Despite Dangers and Distractions, Afghanistan Staff Remain Committed to Improving TB Care and Control

 {Photo credit: MSH staff.}TB CARE I Project Director, Mohammad RashidiPhoto credit: MSH staff.

Last year, "Diwa Sahar's" work with the TB CARE I project in Afghanistan put his life at risk. Although Diwa had conducted dozens of supervision visits to the TB control team in his province, this time he discovered the team’s managers had been stealing project funds.

After revealing the theft, restoring the funds, and developing a stronger governance strategy, Diwa returned to his home in Kabul. Hours later he received an unnerving phone call. The speaker refused to reveal his identify but knew Diwa’s full name, his wife’s name, his children’s names, and his home address. He warned Diwa that he’d be killed if he did not step down from his position as the province’s TB control coordinator. Although he knew his actions had improved transparency among the managers and would strengthen the province’s TB control interventions, Diwa was worried that he had put his family at risk.

The next day, he visited the TB CARE I Project Director, Mohammad Rashidi, seeking advice.

“When Diwa came to me, he was worried,” said Dr. Rashidi. "I told Diwa that he should move his home, take more security, go with public transport, not walk alone, and take care of this family going to school and the market. He did these things and has not been threatened again. This is very rare, but it happens."

Dr. Rashidi supervises Diwa and six other TB experts who work in 13 provinces of Afghanistan. Although seven of these provinces are insecure, his team is not inhibited by the Taliban presence, frequent threats, or brutal murders of government and US workers.  Instead, Dr. Rashidi has strategically selected staff members that are best suited, not only for TB control activities, but also for navigating the political and cultural contexts in which the project works.

It’s in the recruitment. If I see a candidate who has 100 percent TB technical knowledge and no experience in the province and a candidate who has 70 percent knowledge, but was born in the province and knows the culture, I pick the latter. We can train them in TB, but for security issues—they need to know their own way.

Selective recruitment and training is only part of Dr. Rashidi’s strategy. In preparation for site visits, he also tells his staff to dress in traditional clothes, take public transportation, build relationships with local authorities, and allow their regional counterparts to arrange accommodations and travel.

Quarterly trips to the provinces, while dangerous, allow the project staff to perform essential TB control interventions, including health worker trainings, supervision, community-based DOTS, materials distribution, and monitoring and evaluation. Although the National TB Program supports the project’s activities technically and financially, it is the TB CARE I staff that puts their lives at risk each quarter to implement these activities.  

When asked why his team stays committed to such dangerous work, Rashidi pauses and smiles before answering.

If you respect your staff and give them opportunities to build their capacity, you develop a good reputation. Then, sometimes, the money is not such an issue. One of my staff was offered a higher job with more money and less risk but he said, ‘No. I am with Rashidi.’ We keep a good relationship - a friendship - we work beyond the project… for the country.

Dr. Rashidi has retained the same team of seven professionals since the project began in 2009. Although some have been offered other jobs, started master degree programs, and been threatened, like Diwa, none have left the project. In 2011, when USAID asked Dr. Rashidi to downsize his team to reduce costs, staff that were laid off began volunteering for the project so they could continue their work in the provinces. Said Dr. Rashidi:

"We are honestly committed to this country… we go beyond tradition, religion, and politics… we focus on outcomes and how to reach the people."

Since 2009, TB CARE I’s community-based DOTS activities have increased TB case detection in the 13 provinces by 70 percent and the TB treatment success rate by 98 percent. These interventions, as well as increased health worker capacity and improved TB program management, have enhanced the quality and availability of health services for thousands of Afghans. Although the project’s achievements impress donors and inspire global health professionals, Dr. Rashidi’s team is working for more than funding and fame:

Projects come and go but we are Afghans, we stay forever in this country and so we work for our most needy.

("Diwa Sihar" is a pseudonym. The name has been changed to protect the staff member’s identity.)

Learn more about TB CARE I