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Addressing health workforce shortages and maldistribution in
Afghanistan
Najibullah Safi,1 Ahmad Naeem,2 Merette Khalil,3 Palwasha Anwari 4 and Gulin Gedik 3
1WHO Country Office, Kabul, Afghanistan. 2Ministry of Health, Kabul, Afghanistan. 3WHO Regional Office for the Eastern Mediterranean, Cairo,
Egypt. 4Independent consultant, Kabul, Afghanistan. (Correspondence to: Merette Khalil: merette.ramses@gmail.com)
Introduction
The World Health Report 2006 declared a global health
workforce crisis; today, more than a quarter of the world’s
countries still suffer shortages and a global shortfall of
17 million health workers is projected by 2030 (1). Since
human resources are arguably the most essential asset
of any system or organization, strengthening the health
workforce and addressing the critical shortage must be
made a priority in moving towards Universal Health Cov-
erage (UHC) (2,3). Imbalanced distribution, especially in
rural and remote areas, poses a barrier in access to quali-
ty health services. Half of the world’s population lives in
rural areas, but 75% of doctors and 62% of nurses serve
urban populations, which suggest a need to increase pro-
duction, deployment and retention of rural-practicing
health workers of all cadres (1).
Afghanistan has an estimated population of 31.6
million, of which nearly 77% lives in rural settings (Central
Statistic Organization 2018 population estimates) (4).
Afghanistan has the second lowest health worker density
in the Eastern Mediterranean Region (EMR), with a ratio
of 4.6 medical doctors, nurses and midwives per 10 000
people, considerably below the threshold for critical
shortage of 23 health care professionals per 10 000 (2,4).
This figure breaks down to 1.2 doctors, 2.1 nurses and 1.3
midwives per 10 000 people (4). However, the ranges for
these densities are wide when comparing provinces; for
instance, the density of doctors is eight times greater in
Kabul than it is in Kunar (with approximately 0.5 doctors
per 10 000 people in Kunar compared to 4 doctors per
10 000 people in Kabul). Nooristan has eight times as
many nurses and five times as many midwives compared
to its neighbouring province Kunar (with estimated
densities ranging 0.5–4.2 per 10 000 people and 0.5–
2.5/10 000 respectively) (4). Geographic imbalances are
prominent as there are 16.7 health workers per 10 000 in
rural areas, compared with 36 per 10 000 in urban areas;
most qualified health workers are in urban areas serving
only 23% of the population (5). Doctors, nurses and
midwives make 26% of the health workforce, whereas
community health workers make up almost 46% (Figure
1).
Afghanistan’s critical health workforce shortage is a
Abstract
Background: Afghanistan has the second lowest health workforce density and the highest level of rural residing popu-
lation in the Eastern Mediterranean Region. Ongoing insecurity, cultural, socio-economic and regulatory barriers have
also contributed to gender and geographic imbalances. Afghanistan has introduced a number of interventions to tackle its
health worker shortage and maldistribution.
Aims: This review provides an overview of interventions introduced to address the critical shortage and maldistribution
of health workers in rural and remote Afghanistan.
Methods: A review of literature (including published peer-reviewed, grey literature, and national and international tech-
nical reports and documents) was conducted.
Results: The attraction and retention of health workforce in rural and remote areas require using a bundle of interven-
tions to overcome these complex multidimensional challenges. Afghanistan expanded training institutions in remote
provinces and introduced new cadres of community-based health practitioners. Targeted recruitment and deployment to
rural areas, financial incentives and family support were other cited approaches. These interventions have increased the
availability of health workers in rural areas, resulting in improved service delivery and health outcomes. Despite these
efforts, challenges still persist including: limited female health worker mobility, retention of volunteer community-based
health workforce, competition from the private sector and challenges of expanding scopes of practice of new cadres.
Conclusions: Afghanistan made notable progress but must continue its efforts in addressing its critical health worker
shortage and maldistribution through the production, deployment and retention of a “fit-for-purpose” gender-balanced,
rural workforce with adequate skill mix. Limited literature inhibits evaluating progress and further studies are needed.
Keywords: human resources, health workforce, Afghanistan, public health, training
Citation: Safi N; Naeem A; Khalil M; Anwari P; Gedik G. Addressing health workforce shortages and maldistribution in Afghanistan. East Mediterr
Health J. 2018;24(9):951–958. https://doi.org/10.26719/2018.24.9.951
Received: 15/04/18; accepted: 01/08/18
Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://
creativecommons.org/licenses/by-nc-sa/3.0/igo).
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result of historic underinvestment in education and
training, migration, lack of infrastructure and equipment
and poor remuneration (2,3). Other challenges also
include lack of opportunities for career advancement,
staff absenteeism, moonlighting, and weak management
(2). Ongoing insecurity, harsh geographical terrain,
cultural and socio-economic barriers have also
contributed to the overall shortage as well as gender
and geographic imbalances in the health workforce. As
per the global pattern, many health workers (especially
specialists and female doctors) prefer to work in Kabul
and other regional centres for a notably better standard
of life (i.e. security, employment, transportation, health
care and education for their children) (5). In addition,
the historic policies limiting girls’ education (during
the Taliban regime from 1995 to 2001) affecting health
workforce production are still felt and encountered today,
especially in more rural provinces. While Afghanistan
has made significant advancements in the last two
decades in increasing female education (World Bank
shows female enrolment has increased from 6.6% in
2003 to 40% in 2017), enrolment does not translate into
graduation, employment rates, or rural retention. The
most recent DHS in 2015 showed 13% of urban females
completing some secondary schooling, compared to
5.6 fully completing secondary schooling and only 4.2
completing more; their rural counterparts were 5.2%, 1.5%
and 0.6% respectively. Furthermore, in 2003 only a third
of health facilities had a female health worker, and only
about a quarter of the health workforce was female (1,6).
The conservative culture – more pronounced in rural
areas – restricts women from receiving health services
from male providers, amplifying the need for female
health workers.
Afghanistan has been rebuilding its health system,
with notable expansion of its Human Resources for
Health (HRH). This review provides an overview of
interventions used to tackle the critical shortage and
distributional imbalances of health workers in rural and
remote areas in Afghanistan.
Methods
A review of published and grey literature was conducted,
searching PUBMED using key terms, such as: Afghan-
istan, health workforce, human resources for health,
doctors, nurses, midwives, community health workers,
retention, incentives, recruitment, deployment, rural,
remote, underserved, fragile, fragile-state, post-conflict
and low-income, mainly in literature after 2000. In addi-
tion to this, national plans, demographic health surveys,
and technical documents produced by the Afghanistan
Ministry of Public Health, and external development
partners, were studied to understand the HRH situation.
Unfortunately, there are inconsistencies in the available
HRH data which prevents more comprehensive analysis
across cadre, province and gender.
Results
Studies have shown that there is no model intervention
that can be used to address critical shortages of health
workers (7). Afghanistan uses a “bundle” approach, in ac-
cordance with the global recommendations to tackle its
health workforce challenges (Table 1). Strategies related
to recruitment, expanding production, focused deploy-
ment and retention have been used to address gender and
geographic maldistribution.
Expanding education and production
From 2009 to 2011, there had been a 70% increase in medi-
Figure 1 Percent of health workforce by cadre (2016) (4)
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cal students in Kabul; however, less than 20% medical stu-
dents graduated from rural regional centers and only 25%
were female (5). Although the production of female doc-
tors has increased due to gender-based enrollment quo-
tas, their attraction and retention to rural areas contin-
ues to pose a challenge towards equitable distribution. In
2012, only a quarter of nursing graduates from Institutes
of Health Sciences (usually in more urbanized areas)
were female; Afghanistan tackled this issue by expanding
nursing education to regional and provincial institutes,
and introduced community nursing education in an ef-
fort to produce more female nurses in rural areas (5).
Acknowledging the immediate need for scaling up the
health workforce, HRH National Strategy 2012 targeted
training an additional 7000 nurses, 6000 midwives,
800 physiotherapists, 600 psychosocial counsellors, and
20 000 volunteer community health workers, all trained
in their provinces and bonded for employment locally,
with the aim of retaining graduates in rural regions
(5). Committed to rural health workforce production,
Afghanistan expanded these pre-service trainings to
many rural provinces. One study from 2015 showed there
were 708 students preparing to graduate in nursing,
midwifery, dentistry, pharmacy, physiotherapy and
technology from Kabul’s Ghazanfar Institute of Health
Sciences (GIHS), compared to 2046 at the Institutes of
Health Sciences in rural provinces (4).
Additionally, Afghanistan increased the number of
health professional education institutions from nine
medical, one pharmacy and one dental in 2012 to 32
medical, four pharmacy and six dental in 2017 (4,5). Its most
notable expansion has been with regards to nursing and
midwifery: In 2009, there were only 21 pre-service training
programmes. Afghanistan introduced community-
based nursing and midwifery cadres and expanded
nursing and midwifery education to 8 institutes in rural
provinces, with an additional 76 community-based pre-
service training programmes across most provinces.
These community-based trainings are contracted out
to private and international NGOs (4–8). Furthermore,
Afghanistan established a standardized competency-
based curriculum, leading to almost no difference in
skills between midwifery graduates from private, public
and community-based programmes (9). Afghanistan also
built a national accreditation programme for midwifery
education. By mandating that all midwifery schools
achieve accreditation, over 91% were in compliance with
national standards (10). Afghanistan has extended this
model in building its accredited Community Health Nurse
Education program, and can apply it in training emerging
health professionals in bio-medical engineering, medical
technology and environmental health.
Despite these efforts, Afghanistan still suffers from
a shortage of health workers, and a lowered density of
doctors, nurses and midwives from 7.6 in 2010 to 4.6 in
2017, particularly in the rural areas (4,5). Deployment
of Community Health Workers (CHWs) has become
a common strategy to expand primary health care at
the community level in many low- and middle-income
countries with high rural population densities (11).
Examples of national programmes include Ethiopia’s
Table 1 Categories of interventions to improve attraction, recruitment and retention of health workers in remote and rural areas,
globally and in Afghanistan
Category of
Intervention
Examples from the Global
Recommendations (23)
Examples in Afghanistan
Education - Students from Rural Background
- Health professional schools outside of major cities
- Clinical rotations in rural areas
- Curricula that reflects rural health issues
- Continuous professional development for rural
health workers
- Recruiting students from rural backgrounds (8–10,21)
- Creating special community-based cadres, trained, recruited
and deployed rurally: CM/E(Community Midwife/ Education)
and CHN/E (Community Health Nurse/Education) (8,9,16,17,19)
- Expanding pre-service training programmes to institutes in
remote provinces (5,7,15,33)
- CHW/CHN/CM curricula are based on rural health issues
(6,7,9,21)
- Continuous professional development (refresher courses for
CHW) (14,15)
- Consideration of preferential admission to meet quotas and
rural rotations
Regulation - Enhanced scope of practice
- Different types of health workers
- Compulsory service
- Subsidized education for return of service
- Introducing new cadres (5,11,16,17,21,23)
- Enhancing scope of practice, especially for CHN, CM (21,25)
Financial - Appropriate financial incentives - Hardship allowances (double for women in rural health) (33)
Professional/
Personal
- Better living conditions
- Safe and supporting working environment
- Outreach support
- Career development programmes
- Professional networks
- Public recognition
- Providing job opportunities to male family members
- Public recognition measures
- Afghan Midwifery Association (CPD, network)
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30 000 Health Extension Workers, Brazil’s 250 000
Community Health Agents, the Islamic Republic of Iran’s
91 000 Behvarz, Pakistan’s 100 000 Lady Health Workers,
and India’s 700 000 Accredited Social Health Activists
(11–13). Afghanistan has been using CHWs for decades
to address the shortage of skilled health professionals,
especially in rural areas (14). Community health workers
are the first point of contact for patients in rural and
remote areas and are responsible for implementing the
Basic Package of Health Services at health posts, serving
as village primary care providers (15). Given their pivotal
role in rural health care, Afghanistan has expanded its
programme in the last decade, doubling its CHWs from
20 000 in 2011 to 40 000 in 2016 (of which 50% are female)
(5,14). Today, CHWs make up almost 50% of the health
workforce in Afghanistan (Figure 1) (4,5).
Introduction of new cadres
While Afghanistan has introduced multiple new cadres
of health professionals, this section outlines two cadres
that have specifically addressed the lack of female health
workers in rural areas. Afghanistan introduced the com-
munity midwife in response to the historically high ma-
ternal mortality rate resulting from lack of skilled birth
attendants (6). Community midwives (CMs) are recruited
from and deployed to rural areas and trained in specific
community-based pre-service programmes (16,17). There
is little difference between midwives and communi-
ty midwives in terms of their training and practice; the
main difference is their geographic location (9,10). The de-
mand for community midwives in rural areas is high, as
seen by the high employability rates of community nom-
inated and educated midwives compared to their urban
peers (9,16). Furthermore, the production of midwives has
increased rapidly, almost 10-fold, from 467 in 2002 to 2167
in 2008, to 3484 in 2012, and 4600 in 2016 (18,19,20).
In an attempt to address the shortage of female health
workers in rural and remote areas, the community health
nurse (CHN) was introduced in 2011 (21). While this cadre
is not exclusively female, it is an attempt to increase the
number of female nurses administering preventative,
curative and rehabilitative ‘first-line’ care (21). Since 2011,
there have been a total of 54 cohorts in 30 of Afghanistan’s
34 provinces, enrolling a total of 1647 students (21).
Notably, two provinces with over 96% rural population
are actively enrolling and producing three cohorts
of CHNs simultaneously. Many health facilities have
celebrated the impact of the ‘female CHN’ on increasing
the utilization of maternal and child health services.
Strategic rural recruitment and deployment
The strongest motivator associated with rural recruit-
ment and retention is rural origins (22). Working en-
vironment, respectability, financial incentives and op-
portunities for professional advancement represent the
other personal, professional and social factors (7,23). Due
to this, efforts have been made to recruit rural and com-
munity-nominated candidates, across all cadres, in hopes
of increasing their retention in rural areas (23).
Community health workers are community members,
nominated by a village health council (VHC), and
then trained for a four-month period on prevention of
infectious diseases, health promotion, family planning,
and treatment of simple illnesses. While most CHWs
are illiterate, they receive pictographic training manuals
and continuous professional development in the form
of a three-day refresher-training every six months (24).
With regard to community midwives, 9th grade rural
female students are hand-picked by their communities
to attend community midwifery schools; community
leaders formalize the nomination through a signed letter
of support (8,17). Similarly, most CHNs are recruited from,
trained and deployed back in provinces where over 80%
of the population is rural-residing (21).
This strategy of recruiting students from rural
backgrounds has yielded higher deployment and
retention rates of community nursing and midwifery
students, as they have the continued support of their
families and the recognition from their communities
when they return to serve. According to one study, 96%
of community midwifery graduates were employed (63%
in rural areas) compared with 74% midwives chosen by
the Institutes Health Sciences (43% in rural) and 82%
(of whom only 9% in rural) by the National University
Entrance Examination (9). Almost 60% of CHN graduates
are deployed to public sector health facilities, in provinces
with over 85% rural populations (21). Notably, provinces
such as Bayman, Kapisa, Laghman and Uruzgan have
a deployment rate over 80%, where over 95% of the
population lives in rural areas (10).
Financial incentives
Afghanistan has developed a national salary policy to
standardize salaries and benefits paid to health care
workers employed through the Basic Package of Health
Services (BPHS) programme, and to motivate staff to
work in rural and under-served areas. The policy includes
payments of hardship allowances for rural and isolated
areas, up to 250% of their base salary for female health
providers (15,25). However, it is well recognized that fi-
nancial incentives are not the only motivating factor in
attracting or retaining health workers to rural and re-
mote areas (26). One study on midwives in Afghanistan
ranked higher salaries in rural areas as lowest motivating
factor at 9%, preceded by mandatory service at 33% and
family and community support at almost 60% (7,9).
Social factors
One of the biggest issues related to the deployment of the
health workforce in rural and remote Afghanistan is that
of insecurity. One benefit of recruiting and deploying
students from rural backgrounds is their existing accli-
mation to the culture, pace and lifestyle, for those already
residing in these insecure areas (7,17,22). According to one
study related to midwife deployment in Afghanistan, lack
of security was cited by 42% as the most important deter-
rent from opting to work in rural and remote areas, while
the remaining 58% reported other concerns including
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lack of medical equipment, proper schools for children
and difficult living conditions (6–8,10,26). This increased
insecurity in remote areas further affects the mobility of
health professionals, especially females. To increase the
retention of female health workers in rural and remote
areas, Afghanistan has started to provide opportunities
for male family members and spouses to deploy to the
same health facilities or villages through establishing
linkages and collaboration with the Ministry of Labour
and Social Affairs, providing recommendation letters for
spouses to facilitate their job search, and improving the
housing and schooling facilities around health facilities
(17,23,24). Additionally, public recognition remains a mo-
tivational factor in pursing rural posts; in the case of the
community-nominated health workers, midwives and
nurses, family and community support and pride facili-
tate their effectiveness and retention to their communi-
ties.
Discussion
Afghanistan has made noteworthy progress in its
post-conflict development by increasing the densities of
health workers, from 1 doctor, 1.29 nurse and 0.24 mid-
wives per 10 000 people in 2003, to 1.2 doctors, 2.1 nurs-
es and 1.3 midwives in 2017 (4,6). Despite these achieve-
ments, Afghanistan must continue developing its health
workforce to surpass the threshold for critical shortage,
and addressing gender and geographic imbalances in or-
der to achieve the ambitious HRH 2030 agenda, UHC and
the Sustainable Development Goals.
Since 2003, Afghanistan has doubled its female
health workforce and further closing the gender-gap. In
2016, almost 50% of Afghanistan’s health workforce is
women (Figure 2) (5,6). Since 2012, the percent of female
allied health workers (dentists, laboratory technicians,
radiologists and physiotherapists) increased from 9%
to 46% in 2016, while other cadres still lag behind with
less than a quarter of their health workers being female
(4,5). These successes surely have strong implications
on improving service delivery and increasing health
outcomes. The number of health facilities providing
BPHS has been increased from 1087 in 2004 to 1784 in
2011, and now 2604 in 2017 (6,27,28). Number of health
facilities with at least one female health worker has
been increased from 45% (2000) to 74% in 2011 to 92%
in 2017 (4,6,27). Moreover, as a result of increasing the
female health workforce and increasing the quality and
availability of maternal health services, the maternal
mortality ratio has improved significantly from 1100 (in
2000) to 396 per 100 000 in 2015 (19,20,28,29).
In addition to this, Afghanistan’s efforts have
increased the density of health workers in rural areas
from 4.5 health workers per 10 000 (in 2009) to almost 17
health workers per 10 000 (in 2012) (5,30). While almost
half of Afghanistan’s provinces have over 95% rural
populations, provinces with the highest rural residing
communities like Kunar, Ghazni, Faryab and Helmand
still had the lowest densities of doctors, nurses and
midwives; their utilization of CHWs at health posts was
around the national average (only 0.6 active post/1000) (4).
While Afghanistan’s bundle of interventions has yielded
improvements in closing the gender and geographic
imbalances, there are still a number of cultural, financial
and regulatory barriers inhibiting equitable distribution
and accessibility to health workers.
Afghanistan’s conservative culture affects recruitment
and mobility of female health workers. Permission from
the male head of family is necessary for a female to join
the health workforce. A male CHW must accompany
their female counterparts, fulfilling auxiliary tasks in
transportation, management and environmental tasks
(14,15,24,31). This barrier is not unique to Afghanistan,
as gender-based task allocation has been seen with
female Behvarz in the Islamic Republic of Iran and Lady
Health Workers in Pakistan (32). While historically there
have been barriers to the recruitment and retention of
female health workers due to traditional roles, family
responsibilities and marriage, there has been an increase
in the recruitment of female CHWs and community
midwives as acceptability, community satisfaction, trust
and improved health outcomes have been observed by
their communities (8,15,32).
CHWs make up about half of Afghanistan’s total health
workforce; these CHWs serve their communities on a
voluntary basis (24). The biggest motivational push factor
for volunteers is their desire to serve their community for
religious and personal reasons. Recognition, and having
the authority (and support from the community) to
distribute contraceptives and simple medicines, provide
counseling, and refer patients up to health facilities are
attractive factors; however, delivering services without
pay or remuneration offsets this pull. India, Ethiopia and
Pakistan all utilize CHWs in delivering primary care; the
only major difference is that their CHWs are salaried
employees of the ministries and are often compensated
in additional fringe benefits (12,13,31,33). Data regarding
retention of CHWs are sparse and inconsistent, showing
dropout rates ranging from 10–80%; the remuneration
model (pay-for-service) and the “Family Health Worker”
model (grandfathering school-aged children with the
CHW curriculum) are proposed policies to address
compensation and retention in Afghanistan (15,24). The
high expenses, reliance on international assistance and
collaboration between stakeholders are also factors to be
considered.
Competition with the private sector, due to the
considerable salary inequalities and remuneration, is
another factor that affects recruitment and retention.
Despite financial incentives, such as pay and grading
increases, health workers employed by projects/
programmes supported by international donors receive
considerably more pay and allowances than their civil
servant counterparts (e.g. doctors working for NGOs get
50% more salary than civil servants, and ‘super-salaried’
consultants often receive five times more) (5,15,33). NGOs
under contracted out arrangement for the implement of
BPHS and EPHS are obliged to abide by the national salary
policy, in addition to the recruitment guidelines, in order
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to reduce competition and inequalities. This overreliance
on international donors is not unique to Afghanistan and
is an issue faced by many post-conflict health systems in
recovery, such as Sudan, Somalia, Democratic Republic of
Congo, Cambodia and Zimbabwe (34).
While introducing new cadres increases the
availability and accessibility of the health workers,
multi-sectoral cooperation is required to address the
implications of task-shifting and expanding scopes of
practice on accreditation, formal recognition, curriculum
development and certification. Separating registered
nurses and CHNs as different cadres has been a challenge
for regulatory bodies, as there are ambiguities in
differentiating their scopes of practice (21).
Finally, there is little literature discussing the
strategies used by low- and middle-income, developing,
or post-conflict countries on addressing the shortage
of health workers. Inconsistencies in data, from varied
national and international sources have resulted in weaker
evidence. There are even fewer studies documenting
the effectiveness or impacts of these interventions on
rural and remote recruitment and retention (26). Further
studies and more specific data stratifying for cadres,
gender and geographic location would be helpful in
monitoring the direct impact of these interventions and
evaluating the continued challenges in distribution and
retention.
Conclusion
Despite the insecurity and geographic, economic and
social barriers, Afghanistan is working to address its
health workforce shortage, gender and geographic mald-
istribution through a bundle of interventions to achieve
strategic recruitment, production, deployment and re-
tention. Afghanistan has made progress in reducing gen-
der imbalances and improved the availability of health
workers in rural areas, resulting in improvements in
access to health care and health indicators. However, the
health system and health workforce challenges continue
to have shortages with skill imbalances, rural deploy-
ment and concerns with the quality and performance of
health workers. The need for further strengthening the
health workforce remains pressing, including: expand-
ing education capacities with emphasis on the quality
of education; improving health systems management to
retain motivated and well trained health workforce; and
strengthening health workforce governance through im-
proving engagement and coordination of leadership and
all relevant stakeholders.
Funding: None.
Competing interests: None declared.
Remédier à la pénurie et à la mauvaise répartition des personnels de santé en
Afghanistan
Résumé
Contexte : L’Afghanistan présente la seconde plus faible densité de personnels de santé et le niveau le plus élevé de
population rurale dans la Région de la Méditerranée orientale. L’insécurité permanente, les barrières culturelles,
socioéconomiques et réglementaires ont également contribué aux déséquilibres entre les sexes et les régions
géographiques. L’Afghanistan a mis en place un certain nombre d’interventions pour remédier au problème de pénurie et
de mauvaise répartition des personnels de santé.
Objectifs : La présente analyse donne un aperçu des interventions mises en place pour remédier à l’importante pénurie et
à la mauvaise répartition critique des personnels de santé dans les zones rurales et isolées de l’Afghanistan.
Méthodes : On a procédé à une analyse de la littérature (y compris les publications de revues à comité de lecture, la
littérature grise et les rapports et documents techniques nationaux et internationaux).
Résultats : Si l’on veut attirer et fidéliser les personnels de santé dans les zones rurales et isolées, il est nécessaire de mettre
en place toute une série d’interventions pour relever ces défis pluridimensionnels et complexes. L’Afghanistan a créé des
établissements de formation dans les provinces isolées, ainsi que de nouvelles catégories de praticiens communautaires.
Le recrutement et le déploiement ciblés sur les zones rurales, les incitations financières et le soutien familial sont d’autres
approches citées. Ces actions ont amélioré la disponibilité des personnels de santé dans les zones rurales, ce qui a permis
de renforcer la prestation de services et les résultats sanitaires. Malgré ces efforts, des défis persistent, notamment la
mobilité limitée des personnels de santé féminins, la fidélisation des personnels de santé communautaire bénévoles, la
concurrence du secteur privé et les difficultés posées par l’élargissement des champs d’exercice des nouvelles catégories
de praticiens.
Conclusions : Des progrès notables ont été accomplis en Afghanistan, mais le pays doit poursuivre ses efforts pour
remédier à la pénurie critique en matière de personnels de santé et à leur mauvaise répartition grâce à la production, au
déploiement et à la fidélisation d’une maind’œuvre rurale « adaptée », avec un juste équilibre entre les sexes et faisant
montre d’un éventail de compétences adéquates. Cependant, la littérature est peu fournie, ce qui ne permet pas d’évaluer
les progrès et d’autres études sont nécessaires.
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