Strengthening Nepal’s Female Community Health Volunteer Network through Public Sector Accompaniment: Experiences at Two Years

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  • this program established the role of Community Health Worker Leader (―CHWL‖). CHWLs are literate residents of their villages who are nominated by village Mothers’ Groups and hired as salaried staff members of Bayalpata Hospital. Each CHWL oversees an average of 9 FCHVs within their village and is responsible for communicating directly with the staff at the local health posts and at Bayalpata Hospital. CHWLs are overseen by a Director of Community Health (―DCH‖) based at Bayalpata Hospital. This enhanced village-level leadership structure is designed to strengthen oversight and support for FCHVs while simultaneously improving ties between individual community members and their local health centers.2 CHWLs conduct weekly meetings with their village’s FCHVs, reviewing patient encounters and any challenges involved in their work. CHWLs subsequently review this information with the DCH during weekly DCH-CHWL meetings, receiving feedback from the DCH and Bayalpata Hospital clinical staff, which they are then able to convey to FCHVs at future meetings. 3. Over 70% of FCHVs in the pilot program are illiterate with minimal formal education, which limits their health literacy capacity. To address this, the program provides thirty minute weekly trainings for FCHVs on health-related topics relevant to their patients. Weekly DCH-CHWL meetings cover materials that CHWLs then re-teach to FCHVs. Additionally, every two months, FCHVs from multiple villages come together for more intensive day-long trainings. CHWLs collect FCHV data regarding weekly patient encounters, which are then evaluated by the DCH to monitor trends and provide feedback to CHWLs and FCHVs. At the end of each month, the DCH presents aggregate monthly data to FCHVs, CHWLs, and Bayalpata Hospital staff 5. Most FCHVs in Achham live in extreme poverty. Because FCHV work is not salaried by the Ministry, competing household, agricultural, and other professional responsibilities pose barriers to consistent, high-quality FCHV work. To overcome these barriers, financial and non-financial incentives are provided to FCHVs in the program. FCHVs receive NR 200 (USD $2.25) for weekly responsibilities (approximately 8-12 hours of work per week). Non-financial incentives are provided in the form of weekly meeting lunches, uniforms, health equipment, supplies, and community recognition. CHWLs and the DCH receive salaries from Bayalpata Hospital.

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  • 1. Strengthening Nepal’s Female Community Health Volunteer Network through Public SectorAccompaniment: Experiences at Two Years Dr. Bibhusan Basnet, MBBS
  • 2. AUTHORS Dan Schwarz, MD, MPH Ranju Sharma Chhitij Bashyal, MPA Ryan Schwarz, MD, MBA Ashma Baruwal, MPH Gregory Karelas, MSc Bibhusan Basnet, MBBS Nirajan Khadka Jesse Brady, MS Zach Silver Laura Corlin Joia Mukherjee, MD, MPH Jason Andrews, MD, SM, DTM&H Duncan Smith-Rohrberg Maru, MD, PhD
  • 3. CHALLENGES Community health workers (CHWs) are key components to public sector health systems in many LMIC’s. Key components of effective CHW programs: - Consistent oversight Continuing education Monitoring and evaluation, Compensation for work No consensus on best practices, and empirical data are lacking
  • 4. NEPALSCENARIO The Nepal MOHP began its Female Community Health Volunteer (FCHV) program in 1988 FCHVs are recruited from each Village Development Committee , and are trained to provide community health services with a focus specifically on immunizations, vitamin A supplementation, and maternal-child health Total work force:48,680 FCHVs Each FCHV serves approximately 50 households
  • 5. PROGRAM SETTING Nyaya Health in association with MOHP: Bayalpata Hospital, in the remote western district of Achham, Nepal Nyaya Health and the Ministry began a pilot program to strengthen FCHV work in villages Currently works with 92 FCHVs in 9 VDCs serving a total population of over 20,000 Program evaluation over two year period: - Expansion - FCHV encounters - Program cost
  • 6. INTERVENTION Centralized Leadership Structure - Nyaya’s CHWL facilitate FCHV work - CHWLs and FCHVs overseen by the DCH once a week FCHV compensation - Financial Incentives: FCHVs receive NR 200 (USD $2.25) for weekly responsibilities (approximately 8-12 hours of work per week) - Non-financial incentives :Weekly meeting lunches Uniforms Health equipment supplies and Community recognition
  • 7. Continued.. Weekly Village-level FCHV Meetings -CHWLs conduct weekly meetings with their village’s FCHVs -Review patient encounters with in-depth discussions -CHWLs subsequently review this information with the DCH during weekly DCH-CHWL meetings - Receive feedback from the DCH and hospital clinical staff - Convey back to the FCHVs
  • 8. Continued.. Weekly Village-level FCHV Trainings -Thirty minute weekly trainings to the FCHVs via CHWLs on certain topics and skill -Bi-monthly training to the FCHVs at the hospital Weekly Monitoring and Evaluation -CHWLs collect FCHV data regarding weekly patient encounters -Evaluated by the DCH to monitor trends and provide feedback to CHWLs and FCHVs in each village - Data communicated back to the community and hospital staff at the month end
  • 9. PROGRAM OUTPUTS Expansion: -Three to nine villages - High attendance rate(99%) at weekly FCHV- CHWL meetings - Average of 183 patient encounters per village/month Program Costs: - Total cost : NR 2,709,995 (USD $30,111) of which - Financial compensation: FCHVs: 45% CHWLs: 19% DCH and CHD staffs: 31% Administrative costs:5% - Financial cost in patient served per annum :NRs 154 (USD $1.72) per encounter
  • 10. Continued.. •Encounters : Matern al Health 22% HIVOthers and TB 54% 4% Family Pediatri New cs Planning Pregnan 11% 20% Newcy Birth4% 5% Abortion 2% Post- natal Ante- 11% natal 67%
  • 11. Pediatrics EncounterARI22%CMA M 3% Diarr hea 75%
  • 12. Some verbatim reports fromFGD’S with the FCHV’s Whenever someone is ill in our community, they come looking for us first. Its a matter of pride for us to be taking care of our neighbors and community members “Even when we have household work to do, we go when they call us for something that we must attend to .”
  • 13. FGD’S with the FCHV’s “We learn great things at the health post. However, the topics taught at Bayalpata Hospital and the ones discussed at our weekly meetings are different than what we are taught at the health post. We are taught new things at Bayalpata Hospital.” “Previously, we used to submit reports at the health posts once a month; sometimes we met our fellow FCHVs and other times we did not. Now we all sit together and discuss our work at least once a week and learn new things.”
  • 14. THANKYOU
  • 15. REFERENCES 1. Bhutta Z, Lassi Z, Pariyo G, Huicho L. Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems. 2010 2. Community health workers: What do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers; 2007 2007; Geneva. World Health Organization. 3. Cherrington A, Ayala GX, Elder JP, Arredondo EM, Fouad M, Scarinci I. Recognizing the diverse roles of community health workers in the elimination of health disparities: from paid staff to volunteers. Ethnicity & disease 2010;20(2):189-94 4. Bhattacharyya K, et al. Community Health Worker Incentives and Disincentives: How They Affect Motivation, Retention, and Sustainability. Basic Support for Institutionalizing Child Survival Project (BASICS II) 2001 5. WHO Country Office N. Female Community Health Volunteers, 2010 May. 6. Population MoHa. Annual Report: Department of Health Services. In: Services DoH, ed. Kathmandu: Government of Nepal, 2010. 7. Population Division: Ministry of Health and Population; New ERA; MD, ICF Macro; U.S. Agency for International Development. Nepal Demographic and Health Survey 2011: Preliminary Report. Nepal Demographic and Health Survey (NDHS) 2011 2011 8. Glenton C, Scheel IB, Pradhan S, Lewin S, Hodgins S, Shrestha V. The female community health volunteer programme in Nepal: decision makers perceptions of volunteerism, payment and other incentives. Social science & medicine (1982) 2010;70(12):1920-7 9. Maes KC, Kohrt BA, Closser S. Culture, status and context in community health worker pay: pitfalls and opportunities for policy research. A commentary on Glenton et al. (2010). Social science & medicine (1982) 2010;71(8):1375-8; discussion 79 10. Justice J. A study of the concept of volunteerism: focus on community-based health volunteers in selected areas of Nepal. JHPIEGO 2003 11. Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA. Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence. Pediatrics 2005;115(2 Suppl):519-6 12. Gelal KS, S.K.; Gautam, T.R.; Dhungana, J.R.; Kunwar, D. Annual Report 2066/067. In: Ministry of Health and Population (MOHP) Nepal F- WRHD, District Health Office, Achham, ed. Achham, Nepal, 2009 - 2010. 13. C.G. Victora REB, J.T. Boerma, J. Bryce. Measuring impact in the Millennium Development Goal era and beyond: a new approach to large- scale effectiveness evaluations. The Lancet 2010;6736(10):608