Nepal National Vitamin A Program

1
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
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
Womens 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

• 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 DevelopmentCommittee (VDC) 3913
Primary Health Care CentersHP/SHPs
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 Volunteers
2
1
3
4
5
7
6
8
9
Wards 35,217
Ram Kumar Shrestha, Nepal
11
Female Community Health Volunteers
Ward
80 households each
Ram Kumar Shrestha, Nepal
12

• Approaches applied to revive FCHVs network at
  National level

13
Program Activities
TRAINING
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 NTAGs
support and then the program is integrated into
the Primary Health Care System of MOH.
Ram Kumar Shrestha, Nepal
14
Programs 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, womens
  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
National Vitamin A Program
Program Implemented Districts by Phase - Nepal
18

• Approaches used to maintain the motivation of
  FCHVs

19
Community Health System
Health Post
VDC
Mothers Group

Mother 5-10 HHs
Mother 5-10 HHs
Mother 5-10 HHs
Mother 5-10 HHs
20
Female Community Health Volunteers (FCHV)
Endowment Fund
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 15 000 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 0
1990 1995 2000 2000 2010
2015
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
HC I
Uganda Health Structure below District
Village Health Team
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 CHWs
supervisor
Village Two CHWs (Male and Female
Village
Village (100 HH)
Village
29
Issues

• Definition of CHW
• Definition of support
• CHW limited physical capacity beyond
  incentive wont work
• Understanding of the Community Health System
  strengthening CHS- improve community ownership
  of the program
• Approach
• How does the existing system help to achieve
  ones program goal
• How does ones program support the existing
  system so the program will achieve goal

30
National Vitamin A Program
Multisectoral Support to FCHVs
31

• 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 doesnt she come to our house
• The government has employed her to make house
  visits
• We know she gets money for her work