title: Stakeholder's perspective: Sustainability of a community health worker program in Afghanistan.
abstract: The objectives of this study were two-fold: 1) to examine how different stakeholders define sustainability, and 2) to identify barriers to and facilitators of the sustainability of the Afghan CHW program.
  
  
  
  We interviewed 63 individual key informants, and conducted 11 focus groups [35 people] with policymakers, health managers, community health workers, and community members across Afghanistan. The participants were purposefully selected to provide a wide range of perspectives.
  
  
  
  Different stakeholders define sustainability differently. Policymakers emphasize financial resources; health managers, organizational operations; and community-level stakeholders, routine frontline activities. The facilitators they identify include integration into the health system, community support, and capable human resources. Barriers they noted include lack of financial resources, poor program design and implementation, and poor quality of services. Measures to ensure sustainability could be national revenue allocation, health-specific taxation, and community financing.
  
  
  
  Sustainability is complicated and has multiple facets. The plurality of understanding of sustainability among stakeholders should be addressed explicitly in the program design. To ensure sustainability, there is a need for a coordinated effort amongst all stakeholders.
authors.affiliation: Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, Canada. Electronic address: snaja100@uottawa.ca.
authors.forename: Said Ahmad Maisam
authors.initials: SAM
authors.lastname: Najafizada
authors.affiliation: School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada. Electronic address: rlabonte@uottawa.ca.
authors.forename: Ronald
authors.initials: R
authors.lastname: Labonté
authors.affiliation: Telfer School of Management, University of Ottawa, Ottawa, Canada. Electronic address: Ivy.Bourgeault@uottawa.ca.
authors.forename: Ivy Lynn
authors.initials: IL
authors.lastname: Bourgeault
mesh_terms: D000288:Administrative Personnel; D000346:Afghanistan; D003153:Community Health Services / Q000191:economics / Q000458:organization & administration*; D003150:Community Health Workers / Q000191:economics / Q000458:organization & administration*; D003256:Community Participation; D005381:Financing, Organized / Q000458:organization & administration; D017144:Focus Groups; D006801:Humans; D016730:Program Development; D015397:Program Evaluation; D036301:Qualitative Research
keywords: Afghanistan; Community health workers; Primary health care; Sustainability