Community Health Workers as Frontline Health Responders in Complex Environments: Nepal and Pakistan

1. COMMUNITY HEALTH WORKERS AS FRONTLINE HEALTH RESPONDERS IN COMPLEX ENVIRONMENTS: NEPAL AND PAKISTAN Liz Creel, JSI Research & Training Institute CHW Symposium, Kampala, Uganda February 22, 2017

2. SETTING THE STAGE • Role of community health workers in responding to the unexpected: natural disasters and political unrest. • Health system resilience: capacity of health actors to prepare for and respond to crises; maintain core functions when shocks happen; and reorganize if conditions require it. • Resilient strategies can sustain gains and safeguard health in complex environments: • Female Community Health Volunteers (FCHVs) in Nepal • Pakistan

3. ROLE OF FCHVS AFTER 2015 EARTHQUAKE IN NEPAL

4. BACKGROUNDOF FCHV PROGRAM • Program began in 1988/89 • FCHVs support the national health system through community involvement in public health activities. This includes: • imparting knowledge and skills for empowerment of women • increasing awareness on health related issues and • involvement of local institutions in promoting health care • FCHVs have prevented and treated key diseases; increased use of modern health services; and helped reduce infant, child and maternal mortality. • Currently about 52,000 FCHVs

5. EARTHQUAKE – April 25, 2015 7.8 Richter scale initial earthquake 450+ aftershocks above 4 Richter scale 8,897 casualties including 23 health workers (15 FCHVs + 8 health workers) 22,303 people injured including 68 health workers 462 health facilities totally damaged, 765 health facilities partially damaged Total damage and losses worth $7 billion Photos: Hari Krishna Bhattarai

6. UNINTERRUPTEDSERVICES AFTER EQ The major concern of the Government of Nepal and development partners was to ensure uninterrupted community health services through health workers and FCHVs in the earthquake-affected areas. Support to FCHVs Capacity Building of FCHVs Training on: CHX for umbilical cord care emergency nutrition WASH mental and psychosocial counseling Distribution of: hygiene and health kits SBCC materials related to health promotion and disease prevention • Resupply of drugs and commodities • Psychological counseling to return to normal life and work • JSI and other partners supported FCHVs with motivation packages and helped bereaved families of 15 FCHVs

7. CONCLUSION • FCHVs served as a link between those who needed services and the organizations and health facilities who could provide emergency services and supplies. • Because of FCHVs’ respected position within the community, the health system and their existing strong networks, they were in the ideal position to coordinate an immediate health response.

8. SCALING TECHNOLOGY AND INNOVATION TO INCREASE IMPACTEPI PILOT: SINDH PROVINCE, PAKISTAN Health Systems Strengthening Component USAID’s MCH Program

9. STRENGTHENING HEALTH SYSTEMS FAMILY PLANNING/ REPRODUCTIVE HEALTH HEALTH SUPPLIES MNCH MATERNAL AND NEWBORN CHILD HEALTH HEALTH SYSTEMS STRENGTHENING COMPONENT OF USAID’S MCH PROGRAM IN PAKISTAN • The HSS Component is one part of USAID’s Maternal and Child Health Program in Pakistan. • Implemented in Sindh Province • Conducted an EPI pilot

10. PAKISTAN’S HEALTH SYSTEM CRISES AND SHOCKS (Source: Social Protection in Pakistan: Managing Household Risks and Vulnerability, World Bank, 2011)

11. ROUTINE EPI COVERAGE IN PAKISTAN • In Sindh, the province in which the MCH program operates, coverage is 29% despite the Government of Sindh’s efforts. • Between 2007 and 2013, full immunization coverage in Sindh dropped 8% (Pakistan DHS).

12. EPI PILOT SITUATIONAL ANALYSIS Implementation Challenges • Security challenges • Lack of political commitment at the provincial level in EPI implementation • Poor governance and lack of accountability at multiple levels • Poor logistics and supply chain issues • Lack of permanent registers at health facilities • Lack of mobility for vaccinators • Poor data quality; incorrect reporting • Weak monitoring and supervisory system • High knowledge/capacity gaps in staff and communities • Large numbers of defaulters and missing children • No planned community social mobilization activities

13. EPI PILOT APPROACH Goal: Improve “Routine Immunization” through an HSS perspective which would allow for better planning & implementation in order to reach every child under two years of age and all pregnant women Targeted HSS Interventions (supply and demand): • Build capacity to improve recording, reporting, monitoring and supervisory systems (governance and health workforce) • Ensure mobility of EPI staff (service delivery) • Engage local communities through Lady Health Workers (LHWs) and CBO (service delivery, transparency) • Improved use of health information (information and research) Implementation: • EPI trainings for district managers, EPI staff, vaccinators, local support organization and LHWs • Increased mobility and outreach by providing motor bikes • Identified community focal people to champion immunization • Utilized SMS for awareness-raising and accountability (reporting vaccinator absence to EPI managers) • Conducted community awareness sessions • Ensured community organizations attended district decision-making sessions

14. ENGAGED COMMUNITIES • Identified community focal people to champion immunization and began to register all children under 2 years of age. • Utilized SMS for awareness-raising and text reporting vaccinator absence to EPI managers. • Supported coordination meetings. • Partnered with LHWs to conduct community awareness sessions. • Coordinated with local support organizations. • CBOs nominated volunteers to serve as focal persons to facilitate vaccination activity. • Ensured community organizations attended district decision-making sessions.

15. RESULT #1: INCREASED REGISTRATION

16. RESULT #2: INCREASED % OF REGISTERED CHILDREN WHO RECEIVED POLIO1/PENTA1/PCV1 ACROSS FOUR DISTRICTS

17. RESULT #3: INCREASED % OF REGISTERED CHILDREN < TWO YEARS OF AGE WHO RECEIVED MEASLES VACCINES

18. SCALE UP In 2016, USAID supported the government in scaling up the pilot in 12 additional districts. • Building health systems improves resilience through • Planning and implementation with government counterparts • Working with communities to improve dialogue and ownership • Building governance, accountability and transparency

19. THANK YOU