected by their own community on the basis of their knowledge,
acceptance by their neighborhood and ability to cooperate with others. Women’s
health shuras convene regularly, with female CHW in attendance, and meet once a
month. NGO and health facility staff help shura set goals and plan health activities,
such as promoting child immunizations, reinforcing CHW messages on birth
spacing or increasing the number of women receiving antenatal care.
73
In some communities, men and women serve on a shura-e-sehi together. In others,
male and female shuras meet separately. In either case, men and women coordinate
their activities and work together to achieve action plan goals. For example, men's
and women's health shuras may meet in the same room separated only by a curtain,
allowing mutual consultation; meet in adjacent rooms, with a respected older
woman acting as a mediator to keep each group informed on ideas being discussed
and decisions being made; or share meeting minutes. Often, members of a women's
shura are married or related to members of the men's shura, allowing a free and
steady exchange of information.
Women's shuras improve the use of health services by raising awareness about
health issues, sharing what they've learned with other women in the community
and supporting the advice of CHWs on maternal and newborn health, birth
spacing, vaccination of children, home hygiene, and care of pregnant women. They
work closely with female CHWs and the CHS supervisor to identify, address and
solve problems. For example, when CHWs have patients reluctant to seek needed
help at the clinic, a shura member visits to reinforce the referral.
The members of the women's shura are able to counter
misunderstandings, visiting households to talk to other women
personally and taking advantage of opportunities such as
weddings and funerals to convey health messages. In some
communities, a shura member and a CHW pair as a team to
target 10 to 15 people for specific health messages. CHWs
value the help of women’s shuras.
Women shura members, CHSs and CHWs told USAID’s
REACH project staff the following benefits of having a
woman’s health shura in the community.
1. "People have become more knowledgeable. Previously, people did not
breastfeed newborn babies for three days. Now CHWs and the female shura
encourage mothers to nurse their babies right away because the first milk
provides protection from disease."
2. "Shura members support the CHWs when they have difficulties. If mothersin-law won't accept their sons' and daughters-in law's use of family planning
methods, shura members go to talk to them."
74
3. "A pregnant woman in our village would not take a CHW's advice that she
should have a Tetanus Toxoid (TT) vaccination. She was afraid. A shura
member went to the woman to explain the benefits of TT vaccine and
successfully convinced her to be vaccinated."
4. "Changes have occurred since the female shura was organized. There is
better hygiene in the community, more use of family planning, increased
vaccination, and acceptance of CHWs and antenatal care. And people are
now visiting the clinic instead of using 'homemade medicine.' "
Since the establishment of a women's shura-e-sehi attached to a Basic Health
Center in Kabul province, the number of families practicing family planning and
birth spacing had risen from 20 to 80, and the number of women choosing to
deliver at the clinic had grown from five in five months to five every month. In the
words of one female shura member, “In our villages, women have more health
problems than men. Men do not know them. Where there are more problems for
women, women's voice must be heard.”
75
Chapter 9
Self-assessment
I.
Self-assessment checklist to be used by health shura as a whole
in a special self-assessment meeting to be held once a year
Maximum score: 100
On a question, a ‘no’ response gets 0 points, and ‘yes’ response gets 2 points.
Scoring guide for checklist:
Score of 75 and above: shura’s performance is excellent,
Score of 51-74: shura meets most requirements,
Score of 25-50: shura needs to improve in its performance, and
Score below 25: shura’s performance is unsatisfactory.
Item Question
No Yes Score
1
Did your health shura work with other non-health shuras
in the past 60 days?
2
Did your shura interact with any other health post shura or
facility shura in the past three months?
3
Did your health shura meet in the past 30 days?
4
Was there a quorum when your shura met last?
5
Does your health shura have a minute book?
6
Were the minutes recorded for the last shura meeting?
7
Are all ethnicities in the community fairly represented in
your shura?
8
Are all geographical areas where the community lives
fairly represented in your shura?
9
Did your health shura review the performance of health
workers in at least one of the last two meetings?
10
Did a member of your shura visit a health post or a health
facility on behalf of the shura at least once in the past
three months and reported back to shura?
11
Did your health shura give feedback to health workers in
at least one of the last three meetings?
12
Did your health shura develop annual action plan this
year?
13
Did your health shura review stock outs of medicines in
the past three months?
14
Did your health shura conduct self-assessment this year?
76
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Has your health shura mobilized local resources during
the past three months?
Did your health shura discuss how to address health
problems of the community in its last meeting?
Did your health shura discuss how satisfied people are
with the health services in at least one of the last three
meetings?
Did your shura work with the schools and school teachers
in the past three months?
Did your shura facilitate referral of sick persons in the
past 30 days?
Did your shura help the poor people access health services
in the past three months?
Has your shura helped the disabled people in accessing
health services in the past three months?
Has your shura helped the people with mental health
issues in accessing health services in the past three
months?
Has your shura encouraged the TB patients to take
treatment in the past two months?
Has your shura been supportive of skilled birth attendants
in the past three months?
Has your shura been attentive to pregnant women and
their problems in the past two months?
Has your shura provided transportation to pregnant
women in the past three months?
Did your shura discuss people’s reluctance to use health
services in at least one of the last three meetings?
Did your shura persuade people to go the clinic in time for
health care, vaccination, antenatal care, delivery and
consultation in the past 3 months?
Did your shura check if the health workers are regularly
receiving training in the past three months?
Has your shura participated this year in national
immunization days?
Has your shura reviewed this year if the health workers
are organizing campaigns?
Has your shura organized a mass meeting of people at
least once this year?
77
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
Did your shura mobilize resources for the health post or
the health facility in the past three months?
Did your shura mobilize the community on a specific
health problem or a health behavior in the past three
months?
Did your shura invite the community members to talk
about their health needs in the shura meeting in the past
three months?
Did your shura give the community members opportunity
to raise questions and offer comments on the functioning
of your shura in the past three months?
Did your shura discuss in the shura meeting health
hazards or health risks in the community in the past three
months?
Did your shura meet with the community health worker or
community health supervisor or head of the health facility
in the past 30 days?
Did your shura define the shura’s vision of a healthier
community in the past three months?
Did your shura encourage the health worker or the facility
staff or the head of the health facility to undergo training
or acquire new skills in the past three months?
Did your shura give information to the community about
health issues it is currently facing, in the past three
months?
Did your shura take active steps to establish trust and
rapport with the community in the past three months?
Did your shura involve mulla imams in a community
health program in the past three months?
Did your shura promote healthy behaviors and lifestyles
in the community in some way in the past three months?
Did your shura encourage establishment of a women’s
health shura in the past three months?
Did your shura coordinate and collaborate with BPHS
implementing NGO in the past three months?
Did your shura conduct a community health needs
assessment in past one year?
Has your shura been effectively fulfilling its role in the
past three months?
78
49
50
Do people find your health shura to be useful?
Did people respect shura recommendations in the past
three months?
II.
Self-assessment for individual members of a health shura
Maximum score: 10
On a question, a ‘no’ response gets 0 points, and ‘yes’ response gets 1point.
Scoring guide for checklist:
Score of 8 and above: shura member’s performance is excellent,
Score of 5-7: shura member meets most requirements,
Score of 3-4: shura member needs to improve in his or her performance, and
Score below 3: shura member’s performance is unsatisfactory.
Item Question
No Yes Score
1
Did you visit a health post or a health facility at least once
in the past two months?
2
As a health shura member, are you clear about what is
expected of you?
3
Are you satisfied with your attendance at board meetings?
4
Have you suggested an agenda item for consideration in
the past two shura meetings?
5
Did you give your time to community health work
between regular shura meetings?
6
Did you support the health post or the health facility with
a personal contribution of resources in past one year?
7
Are you satisfied with your personal commitment to
ensuring adequate resources for the health post or the
health facility?
8
Did you suggest qualified nominees for future shura
membership?
9
Are you able to explain the purpose of the health shura?
10
Are you able to explain your role on the health shura?
79
Chapter 10
Community scorecard, shura checklist, map, tally sheet and health
campaigns
Community scorecard
Community Scorecard is a participatory tool that can be used in the assessment,
planning, monitoring and evaluation of service delivery. The community score
card can be very useful to a health shura.
It is a participatory, community based monitoring tool that enables community
members to express their assessment of the health services provided by the health
post and the health facility. It is used to inform community members about
available services and to solicit their opinions about the accessibility and quality of
these services. It can increase social and public accountability and the
responsiveness of the health works and facility staff.
To implement a community scorecard in your community, take the following
steps:
I.
Develop a scorecard
1)
2)
Convene community members into one or more discussion groups.
Ask each group to identify performance indicators for the health service
the community gets.
Ask the group to score each indicator and give reasons for the scores.
Ask the group to develop their own suggestions on how to improve the
service, based on the performance criteria they have identified.
3)
4)
80
II.
The health workers and the facility staff conduct self-assessment
1) Help the community health worker and the facility staff to develop a selfevaluation score card.
2) Hold a session with them to develop self-evaluation indicators.
3) Ask them to score each indicator and give reasons for the scores.
4) Discuss possible solutions.
III.
Convene a joint meeting between community and the health staff
1) With the facilitation assistance of shura members, each group presents its
indicators and scores.
2) Reasons for scores are discussed.
3) The health staff gives feedback and response to the score given by the
community members.
4) All participants discuss and agree on possible solutions.
IV.
Follow-up
1) Record score card results and announce the results to the community and
to the health staff.
2) Use score card results for improving the experience of the community
with the health services.
3) Ensure the implementation and follow-up of the solutions.
4) Involve community-based organizations in the scorecard initiative.
5) Repeat this scorecard exercise on an annual basis.
Sample community score card for a health facility
No. Indicators (in
order of
importance)
1
Availability of
female staff
2
Night duty
3
Behavior of staff
4
Availability of
medicine
5
Waiting place
Maximum Score
score
at the
baseline
10
10
10
10
10
81
Score
after 4
months
Reasons for giving
a specific score
Example of scorecard from pilot project in Kalafgan, Takhar Province
(Community Scorecard Project jointly implemented by Community Based Health
Care Department of the Ministry of Public Health, Future Health Systems II and
The Johns Hopkins Bloomberg School of Public Health):
Health staff self-assessment
SN
Input Indicators
1
Clinic staff (lack
of female doctor)
2
Medicines (lack
of community’s
information
regarding
availability of
medicines)
3
Waiting place for
patients
4
Reasons for scoring 1st
round
1- because there is no
female doctor and
nurse in the clinic
2- because it is better
if a female doctor visit
female patients with
women’s problems
1-From the community
perspective, there is
shortage of medicines
in the clinic, but
according to the BPHS
list the medicines are
complete
Reasons for scoring 2nd
round
1-Too much load of
work on male doctor
and midwife.
2-Most of the female
patient could not share
their problems with
male doctor.
1-The medicines
arrives according to
BPHS list, no lack of
medicines.
Reasons for scoring 3rd
round
1- Because hopes are
decreased and both the
implementer NGO and
PPHD are not able to
hire a female doctor.
6
1-There is no suitable
waiting place for male
and female patients
4
9
1-Some equipment is
used in different wards
of the clinic and by
various staff, and also
there is no
sphygmomanometer
and stethoscope,
some pieces of
equipment are not
functional
1-In previous there was
no such tent.
2-With brining this tent
must of the problems
of women’s have
salved.
1-With spending four
months the equipment
which was old got
older and still we did
not receive new BP
checker
1- Kalafgan district has
a cold winter and the
tent could not solve the
problem.
2- We need a waiting
room with metal roof.
1- We got two BP
checker and the old
equipment does not
prevent our normal
activities.
1-The guards need to
be close to the door
and also delivery
room needs to have
separated bathroom.
1
3
1-There is a reasonable
place to build a room.
1- The bathroom attach
to the delivery room has
completed,
2- The list of the people
who will donate for
construction of a room
is prepared
Reasons for
Performance
Indicators
1-With both wealthy
and poor people have
the same behavior.
2-Some time the
patients are not
satisfied due to too
much load of the
patients
1-Every morning the
patients instructed to
different parts of the
clinic according to
their sicknesses
2-The waiting time is
reasonable, except the
time in which the load
of patients is higher
1- Health education is
conducting in
different parts of the
HF for clients and
patients by HF staff
2-Health education is
Score out of 10
1st
2nd
3rd
Reasons for scoring 1st
round
Reasons for scoring 2nd
round
Reasons for scoring 3rd
round
Reasons for Input
Indicators
1-Lack of the clinic
staff.
2-Femal doctor
should be hired
Score out of 10
1st
2nd
3rd
9
8
4
1- Giving white pills
to every patient, but
the community need
to know that their
effect and types are
different
2- Medicine is
supplying to us
according to BPHS
list.
1-Clinic building is
not standard
2-No Separated place
for male and female
patients
10
10
10
5
8
Medical
equipment
1-Medical equipment
got older and some of
them are useless.
2- BP checker is not
available.
8.5
5
1-Building a
room for guards
beside the door
and bathroom for
delivery room
SN
Performance
Indicators
1
Staff behavior
2
Patients waiting
time
3
Health education
and counseling
9
1- The list of medicines
has been increased.
2- The people are more
aware regarding the
effect and quality of
medicines now.
9
10
1- because patients are
satisfied with our
service provision
2- BCC cannot be
carried out in a
standard way
1-There is no
difference between
wealthy and poor
people for us, we are
treating them the same
The behavior of staff is
very good, the patients
and clients are satisfied,
the guards and the
supportive staff guide
them to required
department
8
8
9
1- Because there is no
suitable waiting place
for patients
1-All the patients could
not be Counseling at
one time,
2- Our CHC need to be
promoted to DH
The lode of the patients
is still high because we
did not have female
doctor. And the
counseling taking more
time
9
9
9
1- Existence of a wellorganized plan for
health education in
each section
2- proper prescription
of medications, and
1- The health
education is going on
in the community and
HF but we are forcing
for the increasing of
education
The health education is
going on, it’s got better,
it’s an ongoing process
need to be proceed
82
conducting by CHS
and CHWs for the
villagers
clear description of
medication on pockets
4
Staff Punctuality
1-HF staff are always
present on their duty
2- Night duty is going
on smoothly in the
clinic according the
time table
9
9
10
5
Accurate
examination
1-According to the
protocol all the
examinations are
conducting in every
part of the HF.
2-Due to too much
load of the patients
especially in IMCI,
the waiting time is
very difficult to
manage
9
5
9
1- Because when we
come to the facility in
the morning first of all
we starting our work
and whenever we find
chance we go and sign
our attendance then.
2- they sometimes do
not come due to long
distance to work (from
their homes) and bad
weather
1-sometime with load
of patients accurate
examination is not
possible
2- all steps of
examination are
considering when
checking up the
patients
1-All the staff are
present on their duty
during the working
hours
The staff of the HF is
punctual, they serving
their clients day and
night
1- Till now the IMCI
training is not
conducted for the HF
staff
2-There is no BP
checker in the HF
The accurate
examination is better
now, one of our nurse
received IMCI training
now and because of that
we do not have
problems with
examining the patients
Community Scorecard
Female Scorecard
Reasons for Input
Indicators
1-Before we were not
aware that a female
doctor is necessary for
our clinic we thought
that every exam is
providing by the
midwife.
1-Because there was
no suitable place for
patients
Score out of 10
1st
2nd
3rd
10
8
7
Reasons for scoring 1st
round
1-They solve all of our
problems and we
should have given them
a score above 100.
2-They serve us day
and night
Reasons for scoring 2nd
round
1-Now we understood
that a female doctor is
also necessary for our
clinic to salve all the
problems of the
community.
Reasons for scoring 3rd
round
Because hope for
hiring female doctor
decreased, and female
doctor is an immediate
need of the HF
3
10
5
There is no proper
waiting area and we are
facing serious problem
for both in the summer
and winter.
1-They have brought a
tent and a few chairs
which can answer the
need of the patients in
summer and winter
Medicines
(Information
regarding
availability of
medicines)
1- Because our people
had no information
regarding the types
and effects of the
medicines.
3
9
10
They give the same
white tablet for all
patients
1-Now we are aware
about the types and
effects of the medicines
The tent could solve
the problem of waiting
time in summer but the
winter of Kalafgan
district is very cold
and could not solve
our problem we are
requesting for a
permanent place for
waiting.
Before we don’t know
about the medicines
and its quality, now we
know that the
medicines which is
providing by our HF
have more high quality
then the medicines of
bazar
SN
Performance
Indicators
Reasons for scoring 1st
round
Reasons for scoring 2nd
round
Reasons for scoring 3rd
round
1
Night duty
Reasons for
Performance
Indicators
1-Because the person
who is responsible for
night duty he/she is
always in people
service
2-The midwife
providing all the
services to the people
1. They solve whatever
problem we have (They
help us even when our
children are wounded
or have fallen from the
heights)
2. They always serve us
and we do not have any
problem
1-Whenvere we got
sick the staff of the
clinic is in our service
and they are doing our
treatment
The night duty of the
staff of the HF is
perfect; whenever we
went to the clinic the
required staff was
available especially
during the night time
SN
Input Indicators
1
Staff of the clinic
(lack of female
doctor)
2
Waiting place for
the patients
3
Score out of 10
1st
2nd
3rd
10
10
10
83
2
Lab services
1-lack of knowledge
of lab technician and
need for training
2-All the necessary
exams and services
providing by lab
1- The health
education is providing
individually and as
group for the patients
but it is not in simple
language
10
10
10
Knowledge of lab
technician is low and
need for more training
3
Health education
9
10
10
Because the midwife is
very kind and advise us
during checkup
4
Accurate
examination
1-Whenever we are
going to the clinic
they check us
accurately
10
10
10
We are glad with
midwife, because if she
is not here, the doctor
does not checkup us
correctly. She is really
kind.
5
Staff Punctuality
1-The staff of the
clinic is punctual.
10
10
10
Although they
sometimes make
absence we are satisfied
with their performance.
They really try hard to
serve us.
Action Plan
No
Indicators
1
2
3
4
Shortage of clinic
personnel (female
doctor)
Waiting place for
patients in the
clinic
Medical
equipments of the
clinic (Old and
shortage)
Construction of
the guard’s room
near the gate and
bathroom
attached to the
delivery room
What to do for
improvement?
Who will do
this?
Continuous search and
requests for hiring a
female doctor by clinic
health Shura (council)
and leadership of the
clinic, CAF NGO’s
directorate and
provincial department
of public health in
Takhar
Suggestion to construct
a shade or bring a tent
for men’s waiting place
in the clinic through
clinic health council,
head of clinic, CAF
org, and attract
cooperation of public
health dept and
Kalafgan people in this
regard
1.
Since CAF NGO
informed of
procurement process of
required medical
equipment by Kabul
main office, this should
be followed by head of
clinic and CAF NGO’s
office in Takhar.
Request should be done
by the clinic health
council and making
joint efforts with head
of clinic, CAF suboffice in Takhar, and
elders of Kalafgan to
1.
2.
3.
4.
1.
2.
3.
4.
5.
2.
3.
1.
2.
3.
Head of
clinic
Clinic
health
Shura
CAF NGO
Takhar
Public
Health
Department
Head of
clinic
Clinic
health
Shura
CAF NGO
Takhar
Public
Health
Department
Kalafgan
People
Head of
clinic
CAF
NGO’s
Sub-office
in Takhar
Clinic
health
Shura
Clinic
health
Shura
Head of
clinic
CAF Suboffice in
84
1-The tests which are
necessary and the lab
technician is capable of
providing, such: Urine,
Sputum, and blood
exams
1-On time consultation
providing to all patients
2-Explians the basic
massages, even telling
about the usage of
medicines in simple
language
1-They pay attention
and examine us
accurately, whatever its
male doctor or female
The lab services
improved because of
recent trainings the lab
technician received,
we are fully satisfied
1-24 hours present to
our service
2-Because most of the
patients referred during
night time to the clinic
and the responsible
person for night duty is
always available and
we are not facing any
problem
Staff is always
punctual even on
official holidays if we
got any problem they
are always available
for us
Health education is
providing every day at
every branch of the HF
to the patients and
clients and knowledge
of the people got better
Accurate examination
is good, because every
patient examining at
the best way and
according his/her
sickness
When they will do
this? (In short or
long time)
Note: Efforts to hire
a female doctor has
been ongoing since
long time ago.
Efforts should be
done to hire a female
doctor within 6
months.
Actions proposed
A tent was brought
for women’s waiting
place. Efforts should
be done to resolve
the problem of
waiting place for
men with
construction of shade
or bringing of tent
within 3 months.
The time frame
extended for 3
months.
Within 2 months
By end of 3 months, Kalafgan people
should be informed about the resolving of
this problem
It was extended for 2
more months
People should be informed about progress
of the issue during conducting monthly
meetings of health Shura, as well as attract
people’s cooperation in any phase
Anytime during conducting clinic health
meetings till hiring of a female doctor,
information should be provided to the
community about the progress been made
in the process and to attract their
cooperation
By end of 2 months, Kalafgan CHC
should be supplied with required medical
equipment and keep informed the clinic
health council and ensure the community
people
find a fund and collect
needed instruments for
construction
5
Time of patients’
waiting in the
clinic
As long as the main
reason of long time
waiting of patients in
the clinic is lack of
female doctor as well
as the huge number of
patients, request for
promoting this clinic to
a district hospital level
by clinic health council
and head of clinic with
approval of District
governor to the CAF
NGO’s sub-office in
Takhar and Takhar
Public Health Dept. for
further follow up.
4.
1.
2.
3.
4.
5.
Takhar
People and
elders of
Kalafgan
District
Clinic
health
Shura
Head of
clinic
Kalafgan
District
governor
CAF
NGO’s
office in
Takhar
Takhar
Public
Health
Department
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Within 3 months
Head of clinic should keep posted clinic
health council about the progress, so local
community get information. In addition,
efforts to hire a female doctor should be
continued to resolve the immediate
problems of this section’s patients.
National monitoring checklist for shura
Functional health shuras
These are minimum criteria to say that a health shura is active and functional:
1. Constitution: It is a written document which describes the purpose and TOR
of a health shura and introduces its members to the reader. The document
should have the date of its establishment and the signatures of its
participants.
2. Health shura’s annual work plan: This is a work plan developed by shura
members working with the health workers and health facility staff, and the
community. The plan identifies, and prioritizes activities which improve the
community health. The plan has a timeline of one year. The health shura
follows up the implementation of this work plan in its regular meetings.
There is a document that describes the progress made against each activity in
the plan.
3. Monthly meetings: Shura should have had at least one meeting every month
to review the current community health situation, progress of work plan and
updates from health facility.
4. Community in-kind or monetary contribution: This is an important aspect of
health shura activities and it shows that people are making contributions.
Shura should maintain a record of such contributions.
Coordination of activities among health posts, health shuras and health
facility
Regular communication and sharing of information, ideas and updates among
health shuras, health facility staff and health workers, and the community is vitally
important for the community health. Health shuras and health facility staff and
health workers have a key role to play in this exchange of information, ideas and
updates.
Monthly meetings of community health workers at the health facility
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The head of the health facility, community health supervisor, and midwife invite
the community health workers once a month to the health facility to discuss the
following topics.
1. Community health worker performance in the last month, challenges and
how to overcome these challenges
2. Reporting of issues
3. Progress in referrals
4. Supply and stock outs at health posts
5. Supervision and monitoring plan
6. Upcoming events and campaigns
7. Other topics relevant to community health
All the above topics are discussed and a summary of discussions is recorded and is
kept with health facility. These discussion points must be shared by the health
facility staff with the health shura.
Facility health shura meeting
The head of the health shura should schedule monthly meetings of the health shura.
The meetings should cover:
1. Annual action plan progress
2. Health service delivery at the facility and challenges in delivering health
services
3. Community health worker updates
The minutes of these meetings should be shared with the health facility staff,
health post shuras and community health workers.
Health post shura meetings
Community health supervisor and community health worker participate in the
meetings of health shuras. Because of a large number of health posts, the
community health supervisor may not be able to participate in the monthly
meetings of each health post. Health posts in the catchment areas of a facility
should to the extent possible have their monthly meetings on different dates so that
community health supervisor is able to participate in most of the health post shura
meetings every month. The information gathered from health post shuras in a
month should be recorded by the community health supervisor and shared with
health facility shura, health facility staff and community health workers in their
monthly meeting.
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Community map
A community map is a simple graphic representation of the location of married couples in a
community who are eligible for or potential users of any component of the basic package of
health services. The map is drawn by a health worker or by volunteers based on information
gathered from a household survey. The volunteer draws each neighborhood residence on the map
and uses color coding and different icons to indicate which of the BPHS each individual is
currently using. Community maps can be useful in addressing:
1. Maternal health care, including prenatal and post natal care
2. Child health care, including immunization
3. Reproductive health care, including family planning
A community map can provide the health shura with a simple and accurate picture of maternal
and child health (safe motherhood and child care) and of the state of reproductive health and
family planning in the community.
A community map illustrates the following features of a community:
1. The location of all households in the community
2. The major landmarks in the community, such as roads, rivers, lakes, schools, health
centers, markets, graveyards and mosques
3. The most direct or efficient route to a particular household.
A map can also provide following information on the state of reproductive and child health in the
community:
1. The reproductive status of the woman in the household
2. The immunization status of children in the community
3. The current contraceptive status of each eligible couple.
The community maps are easy to understand. Health shura members should familiarize
themselves with the community map of their community. Health shura can use the map to:
1. Become aware about current health situation of the community. They become aware of
the number of users for each type of family planning methods and other maternal and
child health care services.
2. Review the use of health and family planning services.
3. Identify individuals for more extensive counseling about maternal health, immunization,
child care, family planning or referral to other health care facilities.
4. Identify women who need pre and post-natal care services, and high risk pregnant women
in need of attention.
5. Identify problems encountered by community health workers, and provide appropriate
support in solving them.
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Pictorial tally sheet
1. This pictorial form is used to record information about monthly household
visits and services provided by the community health worker.
2. One sheet is filled out for one community health worker catchment area each
month.
3. Community health worker fills out the tally sheet after each visit or at least
at the end of the day.
4. A line symbol like this (│) represents one visit or one activity, (││)
indicates two visits or two activities, (│││) indicates three, and so on.
5. This tally sheet has pictorial entries pertaining to maternal and child health.
6. This form is used by community health workers to tally the data from their
individual villages/catchment area.
7. The community health worker prepares the pictorial tally sheet for the
village, gives it to the community health supervisor, who reviews and
corrects the sheet working with the community health worker.
8. The community health supervisor copies the totals for each entry and
summarizes the information on the monthly activity report of the health post.
9. A tally mark is put in “Total number of families visited” each time a family
visits the CHW or was visited by the CHW in the month.
10. The pictorial form consists of the following 5 sections:
1.
2.
3.
4.
5.
Family planning
Maternal Health
Child Nutrition
Under-five ill health
Immunization
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A. Family planning
1. Oral contraceptives distributed: A tally mark is put for each cycle distributed.
2. Condoms distributed: A tally mark is put each time condoms were distributed.
3. Contraceptive injections given: A tally mark is put for each injection given.
B. Maternal Health
1. Normal Delivery Referred: A tally mark is recorded for each Normal delivery referred during this
month.
2. Number of women referred for an obstetric complication: A tally mark is entered for each woman
from the catchment area referred for an obstetric complication during the month.
3. Number of maternal deaths in the catchment area: A tally mark indicates each woman from the
catchment area who died during pregnancy, delivery or within 42 days after delivery, except
those that died from accidental causes.
4. Number of neonatal deaths in the catchment area: A tally mark is put for each newborn that died
within 28 days of birth in the catchment area.
C. Child nutrition
1. Number of children screened for mid upper arm circumference: A tally mark shows each child
screened for mid upper arm circumference by the CHW during the month.
2. Referrals for child malnutrition: A tally mark is entered for each child referred to a facility for
malnutrition treatment during the month.
D. Deaths of children under five years of age
1. Treatment for acute respiratory infection: A tally mark is put for each child treated or seen for
acute respiratory infection in the community this month.
2. Referrals for acute respiratory infection: A tally mark is put for each child referred to a facility for
acute respiratory infection during the month.
3. Treatment for diarrhea: A tally mark is recorded for each child treated or seen for diarrhea in the
community during the month.
4. Referrals for diarrhea: A tally mark is entered for each child referred to a facility for diarrhea in
the month.
5. Treatment for malaria: A tally mark is put for each child treated for malaria during the month.
6. Referrals for malaria: A tally mark is recorded for each child referred to a facility for malaria
during the month.
E. Immunization
1. Referrals Children for Immunization: A tally mark is entered for each child referred to a facility
for BCG, DPT, Polio, and Measles during the month.
2. Referrals women for TT: A tally mark is put for each woman referred to a facility for Tetanus
immunization during the month.
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Community health campaigns
One of the activities that health shuras should support is community campaigns for
creating and sustaining healthy behaviors that will result in lowering death and
disease among mothers and children. The campaigns raise community awareness
about healthy behaviors.
Organize the following campaigns in your community:
1.
2.
3.
4.
De-worming
Personal hygiene
Chlorination of wells
Preventing malaria
Each campaign should have three components:
1. Health education—information about healthy behaviors
2. Dissemination of Information, Education and Communication materials
3. Distribution of health products, medicines, drugs etc.
Campaign activities:
1. Plan the campaign ahead of time with your community health worker and
the facility staff.
2. Organize gatherings in mosques, guest houses, schools and the homes of
family health action group members.
3. Sessions should be inaugurated by officials and community elders. They
should clearly describe the purpose and objectives of campaign.
4. Focus on health education. Highlight the harm and also explain how people
can prevent or avoid the illness. This will help individuals change their
behaviors to healthy practices.
5. Visit homes to cover those who missed gatherings. Briefly orient them on
the campaign objectives. Ask them why they did not come to the gathering
and encourage them to attend the gathering next time.
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Annexes
Job description of Facility Shura-e-Sehie
1. Be knowledgeable on selected BPHS, CBHC policies and CHW’s job description
2. Write and sign a constitution for the facility level shura. The constitution will record the
names and gender of the members and their village of origin (to ensure equitable
representation of the communities in the catchment area), the name of the elected
chairperson and member-secretary. The facility in-charge or community health supervisor
will act as the member-secretary of the shura. The member-secretary will be responsible
for recording and maintaining meeting minutes.
3. Facilitate a health needs assessment with the facility level shura members. The needs
assessment should focus on the major health related problems perceived to be faced by
the community.
4. Based on the BPHS and the health problems perceived by the communities they
represent, the members will develop an annual action plan.
5. The members should organize an open door event held at the health facility for public
participation every six months. This event should be organized on a specific day like
Bazaar Day, when people can visit the health facility to know about the staff and the
services provided. This will establish a relationship of trust between the people and the
health facility staff.
6. Mobilize local resources for strengthening and sustaining BPHS activities
7. Support health facility and community health shura in fulfilling their responsibilities
8. Conduct monthly meetings and maintain meeting minutes
9. Monitor monthly performance of the facility and determine level of client satisfaction
10. Review implementation status of annual action plan
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Job description of Health Post Shura-e-Sehie
1. Be knowledgeable on selected BPHS, CBHC policies and CHW job description
2. Reviews monthly progress/performance of CHWs’ activities including CHW’s updating
of community maps, CHW’s completion of monthly Pictorial Tally Sheets, and CHW’s
referral of clients to health facilities.
3. Shura gives feedback to the CHS and CHWs regarding their performance.
4. Reviews progress of annual action plan for popularizing BPHS activities
5. Supports the CHWs in the promotion of healthy behaviors and appropriate use of health
services at community and facility levels
6. Supports outreach activities from the facility and mobilizes the community to participate
7. Mobilizes local resources for strengthening and sustaining BPHS activities
8. Conducts monthly meetings and ad hoc emergency meetings
9. Shares ideas and actively participates in the selection/election of CHWs
10. Shares ideas and actively participates in the selection/election of Family Health Action
Groups
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Job description of a community health worker
The CHW promotes healthy lifestyles in the community, encourages appropriate use of health
services, treats common illnesses, and provides referral for complicated cases. The CHW is
accountable to the local Shura for performance and community satisfaction and is technically
accountable to the community health supervisor (CHS) assigned by authorities from the nearest
health facility.
A. Community Collaboration and Health Promotion
1. Actively participates in community meetings and major community events.
2. Actively works with mothers’ groups to promote healthier homes and maternal and child
health.
3. Encourages and mobilizes family and community participation in the immunization of
children and women of child-bearing age.
4. Supports national initiatives at the village level and actively participates in all
campaigns/activities e.g., national immunization days and surveillance for acute flaccid
paralysis.
5. Promotes good nutrition practices and encourages early breastfeeding and exclusive
breastfeeding of children less than six months of age.
6. Promotes use of Oral Rehydration Salt (ORS) and other homemade rehydration fluids for
home management of diarrhea and dehydration.
7. Promotes hygiene and sanitation, and the preparation and use of safe drinking water.
8. Encourages couples to practice birth-spacing and receive family planning services.
9. Promotes psychosocial well-being and mental health in the community and raises
awareness about prevention and identification of disabilities.
10. Creates awareness within the community and provides information on the dangers of
addictive substances such as tobacco, naswar, opium, hashish, and alcohol.
11. Establishes and supports Family Health Action Groups to speed up behavior change
including health care seeking behavior.
B. Direct Services
1. Identifies and manages acute respiratory infections, diarrhea, malaria, and other common
communicable diseases according to national protocols. Treats mild to moderate cases
and refers complicated cases to the nearest health center.
2. Counsels patients on correct use of medications included in the CHW kit.
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3. Creates awareness among the community on how to prevent TB and should refer or
accompany suspected cases to a health facility. Following completion by a tuberculosis
patient of the first phase of treatment at the health facility, the CHW should ensure
compliance of TB patients with the second phase treatment course in the community,
based on DOTS.
4. Communicates the importance of antenatal and postnatal care. Distributes micronutrients
and anti-malarial drugs to pregnant women according to national policy. Encourages the
community to make regular and timely use of Maternal Child Health (MCH) services.
5. Encourages the use of skilled birth attendants, where possible, and helps families make
birth plans. Provides and teaches the use of a mini-delivery kit. Teaches family members
to recognize the danger signs of complications of pregnancy and childbirth, and assists
them in making preparations for emergency referral.
6. Distributes oral contraceptives and condoms to willing members of the target population
according to national policy. Promotes LAM together with exclusive breastfeeding for
the child’s health during the first six months of a child’s life. Administers first and
follow-up injections of Depo Provera. Encourages interested families to seek long-term
family planning methods at a health facility.
7. Provides first-aid services for common accidents at the family and community level.
8. Ensures administration of vitamin A to children aged six months to five years.
C. Management
1. Meets regularly with the Shura to develop, implement, and monitor community action
plans for health improvement.
2. Meets regularly with the community health supervisor to review reports and action plans,
receive supplies, and for in-service training.
3. Collaborates with and supports community midwife activities in his/her catchment area,
including health promotion and pregnancy-related referrals.
4. Regularly completes and submits the monthly Tally Sheets to the CHS for the HMIS.
5. Knows the members of the community, and develops a community map of the eligible
families in the catchment area and knows the services they have used as well as those
they need
6. Reports all deaths and other vital events included in the report form of the health post.
Informs the health facility of any disease outbreaks.
7. Manages the health post, maintains supplies and drugs and reports utilization of drugs
and supplies.
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Job description of a community health supervisor
The CHS will supervise all community health activities, not just CHW activities. He or she will
assist in training, supporting and supervising CHWs and will also supervise public health
programs and promote collaboration between the facility and the community. He or she also
assists in the formation and linkage of community health shuras (Shura-e-Sehie) with the CHW
program and health facilities. He or she is responsible for supporting the community in
identifying and addressing their health problems.
Training
1. Assists in practical training during CHW training, including supervising the practical
experience of the CHWs in the community during their training
2. Provides on-the-job and monthly in-service training to CHWs
3. Reviews and evaluates the performance of the CHWs and identifies need for further
training
Support and supervision
1. Assists the staff of the health facility in making plans for the community health programs
in the facility and its catchment area.
2. Implements, supervises and evaluates the community health program activities in the
catchments area of the health facility.
3. Identifies and reports immediately to the head of the health facility any problems that
may interfere in achieving program objectives
4. Guides the CHWs in the development and implementation of their action plans.
5. Conducts monthly supervisory meetings with CHWs.
6. Ensures regular replacement of supplies in the CHW kits.
7. Conducts regular visits to the CHWs in their communities to assess and assist their work.
8. Encourages team work among CHWs, especially when they are working in the same
catchment area
9. Provides regular reports on CHWs to the head of health facility
Health Management Information System
1. In consultation with the health facility head, makes monthly action plans with 2/3 of
his/her working days spent working with the communities rather than in the health
facility.
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2. Supervises the quality of the pictorial registers and community maps maintained by the
CHWs and assists the CHWs as needed.
3. Supervises completion of the monthly activity reports by CHWs and the completion of
the facility reports.
4. Consolidates the facility reports and assists the head of the health facility in preparing
consolidated monthly reports and assists in maintaining graphs to monitor the facility
health programs.
5. Assists in supervising community health surveys
6. Uses the reporting system and information received from village health committees
(Shura-e-Sehie) to monitor health conditions and submits findings to the officer in charge
of the health facility.
7. Ensures that CHWs have enough referral sheets and are well oriented on how to improve
the referral system
Facility-community collaboration
1. Assists with the formation of community health shuras (Shura-e-Sehie)
2. Provides orientation session on BPHS and on health topics of concern to the community
Shura
3. Guides in formation & implementation of community-based health activities
4. Promotes support for CHWs
5. Provides feedback from the community to the head of the health facility.
6. Participates in HP shura meetings and shares messages from HP shuras to health
facilities, health facility shura, and health providers and vice versa.
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ToR of Education shura
School Management Committee (SMC)
Since 2006, Ministry of Education (MoE) has established SMC for each school mainly in rural
areas as parallel structure to the various existing local governance institutions. The purpose of
this committee is to provide facilities to schools to ensure the proper maintenance and operation
of schools in rural areas. According to MoE, the 13-members school Management committee
which comprising of the following members is the backbone of rural schools:
School manager/principle as chairperson
Six persons (three are women) are from parents group. One member works as
deputy chairperson
Two teachers, one works as secretary
A person from tribal Shura as member
Village Mullah as a member
Two influential persons from community as members
The main duties and Responsibilities of SMC are as follows:
1. Identifying the needs of the school, design and implement sub-projects and submit their
reports to the relevant stakeholders.
2. Building trust between community and the school authorities.
3. Encouraging community to send their children particularly their daughters to the school.
4. Preparing of school improvement plan, checking students and teachers attendance,
students inspection to avoid unpleasant habits, and inform security authority in case of
students’ involvement with harmful work.
5. Protecting of school’s assets and property, monitoring the cleanness and hygiene in and
around the school compound.
6. Strengthening links with parents to understand about homework of students mainly girls.
7. Encouraging the parents for education and literacy.
Each governmental school has a SMC which has several sub-committees. One of the subcommittees is the Parent committee or parent group. The parent group encourages children and
students to continue their education. If a student be absent for three days continuously, the
school principal informs the parent group who in turn inform the parents of absent child.
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ToR of CDC shura
Community Development Council (CDC)
Between 2004 and 2006, the Ministry of Rural Rehabilitation and Development (MRRD)
developed an approach for greater community participation in the design and implementation of
development activities. This approach has resulted in the creation of Community Development
Councils (CDCs) and District Development Assembly (DDA) at village and district levels
respectively.
The CDCs are important and organized local self-governance institutions. The CDC is the social
and development foundation at community level, responsible for implementation and supervision
of development affairs and liaison between the communities, government and non-government
organizations (NGOs). According to CDCs by-law the CDC comprises of minimum of 25
families. The purpose for the establishing CDCs is (a) to draw cooperation and volunteer
participation of community members to strengthen local governance; (b) promote, develop and
maintain welfare of the community members; and (c) strengthen sense of unity, cooperation and
solidarity in the village.
The CDCs functions at the community level and consisting of minimum 10 and maximum 30
members (50% women) depending on number of population of the locality. The members of
CDCs are the elected people for a three-year and they cannot be elected for more than two
consecutive terms. The executive members of a CDC comprises of Chairperson, Deputy
Chairperson, Secretary and Treasurer.
The roles and responsibilities of CDCs at the community are:
1. Prepare community development plan including identification, planning, implement and
monitoring development projects in partnership with government ministries and NGOs.
2. Dispute resolution.
3. The CDC is responsible to record the population statistics in the community, including
the number of men and women, births, mortality, and marriages.
4. For better coordination of development affairs, the CDC established sub-committees such
as procurement, monitoring etc.
The CDC holds the following meeting/events:
1. General Annual Meeting; to review development activities of the previous year, prepare /
review community development plan and or elect/dissolve sub-committees;
2. Quarterly Meeting; to discuss progress, assess problems and present financial reports in
respect to community development plan; and
3. Monthly Meeting; to produce/monitor monthly plan and review the progress. Discussion
of the meeting is recorded in the CDC logbook and disseminate within seven days of the
meeting.
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The CDCs have the authority to receive fund from government, NGOs, donors or collect
voluntary contribution from people to implement their plan. All community funds are deposited
in the CDC bank account, and each withdrawal of funds from bank account requires the
signature of four members (chair person, deputy, treasurer and one member of CDC). The CDC
is responsible for transparency and accountability to community people and they make the
financial records always available for public inspection.
District Development Assembly (DDA)
The DDA members are composed of CDC chairs and vice chairs. The principle functions of
DDA are to “help the district with planning, management, implementation, monitoring of
progress, evaluation and mobilization of the resources”.
DDA follows the footsteps of CDC at the District Level. The CDCs formulate Community
Development Plans (CDP) based on the needs and ambitions of the villages, while DDAs are
established from clusters of CDCs to formulate District Development Plans (DDP), which take
the CDPs into account. DDAs have a range of planning, coordination and advisory
functions. Their responsibilities include identifying district priorities and strategies that reflect
the interests of communities and villages to feed into provincial level planning processes and
leading the formulation of DDPs. Their terms of reference also say that they are responsible for
providing a channel for effective coordination between all development agencies, programs and
projects at the district level. In this sense, they are expected to be assisting in planning, resource
mobilization, implementation, monitoring and evaluation at the district level. The establishment
of CDCs and DDAs has provided a platform where communities can express their needs and
ambitions, make development plans for their communities and districts, and share such with the
government and other development actors. The DDA has regular meetings at both district and
provincial levels, where activities are coordinated with the existing governmental and nongovernmental offices.
District Council/Shura (DC)
The purpose of District Council is to organize activities involving people and provide them with
the opportunity in the local administration. DCs represent community in formal and
governmental activities. They will be elected every three years by secret and direct elections
conducted by IDLG.
The DCs will utilize a number of tools for monitoring and evaluating the performance of line
departments and for informing the public of the levels of services that they can expect from the
district offices of provincial line departments. The DCs have authority to hold the district
governor and district offices of line departments for their performances and nonperformance. The District Governor and District offices of provincial line departments will be
answerable to the DCs for their decisions. The DCs will create a structure for partnership and
participation of people and civil society organizations (CSOs) with the district
administration. The DC will consult with citizens and CSOs, including Shura on a regular
basis. The DC will promote participation of people and CSOs in the governance of the district.
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Other Shuras
Youth Association (Shura-e-Jawanan)
Definitions of youth include:
1. UN general assembly: 15-24 years of age;
2. Government of Afghanistan: 12-17 years of age new Jawan (pre-youth), 18-35 years of
age Jawan (youth)
3. New Afghan penal code: If a criminal is above 18 years old, he is considered a
responsible adult and will be prosecuted as such;
4. In Islam entering the age of maturity (youth-hood): for girls is 12 years of age, for boys is
14 years of age; and
5. CSO breaks down youth in three practical sub-categories: 11-14 years old pre-youth, 1519 years old teenagers, 20-24 years old university students and young professionals.
There are three types of youth associations in Afghanistan (a) Village Youth Committee, (b)
Local Youth Committee, and (c) Provincial Youth Council. The purpose of these institutions is
(a) Afghan Youth participate effectively in socio-political process, with emphasis on national
and local governance, democracy, reconstruction and peace building, and (b) Afghan young
women and men have access to, and participate in, the socio-economic development, with
emphasis on education, skills development and employment opportunities. Number of members
of a youth group is between 15-25 persons with no female members in the youth groups in rural
areas. The internal structure of the association is generally composed of head and deputy and
some association has a secretary.
Role and Responsibilities:
Encourage youth and society for education
Encourage people to maintain the Afghan Culture
Provide sports ground for youth and encourage them to participate in sport
Discourage youth from using of narcotics.
Promote the rights of youth in the society.
Agriculture Cooperatives and Farmers’ Unions
Agriculture Cooperatives and former unions are the associations of landholders, farmers,
gardeners and other functionaries of agriculture whom come together by themselves or mobilized
by Ministry of Agriculture, Irrigation and Livestock (MAIL) to create associations, cooperatives
and union for the benefits of farmers. There are many agriculture unions like gardeners’ union,
vegetable growers’ union, dry fruit union, honey bee union etc., established by INGOs and
private entrepreneurs. Most members of these unions are agriculture experts and formers.
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Shura Success Story
Nangarhar province is located in the eastern part of Afghanistan and there is a district named
Khogiani in this province. People of Khogiani district are always concerned about accidents that
occur along the road to Jalalabad city, the capital of Nangarhar province. Maulavi Saheb is a
person who lives in a village in Khogiani district of Nangarhar province. He is a widely
respected person in the district and he is always eager to serve people. He counsels people to
avoid violence and shun bad practices, and advises them to be honest in all their dealings. He is
head of community health shura or council (Shura-e-sehi) in the village. He conducts monthly
meeting of the shura and his shura makes decisions to solve challenges of community members
and health providers. He keeps record of shura meetings and ensures that decisions made in his
health shūrā are implemented. People always accept his ideas and advice.
One day along the Jalalabad-Khogiani highway due to inappropriate road conditions and
carelessness of two drivers, two cars full of passengers collided and crashed. Around 20 persons
including women and children got severely injured. Maulavi came to know of accident and he
rushed to the place of accident. Injured persons were crying in pain and there were no one to
help. When Maulavi saw their plight, he immediately began to act in order to provide help. As a
first step, he immediately called community health worker of the village and health shura
members, and asked them to come to the place of accident to help injured persons. He also called
Jalalabad regional hospital, gave them the address of the place of accident, and requested
ambulances and emergency medical help. Within a few minutes, community health worker and
five health shura members arrived and started helping Maulavi with first aid. Very soon, the
ambulances arrived and injured persons were taken to the hospital. Maulavi also went with them
to the hospital and he was in the hospital for 7 days with the injured persons who were now
hospitalized patients till all of them became alright and were discharged from hospital and went
to their homes.
Maulavi played another important role. He appreciated the contributions of community health
worker in the health shura meeting. He said to his shura member colleagues, “it is our
responsibility as a shura to appreciate good work done by our community health worker in
providing relief to accident victims.” He shared shura’s appreciation of community health
worker’s contribution with the elders of village and encouraged them to provide in-kind
incentive to the community health worker. Elders of the village, in turn, shared the issue with
people in the community. Accordingly, community members happily gave in-kind reward to the
community health worker for providing exemplary service to the accident victims.
Now the community health worker is more motivated. People in the community say “Maulavi is
our real leader and we always take his advice. Working with the community health worker, he
saved lives of 20 members of our community.” Maulavi continues to serve his community as
head of the community health shura and he always prays Allah to keep him fit and give him
strength to continue to serve people of his community.
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