Table 5 Selected illustrations from focus group discussions on CSC strategy

Theme 1: Engagement in the CSC process

Sub-theme: Gender and equity in CSC participation

Codes: Influence of family support (husbands and mothers-in-law); socio economic equity (participation of members of all socioeconomic strata); Equitable participation/involvement of women; Equitable participation/involvement of all members of other minority groups (i.e. religion, ethnicity, etc.) (excludes women); Reiteration of gender roles; Women’s subordination

Illustrative Quotations:

We have no discrimination. All of our people, they are poor or rich, are participating in the meetings according to the need for their participation, specially the whitebeards who have more experience of life.

- Community member (female), Zir Shakh village

Both poor and rich people participated…and eat from one plate. - Community member (male), Norka village

In the first round, women participated more than men. But, in the 2nd and 3rd, men and women were equally represented and participated – Health council member (male), Norka village

All of them were participating, even women were more in number than men in some meetings.

– Community member (male), Minar Sofla & Olya village

Currently you see the head of development council and teacher and also some others are present in this meeting and they participating actively in other meetings too. – Community member (male), Zir Shakh village

As you witnessed, elders and influential community members all participated in the meeting.

- Heath post council member (male), Norka village

Community elders, including the head of the community development council and a white beard, were present at that meeting, and they actively took part in the gathering. – Health clinic staff (female), Zir Shakh village

Men and women both were coming to the meetings. The head master of the girls’ school always used to participate in the meetings and women were more active regarding participation in the meetings, than men.

- Health facility council member (male), Sarqol village

Sub-theme 1.2: Barriers to CSC participation

Codes: Distance to clinic; Availability of transport; Security; Weather; Scheduling of FGDs (dates and times); Awareness of CSC; Influence of others on participation (e.g. mother-in-law, husbands)

Illustrative Quotations:

Some people who are living in far places from the clinic or are employed; it is difficult to them to participate in these meetings. – Community member

Now our clinic is improved. When the community health supervisor informed us about the meetings or any other matters related to the clinic, we would leave our urgent work to come and participate. The main problem is the far distance to get to the clinic. –Community member (male), Norka village

It took three hours for me to reach the clinic by foot. People have problems of long distance and cold weather. –Health facility council member (male), Sarqol village

There is long distance and it is winter season so the people who are living near here can participate in the meetings. - Health facility council member (male), Sarqol village

Sub-theme 1.3: Awareness of the types of health services and entitlements under BPHS

Codes: Knowledge of the roles and responsibilities of service providers; Understanding of entitlements guaranteed under the government services; Health education/literacy; Gaps in service coverage

Illustrative Quotations:

When we participated in the meetings, we were aware of the service hours for the providers, previously we thought they only worked till lunchtime. – Community member (female), Zir Shakh village

Previously we were not aware about the monthly expenditures of the clinic for generator fuel, CHW monthly meetings, transportation costs, and clinic repairs, after participating in the CSC, we are aware that the NGO provides 9000 Afs to the clinic for these expenditures and it should be spent in consultation with the Shura for more transparency - Health council member (male), Sarqol village

Theme 2: Perspectives of healthcare services and health providers (i.e. health care experience)

Sub-theme 2.1: Perceptions of health services and quality of care

Codes: Health facility staffing; availability of female providers; Infrastructure; Provider behavior and competency to provide quality care; Preferred (first) source of care; Equipment and supplies; Disparities in care (sex, socioeconomic status); Waiting time; Availability of specialists ; Effectiveness of medicines and treatment; Expectations for care; Satisfaction with care; Increased use of facility by members of rural/remote communities; Increased use of facility by pregnant women; Facility as source of pregnancy-related information and/or education, including the importance of facility-delivery

Illustrative Quotations:

As the information about the clinic’s services is given to the people, nowadays people are increasingly going to the clinic and even pregnant women give birth in the clinic. – Community member (female), Zir Shakh village

Nowadays more people are coming to the clinic and receive medicines and they are not going to other places for treatment. – Community member (male), Minar Sofla & Olya village

All people are coming for medicines to the clinic and especially pregnant women are coming to seek advice and giving birth in the clinic. – Community member (female), Minar Sofla & Olya village

More patients are now coming to the clinic and people even from remote areas, such as Lal and Ghor, come to this clinic for treatment. – Health council member (male), Norka village

The quality of health services improved after your meetings…It has been said that pregnant women now go to the clinic for giving birth. – Health council member (male), Sarqol village

It is the first time we learnt about safe delivery and the importance of delivering with a midwife in the clinic and not at home – Community member (female)

Sub-theme 2.2. Perceived trust in providers and decision making

Codes: Decision-making processes; Transparency; Communication; Support; Respect for patients’ rights/privacy; Trust in facility staff; Acceptability of health information provided; Accuracy of health information provided

Illustrative Quotations:

We trust the clinic personnel and clinic personnel are giving accurate information.

– Community member (male), Norka village

After providing water and electricity for the clinic as well as good behavior of clinic personnel, people trust the CHWs and clinic personnel more. - Health council member (female), Norka village

Transparency, understanding and trust have been created. The affairs which have been done or not, we discuss and resolve the problems. - Health council member (male), Chinar-e-Gungishkan village

Theme 3: Perspectives on CSC Effectiveness and Action Plans

Sub-theme 3.1. Perceived effectiveness of the CSC Strategy

Codes: Health care utilization; Quality of care;. Follow-up monitoring; Tracking progress; Use of data to inform decisions (i.e. maintaining and utilizing records); Appreciation for health performance metrics;. Increased and strengthened relationships between the community and providers

Illustrative Quotations:

We learned more, we understood what an indicator is, what is input, what is performance, it’s the first time we learnt such terms. - Community member (male), 50 years old and employed as a farmer

The CSC is a good program, like a bridge between the community and clinic. We (community) were on one side of the river, and the clinic was on the other side, the CSC is like a bridge that connected us.

- Community member (male), shopkeeper

It was very good practice that they were writing it on the paper and we could find solutions for the problems together with clinic personnel. – Male health council member, Chinar-e-Gungishkan village

Sub-theme 3.2. Ownership of and Accountability to the CSC process

Codes: Accountability (positive and negative) among health care providers and community; Solidarity and shared governance, responsibility/ownership of facility

Illustrative Quotations:

The sense of ownership has increased. According to the sayings of Mr. Bihishti people got lazy and always waiting for NGOs to come and dig some well for them, or construct road and concrete stream for them. People should wake up and actively participate in any activity. - Community member (female), Minar Sofla & Olya village

Before some people used to utilize the building for wedding ceremonies and a power broker used to park his vehicle in the clinic. Till the CSC meetings, we didn’t understand that the clinic is our property and we are responsible for its protection. - Community member (female)

Now people perceive the clinic as their own property and are trying their best to complete the clinic’s surrounding walls… - Community member (male), Minar Sofla & Olya village

People now take care of the clinic even better than their homes. – Health council member (female), Norka village

People know that the clinic belongs to them and should be well kept. –Health council member (male), Norka village

We feel more and more the ownership of our clinic. Clinic is like our own house and each community member should ask about the services of the clinic.

– Health post council member (male), Chinar-e-Gungishkan village

It is true that people now perceive that the clinic is their own property. When mothers are going alongside with their children inside the clinic, they not allow their children to touch the clinic walls and the clinic building’s glass, to not be scratched or broken. – Health post council member (male), Shura, Sarqol village

After the three rounds, people trusted the clinic increasingly. Meetings also created a sense of ownership of the clinic. They say that before they thought that the clinic belonged to the government and they were not aware of its affairs. Now they are aware about all clinic issues and they know that the clinic belongs to them.

– Health facility staff (physician), Kalafgan

Our clinic building does not meet standards or have a waiting place. Thanks to the CBHC officer who brought a tent, our problems lessened…during the spring and summer. In the winter, it is impossible to use, because it is far too cold. – Health facility staff (supervisor), Kalafgan

Sub-theme 3.3. Added value of the CSC process

Codes: Improvements in the provision and delivery of care; Strengthened community-provider relationships;. Increased availability and accessibility of care; Enhanced gender engagement; Governance and transparency

Illustrative Quotations:

This program is excellent. It gives women a forum to share their experience and perspective on healthcare. If we work with them and inform them, it’s better for the future of the health system. In Bamyan, we had joint male and female meetings. We are a closed society. Of the many projects I have worked on, this is the first time I witnessed this. – CBHC team member

Before this program, vacancy announcements for a female doctor were only on the signboards of the NGO’s office and the PPHD, but now they are in other places, such as hospitals and clinics. – Health facility staff (physician), Kalafgan

This is the best program. Through it, people get information about all programs, personnel and services of their related health facilities. For example, people were not aware about clinic affairs. Now they know many doctors a clinic should have and what services it should provide. – Health facility council member

Theme 4: Opinions of the sustainability and scale up of the CSC strategy in other communities and regions

Sub-theme 4.1. Sustainability of the CSC approach

Codes: Factors contributing to the CSC sustainability ;. Benefits of sustaining the CSC approach;. Stakeholders critical to CSC sustainability; Factors contributing to the CSC scale up; Benefits of CSC scale-up

Illustrative Quotations:

This program should be developed across all of Afghanistan. In the past there was measles disease in our area. Now that we have clinics, children are vaccinated and measles are eliminated. It is very good to extend the program for all provinces of Afghanistan whether it is south or east; in Kandahar and Herat as they are all our brothers. – Community member (male), Norka village

If people participate in the meetings, solidarity will be stronger. – Community member (female), Zir Shakh village

The program should be expanded to all provinces of Afghanistan and this program should run countrywide in Afghanistan. – Health council member (female), Chinar-e-Gungishkan village

This program should continue in all Afghanistan. All afghans are our brothers and their health is important like our health. Each resident of Afghanistan should get benefits of this program.

– Health council member (male), Sarqol village

[From a community perspective], this is a really good project even better than PDQ. It is also different from FFSDP and BSC, because your indicators are selected by the community and providers. There was client satisfaction within BSC, but not like CSC. – NGO staff