25 years of Nepal’s FCHV Program: Lesson Learned

Dr. Ram Kumar Shrestha
Community health and Nutrition
Senior Quality Imp...
National

FCHV Program,
Family Health Division
Districts Health Office

FCHV focal person
PHC
Health Post /Sub-Health Post...
Problems with FCHV program before implementation
of NVAP (1993)
• FCHV were not selected properly
• Not all FCHVs received...
National Vitamin A Program, Nepal (1993 – 2002)
Program spread to all districts by Phase
Humla
Darchula
Bajhang
Baitadi

M...
Approach – Community Health Worker

CHW
Current Situation of Community Health Workers
SUPPORT TO FCHV
FCHV Planning with multi-sectoral staff
• FCHVs play the leading role for
message dissemination
• Interactive miking, magi...
Motivation
Motivation is defined as the driving force behind our
desire for something. It could either results from our
de...
Factors sustaining motivation of FCHV
for more than 20 years
Hand-over of EF passbook to FCHV
"Finally we have received some support for our hard work"
Achievements of FCHV program
National Vitamin A Program

% of Coverage

Average Capsule Coverage by the Number of the Years in Program (2007)

100
90
8...
Community Based Treatment of Pneumonia
70

Proportion of Expected Pneumonia Cases Treated (%)

60
50
40
30
20
10
0
1996

1...
Trend in Under-Five Mortality
Deaths per 1000 live births

1986-2016

200

201

Estimates

155

150

Based on DHS 1996

12...
Coverage with ANC anemia interventions, Nepal
DHS, 2001-2011
Indicator

Zone

Year of Survey
2011

38^

64^

79^

Terai

5...
Next Steps
$

Savings &
Credit Group

Community Health System
Local
Government

Community Committee
Women’
s
Group

Schools

Religiou...
Community Health System

$

Savings &
Credit Group

CHW
Local
Government

Women’
s
Group

Schools

Religious Community

Lo...
Equity and Empowerment_R. Shrestha_10.17.13
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Equity and Empowerment_R. Shrestha_10.17.13

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  • Main points to mention:
    2/3rd of Nepal covered with hills and mountains
    Main transportation in most hills and mountains is walking ( a few days to a couple of weeks)
    Big rivers and high monsoon; flood and land slides
    Main focus of the presentation :
    How Nepal’s government FCHV program has been able to Sustain the motivation of 50,000 FCHVs for over 15 years (since 1993)
    Scaled-up Community-based programs like NVAP, deworming program, IMCI program , Iron supplementation program etc.
    Resulted in significant reduction in child mortality and mortality
  • FCHV Program in Nepal :
    This is a national level Volunteer program
    FCHV program has structure from center to village
  • Main points:
    Initial phase FCHVs received Rs100 (two $)
    Govt could not afford paying cash to FCHVs so they were disappointed that resulted their low motivation
    This was the situation of FCHVs in Nepal before 1993
    After motivating FCHVs during the implementation of NVAP program
  • Main points:
    Started with 8 districts and added 10 districts each year
    Plan was to complete all districts in five years but , because of the conflict in the country it took more time
    Completed in 2002
    Implemented by phased out model which developed :
    Confidence
    Trust ( among community people)
    Management skills
  • Main Points:
    There are certain dimensions that people would like to have in their life. We learned the following dimensions in FCHVs that motivate FCHVs
    Recognition
    Status/Respect
    Opportunity
    Income
    Since motivation is dynamic in nature the period of motivation for each dimension is different, it ranges from one year to couple of years. We have to assess where are they and which dimension should be used.
    Long term motivation results TRUST
  • Main points:
    NVAP program used the following dimensions to sustain motivation of FCHVs:
    Recognition in the community from Neighbors and local authorities
    Respect and Status in the community among community people , friends and relatives
    Income in terms of services, time, opportunity, etc. that either brings cash or in-kind income or saves expenses
    Access to cash for essential work and emergency
  • Main points:
    No incentive even during the day of distribution; Neighbor or Village people organize tea and biscuits
    Sustained Motivation of FCHVs for Vitamin A Program
  • This slide shows that the proportion of expected pneumonia cases treated has increased in districts where the programme was implemented, as compared to non programme districts. Our data also show that the programme reduces the proportion of severe pneumonia. In districts with community based treatment of pneumonia, severe pneumonia makes up only 3.6% of all pneumonia cases as compared to 9.2% in districts without this community based treatment programme.
    We estimate that 8,500 deaths are averted per year as a result of this community based pneumonia treatment programme. By 2009, this programme is planned to cover the entire country with an estimated 14,000 deaths averted per year.
  • Over the last two decades, Nepal has made rapid progress in reducing child mortality, from about 200 per 1000 live births in the early 1980s to only 91 per 1000 in the late 1990s. Our MDG target is to reduce child mortality to less than 54 per 1000 by 2015, and at the rate that we are going, we hope to achieve this goal.
    We believe that much of the progress made in child health is due to an expansion of the government’s healthcare network reaching all villages in the country, and to specific public health interventions.
    Nepal provides several successful examples of introducing new health interventions known to improve child health in a few districts and later scaling up the programme throughout the country. In the next slides I will show how we translate research into policy and practice, and present what I consider to be keys to Nepal’s success in reducing child mortality.
  • This table shows how coverage of the program has increased sharply with the implementation of the program.
    The data are from 2001 and 2006 are DHS national estimates.
    Three key indicators shown all show impressive gains from 2001 to 2011.
    ANC attendance more than doubled,
    any IFA increased 3-4 times
    Deworming treatment didn’t exist in 2001 and by 2011 was more than 50%.
    Given strong efficacy data for IFA and deworming interventions to reduce anemia in pregnancy women, one can reasonably expect substantial reductions in maternal anemia would result from this increased coverage in pregnant women.
    No other national programs promoting this interventions were implemented and so it is plausible to conclude that the program caused these increases.
    Lastly on this slide, please note that in general the indictors for the districts in the Terai performed better than in the districts in Mts and Hills.
  • Equity and Empowerment_R. Shrestha_10.17.13

    1. 1. 25 years of Nepal’s FCHV Program: Lesson Learned Dr. Ram Kumar Shrestha Community health and Nutrition Senior Quality Improvement Advisor ASSIST Project/URC Ram Kumar Shrestha, Nepal
    2. 2. National FCHV Program, Family Health Division Districts Health Office FCHV focal person PHC Health Post /Sub-Health Post HP VHW/MCHW Mothers Group
    3. 3. Problems with FCHV program before implementation of NVAP (1993) • FCHV were not selected properly • Not all FCHVs received basic training • FCHV did not receive regular Refresher Training • HF did not consider FCHV as a part of their system • FCHV Supervision from HF was weak • FCHV did not receive financial support • FCHVs were not motivated • Continued addition of New tasks • Expected to visit all HHs
    4. 4. National Vitamin A Program, Nepal (1993 – 2002) Program spread to all districts by Phase Humla Darchula Bajhang Baitadi Mugu Bajura Jumla Dadeldhura Doti Achham Kalikot Dolpa Mustang Rukum rk he t Myagdi Gulmi Syangja Dang Arghakhanchi Rasuwa Tanahun Palpa p Ru an hi de Nawalparasi Sindhupalchok Dolakha Solukhumbu Chitawan Ma kaw an p ur Kavrepalanchok m Ra Sindhuli (October 1993) (April 1994) PHASE III PHASE IV (October 1994) (April 1995) PHASE V PHASE VI PHASE VII (October 1995) (April 1996) (September 1996) PHASE VIII (October 1997) PHASE IX (April 1998) PHASE X PHASE XI PHASE XII PHASE XIII (October 1998) (April 1999) (October 1999) (April 2000) PHASE XIV PHASE XV (October 2000) (April 2001) PHASE XVI (October 2001) PHASE XVII (October 2002) lah i PHASE I PHASE II Sa r Bara Rautahat Parsa Legend: Legend: hh ec ap a bh sa wa hu nk Sa Kapilvastu Nuwakot Okhaldhunga Khotang Ud ay ap ur Bhojpur Taplejung hu m Pyuthan Lamjung ta nku Dha Te rh at Banke Gorkha Kaski lun g sh a Ba g Rolpa Mahottari Salyan Dhan u Bardiya Manang ing Su t Kailali Jajarkot Dha d Dailekh Parba Kanchanpur r ha ht nc Pa Ilam Siraha Saptari Sunsari Morang Jhapa
    5. 5. Approach – Community Health Worker CHW
    6. 6. Current Situation of Community Health Workers
    7. 7. SUPPORT TO FCHV
    8. 8. FCHV Planning with multi-sectoral staff • 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
    9. 9. Motivation Motivation is defined as the driving force behind our desire for something. It could either results from our desire for something that is internally driven (Intrinsic) or it could result from our desire for something outside (External Driven) of us. Motivation is Not Static but it is Dynamic in nature TRUST
    10. 10. Factors sustaining motivation of FCHV for more than 20 years
    11. 11. Hand-over of EF passbook to FCHV
    12. 12. "Finally we have received some support for our hard work"
    13. 13. Achievements of FCHV program
    14. 14. National Vitamin A Program % of Coverage Average Capsule Coverage by the Number of the Years in Program (2007) 100 90 80 70 60 50 40 30 20 10 0 91 89 89 90 91 90 95 96 97 97 95 97 98 1 2 3 4 5 6 7 8 9 10 11 12 13 Number of Program Years
    15. 15. Community Based Treatment of Pneumonia 70 Proportion of Expected Pneumonia Cases Treated (%) 60 50 40 30 20 10 0 1996 1997 1998 Programme Districts 1999 2000 2001 2002 2003 Non-programme Districts 8,500 deaths averted each year
    16. 16. Trend in Under-Five Mortality Deaths per 1000 live births 1986-2016 200 201 Estimates 155 150 Based on DHS 1996 120 91 100 50 Based on DHS 2001 72 56 MDG = 54 deaths per 1000 live births by 2015 43 0 198186 198691 199196 199601 200106 200611 201116
    17. 17. Coverage with ANC anemia interventions, Nepal DHS, 2001-2011 Indicator Zone Year of Survey 2011 38^ 64^ 79^ Terai 56 49 81 75^ 90 National Mtn/Hill 19^ 51^ 75^ Terai 25 66 84 National % receiving any iron 2006 Mtn/Hill % attending ANC 2001 23 61^ 80 15^ 52^ 25 22^ 58 Mtn/Hill % receiving dewormer Terai ^Approximate numbers for illustrative purposes only National 17 85 55
    18. 18. Next Steps
    19. 19. $ Savings & Credit Group Community Health System Local Government Community Committee Women’ s Group Schools Religious Community Local Health Clinic Ram Shrestha
    20. 20. Community Health System $ Savings & Credit Group CHW Local Government Women’ s Group Schools Religious Community Local Health Clinic

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