1. 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

2. 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

3. Evolution of Female Community Health Program

4. 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)

5. 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

6. Functional Structure of FCHVs

7. 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

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

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

10. Female Community Health Volunteers2 1 3 4 5 7 6 8 9
Wards
35,217
Ram Kumar Shrestha, Nepal

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

12. Approaches applied to revive FCHVs network at National level

13. 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

14. 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

15. 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

16. Vitamin A Parade and Magic Shows
Ram Kumar Shrestha, Nepal

17. 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 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)

18. Approaches used to maintain the motivation of FCHVs

19. 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

20. 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

21. Multi-sectoral staff at FCHV EF presentation-Bardiya District

22. Presentation of EF passbook to FCHV

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

24. 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 – each year

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

26. 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

27. 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?

28. 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

29. 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

30. 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

31. 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