Ram Kumar Shrestha Female Community Health Program in Nepal Nepal National Vitamin A Program Established in 1993 to reduce vitamin A deficiency to a level that no longer constitutes a public health problem Ram Kumar Shrestha Ram Kumar Shrestha, Nepal

Female Community Health Program in Nepal Evolution of Female Community Health Program Functional Structure of FCHVs Approaches applied to revive FCHVs network at National level Approaches used to maintain the motivation of FCHVs

Evolution of Female Community Health Program

2045/046 (1980) Establishment of FCHV History of FCHV: 2036/037 Establishment of CHL 2045/046 (1980) Establishment of FCHV 2052 (1994) Selection of FCHV completed in all 75 districts Selection of FCHV Women’s Organization Mothers’ Group + VHW Functions (MG): Select FCHV Support FCHV Discuss FP with other members Give information to other mothers FCHV Must be local At least 25 years of age Interested Preferably with some education Functions (VHW): Conduct FCHV visit twice every month (to conduct MG meeting and to collect record and report from FCHV Support FCHV Functions (FCHV): Family planning CDD Immunization Nutrition Census (children, pregnant and lactating)

Partially paid (staffs of NGOs/INGOs) Mothers’ Group Saving credit Literacy Income generation Other Volunteers Partially paid (staffs of NGOs/INGOs) Compared to the partially paid volunteers FCHVs were less motivated FCHVs were less active No attempt to support the FCHVs NVAP Recognition Status Respect Population (Hills: 250 HH, Terai: 400 HH, Mountain: 150 HH) Polio Conducted by HF staff FCHV - only as a supporter After shortage of funds - will have to request FCHV to conduct campaign Endowment Fund

Functional Structure of FCHVs

Public Health System in Nepal Administrative Structure Health Structure District 75 District Health Office Village Development Committee (VDC) 3913 Primary Health Care Centers HP/SHPs Program is implemented through the existing PHC system. FCHVs are volunteers and are not paid for their services. Though they are not a health staff, they are a vital link between the public health services and community. WARD 35217 Female Community Health Volunteer (49,000) Mother and Child

Female Community Health Volunteers Nepal 75 Districts MID-WESTERN REGION MID-WESTERN REGION WESTERN REGION CENTRAL REGION EASTERN REGION Ram Kumar Shrestha, Nepal

Female Community Health Volunteers Village Development Committees 3,913 Ram Kumar Shrestha, Nepal

Female Community Health Volunteers 2 1 3 4 5 7 6 8 9 Wards 35,217 Ram Kumar Shrestha, Nepal

Female Community Health Volunteers FCHVs 44,000 Ward 80 households each Ram Kumar Shrestha, Nepal

Approaches applied to revive FCHVs network at National level

Program Activities TRAINING MONITORING PROMOTION DISTRIBUTION 1. District Level 2. Health Post Level 3. Community Level MONITORING PROMOTION 1. FCHV Register 2. Supervision 3. Mini-survey 1. District Level 2. Health Post Level 3. Community Level DISTRIBUTION 1. Baisakh 6, 7 (April) 2. Kartik 2, 3 (October) Note: This cycle happens twice a year with NTAG’s support and then the program is integrated into the Primary Health Care System of MOH. Ram Kumar Shrestha, Nepal

Program’s Promotion Strategies Nationwide campaign to advertise the supplementation dates as well as to raise awareness on vitamin A Occurs in three levels; national, district and community Interpersonal Communication: the dominant promotion strategy Use of Mass media such as TV, radio and posters and pamphlets before distribution Ram Kumar Shrestha, Nepal

Interpersonal Communication at village level FCHVs play the leading role for message dissemination Interactive miking, magic shows, parades and theater performances and town criers are used Schools, police, local business groups, women’s groups, community leaders are mobilized Broadcast of vitamin A messages on radio and TV complements these promotion activities Ram Kumar Shrestha, Nepal

Vitamin A Parade and Magic Shows Ram Kumar Shrestha, Nepal

N National Vitamin A Program Program Implemented Districts by Phase - Nepal Surkhet Bardiya Dadeldhura Dang Kapilvastu Kailali Kanchanpur Achham Darchula Bajura Bajhang Humla Dolpa Kalikot Jumla Mugu Sarlahi Morang Sunsari Jhapa Tanahun Manang Mustang Chitawan Makawanpur Rolpa Salyan Rukum Jajarkot Dhading Gorkha Nuwakot Rasuwa Pyuthan Udayapur Okhaldhunga Sankhuwasabha Solukhumbu Taplejung Palpa Myagdi Syangja Kaski Lamjung Arghakhanchi Gulmi Baglung Parbat Dailekh Banke Rupandehi Doti Baitadi Nawalparasi Parsa Mahottari Dhanusha Siraha Rautahat Bara Saptari Sindhuli Sindhupalchok Kavrepalanchok Ramechhap Dolakha Dhankuta Khotang Bhojpur Ilam Terhathum Panchthar N Bhaktapur Lalitpur Kathmandu Nepal National Vitamin A Program implemented in 1993. The implementation started with 8 district in the first phase and added 10 districts in each year. Each district received one year technical support from NTAG, a Nepali national NGO, and financial support from USAID, UNICEF and later by AusAID. Legend: PHASE I (October 1993) PHASE II (April 1994) PHASE III (October 1994) PHASE IV (April 1995) PHASE V (October 1995) PHASE VI (April 1996) PHASE VII (September 1996) PHASE VIII (October 1997) PHASE IX (April 1998) PHASE X (October 1998) PHASE XI (April 1999) PHASE XII (October 1999) PHASE XIII (April 2000) PHASE XIV (October 2000) PHASE XV (April 2001) PHASE XVI (October 2001) PHASE XVII (October 2002)

Approaches used to maintain the motivation of FCHVs

Community Health System H P Health Post FCHV VDC Mothers Group At first the trust was built among the family members and stakeholders about the NVAP program by providing scientific evidences and then later sharing the family experience whose XN child was benefited by dosing vitamin A capsule. This trust, over the time, generate commitment of people at many levels; mainly at community , government , NGO and Donor agency. The commitment, specially at the community level and government level, developed a sense of ownership of the program which led to mobilize families and community people to bring children at the distribution center to dose vitamin A capsule. This supportive environment from family members, community people and service providers made FCHV feel respected, special and have identity in the community which kept their motivation to dose all children with vitamin A capsule. FCHVs need support from both service providers as well as from family members to bring their children at the distribution center. Community people can help in convincing family members to participate in the program. This delivery mechanism strengthen primary health care system. Mother 5-10 HHs Mother 5-10 HHs Mother 5-10 HHs Mother 5-10 HHs

Female Community Health Volunteers (FCHV) Endowment Fund The health volunteers at the community level without community support can not continue providing service to mothers and children more than a year. Support from different sector people working at the community should provide support to her Support to FCHV

Multi-sectoral staff at FCHV EF presentation-Bardiya District

Presentation of EF passbook to FCHV

"Finally we have received some support for our hard work"

Accomplishment 49,000 FCHVs actively participate in dosing vitamin A Each round of supplementation reach 3.6 million children with vitamin A capsule and 3.1 million children with de-worming tablets Coverage has been maintained above 90% for 13 years Death averted 10,000 – 15 000 each year

Child Mortality Trend and Status Under-five Mortality Rate (per thousand live births) 180 160 140 120 100 80 60 40 20 1990 1995 2000 2000 2010 2015 If this progress continues, it is likely that Nepal will achieve MDG target for 2015.

Challenges Mothers groups not revived Community Health System requires strengthening Implementers understanding the importance of Community Health System Various Programs developing paralel structure(influencing govt. to change the system for their program) rather than developing support system to strengthen the existing system Lack of coordination among various NGOs

Village Health Team HC I Uganda Health Structure below District VHT selection Committee What kinds of community groups exist in the community ? Do they meet regularly? If Yes , for what purpose?

District Benin Health structure below district Commune Commune Commune Health Management Committee -Village Leader; village president; Treasure ; Women ; Health Center In Charge Health Center Health Center Health Center Health Center CHW meet once a month; Nurse or mid-wife CHW’s supervisor Village Two CHWs (Male and Female Village (100 HH) Village Village

Issues Definition of CHW Definition of support CHW – limited physical capacity; beyond incentive won’t work Understanding of the Community Health System : strengthening CHS- improve community ownership of the program Approach: How does the existing system help to achieve one’s program goal” How does one’s program support the existing system so the program will achieve goal

National Vitamin A Program Multisectoral Support to FCHVs MCHW VHW Leader Farmer Field Workers NGO/INGO FCHV Ward Member Women Development Family Member Students Teachers

GOING BACK Current situation of FCHV: Recognized Status - good Respect But still not adequate support Polio: House to House visit Mothers cant’ say NO FCHVs are getting money GOING BACK Why doesn’t she come to our house The government has employed her to make house visits We know she gets money for her work