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, Nepal Female Community Health Program in Nepal Ram Kumar Shrestha

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

Evolution of Female Community Health Program

Functions (MG): Select FCHV Support FCHV Discuss FP with other members Give information to other mothers Functions (MG): Select FCHV Support FCHV Discuss FP with other members Give information to other mothers History of FCHV:  2036/037Establishment of CHL  2045/046 (1980)Establishment of FCHV  2052 (1994)Selection of FCHV completed in all 75 districts FCHV Must be local At least 25 years of age Interested Preferably with some education 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 (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) Functions (FCHV): Family planning CDD Immunization Nutrition Census (children, pregnant and lactating) Women’s Organization Selection of FCHV Mothers’ Group+ VHW

Mothers’ Group Saving credit Literacy Income generation 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 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) 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 Polio –Conducted by HF staff –FCHV - only as a supporter –After shortage of funds - will have to request FCHV to conduct campaign Endowment Fund

Functional Structure of FCHVs

District 75 Village Development Committee (VDC) 3913 WARD Administrative Structure Health Structure District Health Office Primary Health Care Centers HP/SHPs Female Community Health Volunteer (49,000) Mother and Child Public Health System in Nepal

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

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

Wards 35,217 Female Community Health Volunteers Ram Kumar Shrestha, Nepal

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

Approaches applied to revive FCHVs network at National level

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. TRAINING 1. District Level 2. Health Post Level 3. Community LevelMONITORING 1. FCHV Register 2. Supervision 3. Mini-surveyPROMOTION 1. District Level 2. Health Post Level 3. Community LevelDISTRIBUTION 1. Baisakh 6, 7 (April) 2. Kartik 2, 3 (October) Program Activities Ram Kumar Shrestha, Nepal

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

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

Vitamin A Parade and Magic Shows Ram Kumar Shrestha, Nepal

BhaktapurLalitpurKathmandu 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) Program Implemented Districts by Phase - Nepal National Vitamin A Program

Approaches used to maintain the motivation of FCHVs

Mothers Group Mother 5-10 HHs H P Health Post Community Health System VDC Mother 5-10 HHs

Support to FCHV Female Community Health Volunteers (FCHV) Endowment Fund

Multi-sectoral staff at FCHV EF presentation-Bardiya District

Presentation of EF passbook to FCHV

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

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

Child Mortality Trend and Status If this progress continues, it is likely that Nepal will achieve MDG target for Under-five Mortality Rate (per thousand live births)

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

VHT selection Committee What kinds of community groups exist in the community ? Do they meet regularly? If Yes, for what purpose? HC I Village Health Team Uganda Health Structure below District

Commune Health Center District Village Two CHWs (Male and Female Commune Health Center Health Management Committee -Village Leader; village president; Treasure ; Women ; Health Center In Charge VillageVillage (100 HH) Village CHW meet once a month; Nurse or mid-wife CHW’s supervisor Benin Health structure below district

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

National Vitamin A Program MCHW VHW Leader Farmer Field Workers NGO/INGO Field Workers NGO/INGO Ward Member Field Workers Women Development Field Workers Women Development Family Member Students Teachers Multisectoral Support to FCHVs

Current situation of FCHV:  Recognized  Status - good  Respect  But still not adequate support 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 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  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