Dr Naresh Pratap K C Department of Health Services MoHP Community Health Workers Meeting Dr Naresh Pratap K C Department of Health Services MoHP

Milestone 1991:First Health Policy after Democracy National Health Policy 1991 1991:First Health Policy after Democracy to improve mainly RH services, family planning, safe motherhood, child health and communicable disease services International Conference on Population and Development 1994 Nepal was one of the signatory indicating our commitment to RH rights Millennium Development Goals 2000 Nepal was one of the signatory, joined hands with rest of the world , committed to bring changes in the health of the people .

National Health Policy (1991) Formulated to improve RH services where family planning, safe motherhood, child health and communicable diseases were identified as priority programs. Restructuring of the Health System, At least one health facility for one VDC Bringing health services closer to the community Integration of vertical programs (preventive, promotional and curative) Introduction of new Cadre: Maternal and child health workers, maternal health being the priority program. Restructuring of Health System(79 hospitals, 178 PHCCs, 705 HP and 3132 SHPs) Establish special cadre MCHW to provide MCH services at the community level. VHWs to provide immunization services.

Female Community Health Volunteer (FCHV)Program Recognizing the importance of women’s participation in health promotion, GoN Initiated FCHV program in 1988/89 Pillars to Nepal’s Public Health Programs Numerous external developmental partners and NGOs share their implementation level expertise and on going support to the program

Community Health Workers in Nepal Health Care Workers Maternal and Child Health Workers (MCHW) Village Health Workers (VHW) Trained Birth Attendant (TBA)- are not recognized by Government since 2004 Volunteers Female Community Health Care Volunteers (FCHV)-

Community Health Workers MCHWs (3134) and VHWs (4015) are employed by Government. Total of 48,549 FCHVs are currently present in Nepal. One FCHV per ward or one per 500 population

Role of Maternal and Child Health Workers Conduct Delivery Conduct PNC Care of Newborn Supply FP commodities BCC Management of diarrhoea and pneumonia in the community under CB-IMCI Supervision of FCHVs Referral Services

Role of Village Health Workers Immunization services Management of Newborn Infections Supervision of FCHVs

Community Health System FCHV Settlement Settlement Each VDC has nine wards & 1 health facility 1 2 3 5 7 4 9 6 8 Mothers group Settlement District is divided into VDCs Each ward has: 80-100 households 1 Female Community Health Volunteer (FCHV) who provides maternal and child care services in the community. A mother group coordinated by FCHV for community mobilization Female Community Health Volunteers, who are about 52,000 in numbers, are the front-line cadres working at community level. They are providing various community based services mainly in educating, counseling, distributing FP/RH commodities and referring the clients to the health facilities. They are well accepted and recognized at the community level for Integrated Management of Childhood Illness, Community Based Neonatal Care, Birth Preparedness and several community based activities related to health. At least one FCHV is available in each ward, the lowest political unit of Nepal, which offered the opportunity to educate families, distribute misoprostol and followup postpartum. 75 districts in Nepal

Female Community Health Volunteers FCHVs are involved in: Maternal and Neonatal Health Family Planning programs PP Vitamin A and iron tablet distribution Awareness on maternal and neonatal health Provide essential neonatal care during birth and postnatal Child health Vitamin A distribution & de-worming Community based management of pneumonia & diarrhea Awareness on Immunization programs

Role of Female Community Health Workers Demand generation in the community for MNCH services Counseling to Pregnant women and family on birth Preparedness Community based management of pneumonia & diarrhea Management of newborn infections, birth a in the community under CB-NCP program Behavior Change Communication Distribution of FP commodities (condom and pills) During NIDs- Administration of Polio drops Referral services

Achievements through community based interventions NDHS 2001, 2006 and 2011 have revealed significant improvement in Child Health indicators.

Improving Maternal & Child Health in Nepal Dramatic declines in child mortality Improvements in maternal health TFR dropped to 2.6 MMR from 539 to 281 (DHS 1996,2006) Most women in Nepal still deliver at home (64%) and without a skilled provider (65%) NMR remains unchanged: Estimated 32,000 newborn deaths/year during their first month—most in first week Source: NDHS

Achievements through community based interventions FCHVs are extensively counseling and raising awareness in the community for institutional delivery through Birth Preparedness Package

Achievements through community based interventions Nutrition indicators have also improved

Achievements through community based interventions FCHVs have been instrumental in expanding services in the community

Achievements through community based interventions FCHVs have been instrumental in increasing the access of MNCH services

Motivation factors for CHWs MCHWs and AHWs meeting the educational qualification requirement have been promoted to senior AHWs and ANMs. MCHWs and VHWs are the only health workers who receive DSA and TA for conducting out reach clinics every month.

Motivation factors for FCHVs Establishment of FCHV fund Dress allowance Incentive NPR 10,000 for timely retirement community recognition- 3 FCHVs who are nominated as the parliamentarian members. well respected among the community.

Challenges The main function of VHWs was on Immunization. With MoHP decision to promote the VHWs to Senior AHWs, they do not want to provide the immunization services anymore which has huge implications to the program. FCHVs are utilized by many programs (not only heatlh) to reach the community and are incentivized. This might hamper the overall spirit of volunteerism in future Even old FCHVs are reluctant to retire which is having implications to the quality of the services they provide. FCHVs are politically affiliated which is hampering their work.

FCHVs are vehicle delivering various program to the community 21

Challenges Deviation from volunteerism Effective fund utilization Coordination Over complication of ward register Voluntary and mandatory withdrawal 22

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