Nepal National Vitamin A Program

1. FemaleCommunity Health Program in Nepal Nepal National Vitamin A Program Established in 1993 to reduce vitaminA 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 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. 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. FCHVs 44,000 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 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. Humla Darchula Bajhang Kathmandu Lalitpur Bhaktapur N Mugu Baitadi Bajura Jumla Dadeldhura Achham Doti Kalikot Dolpa Mustang Kanchanpur Dailekh Jajarkot Kailali Rukum Manang Surkhet Myagdi Bardiya Salyan Gorkha Rolpa Kaski Baglung Lamjung Rasuwa Parbat Banke Pyuthan Gulmi Syangja Dhading Dang Tanahun Sindhupalchok Nuwakot Arghakhanchi Palpa Dolakha Solukhumbu Kapilvastu Nawalparasi Rupandehi Chitawan Taplejung Sankhuwasabha Kavrepalanchok Ramechhap Makawanpur Okhaldhunga Sindhuli Parsa Khotang Terhathum Bhojpur Bara Panchthar Rautahat Dhankuta Sarlahi Mahottari Udayapur Ilam Dhanusha Siraha Sunsari Legend: Saptari Morang Jhapa PHASE IX (April 1998) PHASE I (October 1993) PHASE II (April 1994) PHASE X (October 1998) PHASE XI (April 1999) PHASE III (October 1994) PHASE IV (April 1995) PHASE XII (October 1999) PHASE XIII (April 2000) PHASE V (October 1995) PHASE VI (April 1996) PHASE XIV (October 2000) PHASE VII (September 1996) PHASE XV (April 2001) PHASE XVI (October 2001) PHASE VIII (October 1997) PHASE XVII (October 2002) National Vitamin A Program Program Implemented Districts by Phase - Nepal

18. Approaches used to maintain the motivation of FCHVs

19. H P FCHV 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. Under-five Mortality Rate (per thousand live births) Child Mortality Trend and Status 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 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. Ward Member Teachers MCHW Students VHW Family Member Leader Farmer FCHV Field Workers Women Development Field Workers NGO/INGO Multisectoral Support to FCHVs National Vitamin A Program

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 doesn’t she come to our house • The government has employed her to make house visits • We know she gets money for her work