Front Runners

With the restoration of democracy in 1990, the health sector, like other sectors, also witnessed upsurge of participation of community in primary health care. Thanks to the efforts of donor communities and government, more than 48,000 Community Female Health Volunteers (CFHVs) have been working in different parts of the country providing primary health care to needy population of rural parts of Nepal . From family planning to maternal mortality and child health, and nation wide campaigns like immunization and distribution of nutrition to other general health information, CFHVs are working as front-runners engaged in all corners of the country. At a time when the country’s infant mortality is still higher as the disease like Acute Respiratory Infection (ARI) has emerged as one of the major public health problems among children under 5 years of age, the CFHVs are working hard to bring down the fatality. Following successful participation in reducing maternal mortality, generating awareness in family planning, immunization and nutrition including vitamin A program, the women health volunteers are now dealing in the new front

By KESHAB POUDEL

“Just two months ago, a woman in a hurry knocked door at my house at mid-night. Ignoring the possible danger, I opened the door. She told me in a wail face that her nine-month-old son is serious. I immediately took my kits with some medicines and followed her. After looking at the child, I saw the child was breathing rapidly with eyes closed. As per my recommendation, we took the children to a health post – which is three hours walk. I am happy to say that the child was saved following treatment in the health post,” said Ashunimaya Tamang, a Female Community Health Workers from Katunjebeshi Village Development Committee of Kavrepalanchowk district.

FCHVs Invaluable contribution

Whether at mid-night or early in the morning, whenever there is health related problems of children and women, health volunteers like Tamang have to rush and conduct diagnosis with their limited knowledge. If they find complications, they will refer it to the health posts.

In most of the remote villages, it is deemed risky to walk at night but the volunteers like Tamang do not have any other option. To save lives of others, they risk their own life by walking in the night.

From nation wide immunization to other health campaigns, these groups of women are front-runners in health services working at the grass root level. As the Acute Respiratory Infections is emerging as a major health problem for infant and children, there is a new workload for FCHVs.

“I see many children suffering from cold. Following the five days training conducted by the trainers from Maitighar (Nepali Technical Assistance Group (N-TAG), I realized now that we can save children from pneumonia,” said Tamang.

Tamang is one among thousands of women who are working in villages and saving lives. Despite nation wide campaign to reduce the infant and child mortality, Nepal still has the highest infant and children mortality in South Asia . According to the UNICEF’s State of the World Children 2004, infant mortality is 64 per one thousand and children mortality is 91 per one thousand in Nepal . Bangladesh has 51 and 77 respectively.

As more community women volunteers are mobilized, there are certain positive developments. Despite the threat of violent insurgency, the mechanism to mobilize the volunteers helps to carry out the activities.

Tamang, 56, is among a group of 22 taking part in a training program aimed at controlling the Acute Respiratory Infection (ARI) including pneumonia and severe pneumonia. Conducted by trainers from Maitighar based Nepali Technical Assistance Group, health volunteers learn that cold is the first step of pneumonia.

“We don’t know what pneumonia is and what are its symptoms. When children have cold and find difficulty to use mother’s breast, we used to take our children to traditional healers believing that the god is unkind to child. Although Jhankri (faith-healers) performs all his practices, overwhelming majority of children died and few could be saved,” said Kaili Thakuri, 50, another female volunteers of Katunje.

Although ARI is one of the major health problems in Kavre, a large number of villagers do not know the real reasons behind the children’s death. “If people are given general information and methods for proper diagnosis and management of cases, more children can be saved,” said Sabitri Gautam, 35.

With an aim to reduce the mortality, the government is now launching National Control of ARI program as an integral part of primary health care. The program focuses on children under five years because the majority of deaths in this age group are ARI-related.

This is not a first program participated by FCHVs. Many such programs have already been conducted in different parts of the country including Kavre. These battalions of volunteers are now frontline workers of Nepal ’s health program. From child health to family health and nutrition to immunization, the government mobilizes this group of volunteers to reach to the farthest corners of the country.

“We have already conducted these kinds of training in 44 Village Development Committees in Kavre alone providing training to 392 FCHVs. We have also organized 7673 meetings of mother groups,” said Basudev Khatiwada, program coordinator of N-TAG. “More than 135 Dhami Jhankri (traditional healers) have also been trained by our trainers on ARI.”

Following the training, FCHVs have already checked 2137 patients of Respiratory Infections and diagnosed pneumonia in 52 children. After the tests, 18 children were found to be suffering from severe pneumonia and were referred to health posts.

Who Are FCHVs?

Although they are unpaid staffs, they have played significant role in the area of primary health care in the rural parts of the country.

According to the Ministry of Population and Health, there are about 48,000 FCHVs scattered throughout the country. Majority of health problems prevailing in the country especially in the rural community are related to the health of women and children. High maternal mortality, high infant mortality and child mortality are some of the examples that indicate the poor health status of women and children.

Recognizing the importance of people’s participation especially women’s participation in promoting health of people, the FCHV program was initiated in 1990 in 19 districts of the central development region and eight district of mid-western development region. It has expanded now to all 75 districts. Initially, the approach was to select one FCHV per ward regardless of the population size. Later in 1993, population based approach was introduced in the selected districts. There are 48,307 FCHVs actively working all over the country.

“FCHVs are selected by local Mothers’ Group members with the help of local health personnel and provided 18 days of basic training on selected primary health care components. After the completion of basic training, FCHVs are provided with a kit box free of cost, consisting of paracetamol, iodine, gentian violet, ORS packet, Condoms, Pills Cycle, Cotton, bandages, scissors, a soap case with soap and a towel. FCHVs are also provided with manuals, flip chart, ward register, signboard and identity card” writes the annual report of Department of Health Services 2003/04 prepared by the department and supported by the UNFPA.

The roles of the FCHVs are mainly focused on motivation and education of local mothers and community members for the promotion of safe motherhood, child health, family planning, and other community health services. With support of health personnel from health posts, the FCHVs are expected to promote available health services by educating local mothers and other community members.

With an aim to provide benefits and welfare, FCHV Endowment Fund up to the village level has been initiated. This fund had been established in 432 VDCs, 11 municipalities and 13 districts level till last year.

Training Program

A group of women gathered in a small room at Bhakundebeshi Health Post in Kavre district, 60 kilometer east of capital, have reason to rejoice as they are learning the symptoms to identify different kinds of ARI including severe pneumonia. Holding pamphlets, charts, timers in their hand, women are discussing the ways to detect, treat and save children from respiratory infections.

The villagers have their own traditional medicine to treat respiratory infections and cold. Honey, garlic, Tulsi, turmeric and other local herbals are used to treat general cold but they cannot cure acute respiratory infections.

“The villagers still use these traditional medicines to treat the cold. They are effective in many cases,” said Tamang. “Even I gave turmeric and hot water to my child till he died.”

With the support from District Health Office Kavre and trained by trainers of Nepali Technical Assistance Group (NTAG), FCHVs are learning treatment methodologies and ways to refer modern medicines not ignoring traditional ways.

As majority of FCHVs are just literate and only a few are primary school students, the trainers have to opt for participatory approach. From dancing to singing and showing pamphlets, two trainers of NTAG used all the methods and processes that can be used to effectively communicate to the villagers. To place the exact approach in the mind of female community volunteers, the trainers have to adopt different easy methods.

To see the level of knowledge acquired in the class, the trainers conducted quiz contest and singing competition worded with symptoms of pneumonia and treatment about respirator infections. Those who are just literate memorize the methods through the folk songs composed on the basis of local needs.

The training method is interactive and participatory as trainers and participants actively take pars in all five day course. “High Cough, prolong cold, more than 60 beating in a minute at the side of the body up to armpit and child’s unwillingness to take the breast milk are the symptom of ARI. If the disease is in early phase, we recommend the local medicines. If the cases are going to become severe, we would offer the medicine. In case of severe stage, we will refer it to hospitals and other health facilities,” said female health volunteer Gopkumari Kunwar, 56 of Mithunkot Village Development Committee of Kavre district replying to a query by Kanchan Parajuli, a trainer of NTAG. “If child is suffering from cold, we recommend mothers to feed more breast milk.”

NTAG’s Training

Although NTAG’s trainers have already conducted trainings in more than 80 percent of VDCs, they also have to abandon their training programs from the villages. Maoists detained four health workers including two trainers of NTAG for five hours in Mahadevtar VDC of Kavre recently. “The Maoists asked us to leave the village without holding the training. Following abduction, they took us to nearby jungle and interrogated for three hours before releasing four of us. A health worker Jaman Singh Lama is still under their custody,” said Shailendra Pandey. “It is difficult to hold the program but we cannot ignore the fact that this is related to lives of thousands of people.”

Founded by Ram Kumar Shrestha, a Nepalese public health expert, NTAG's experts have been traveling in different parts of the country giving training to community based female health volunteers.

Trainer Kanchan Parajuli – who is conducting training to the FCHVs in Bhakundebesi, an area where Maoists attacked a police station a few years ago killing more than half a dozen of police personnel – has to move to another remote village. Despite threats and difficulties, half a dozen trainers are conducting similar job in different parts of Kavre. “Actually, we are giving training to women to save children and it involves nothing more than purely professional health issues,” said Parajuli.

“If we train FCHVs, they can save tens of thousands of children all over the country by detecting the disease like pneumonia in early period. “We are there in the villages to save the children,” said Bista.

By conducting successful nationwide program on Vitamin A, NTAG’s trainers and experts have already proved their efficiency and expertise in the mobilization of community health volunteers.

Along with imparting knowledge about the disease, the trainers are also giving training on how to treat pneumonia through cotrimoxazole pediatric tablets – which is used to treat pneumonia patients.

Kavre’s Experience

As Kavre district has one of the highest prevalence of child death by ARI, the government is focusing its attention to train more FCHVs for proper diagnosis and management of cases here.

It is the district with second highest prevalence of ARI. Pneumonia is a leading cause of child and infant mortality. Out of 87 VDCs of the districts, training has already been conducted in 56. According to District Health Office, there are 115 health workers, 4 public health centers, 10 areas health office and 80 sub-health posts.

“I am quite happy to say that this program is going smoothly. The obstructions created in the villages are very negligible,” said Asta Ratna Tuladhar, head of District Health Office. “My district is badly affected by ARI and this program will help to reduce the number of such patients. Pneumonia is leading cause of infant mortality. Health is for all so I don’t think any body will prevent our program.”

For a district like Kavre, it is not easy to cover all the area through paid health staffs. Only through the mobilization of community health volunteers, the primary health facilities can be provided to wider section of society.

According to the annual report of Department of Health Services 2003/2004, 463,396 children with pneumonia under five were treated and 1,219,630 new ARI cases among under five children were reported in the year. The highest cases were reported in Central Development Region followed by Eastern Development Region. The highest percentage of pneumonia was found in Eastern region followed by central region. Mid Western Development region topped in registering the severe pneumonia.

The National Control of ARI program is an integral part of primary health care and it has been accorded high priority. The program focuses on children less than five years of age because the majority of deaths in this age group are ARI related.

In the fiscal year 2003/04, ARI cases per 1000 under five populations were 344. The highest number of ARI new cases was reported in eastern region at 480 per 1000 followed by central region at 335 per 1000. The average national reported incidence of pneumonia among under five children increased from 97 per 1000 in 2003 to 131 per 1000 in 2004

Economic Survey 2005, published by the Ministry of Finance, reveals that 14 percent of the under two year age children suffered from malnutrition. Among them 289 children out of every 2000 suffered from respiratory disease, and 3.3 percent from severe respiratory diseases. Similarly, 200 children out of every 1000 suffered from diarrhea, and 3.0 percent from acute diarrhea during the year 2003.

As Nepal is planning to provide primary health care facilities to all over the country, FCHVs will remain the major tool to administer the health services. Whether in case of ARI control, Vitamin A or immunization and other health problems, FCHVs’ role is increasing.

What Is Nepali Technical Assistance Group (NTAG)?

Shrestha : Impressive Work

Founded in 1993 as Technical Assistance Group (TAG) to implement the program, later with the encouragement from donors and MoH, TAG was registered as Nepali Technical Assistance Group (NTAG). NTAG is a national non-governmental organization established with the view of providing technical assistance to the developmental works initiated in Nepal . NTAG has emerged as the nation's key technical assistance group in extending technical support to the Ministry of Health in implementing the program funded by USAID, UNICEF, AusAID and JICA. The program will continue till the end of 2007. It has undertaken the responsibility of implementing a number of health and nutrition related projects, conducting research studies collaborating with university abroad, organization of national and international workshops/seminars including the National Vitamin A Program, Community Based -Integrated Management of Childhood Illness program for children. These child survival programs have contributed in reducing infant and child mortality in Nepal . NTAG is headquartered in Kathmandu with a branch office in Saptari.

Ram Kumar Shrestha started working in Nepal National Vitamin A Program as an Assistant Program Director in 1993. Since 1996, he has been serving as an Executive Director in NTAG. Shrestha studied Public Health and Nutrition from Tufts University in USA . He has been awarded several national and international awards relating to public health such as the "Best Practices in Global Health 2000" by the Global Health Council, USA and the "Best Contribution to Public Health" by the Nepal Public Health Institution. Recently, government of Nepal gracefully conferred him with the prestigious "Prabal Gorkha Dakshin Bahu". Currently, he is working as a Senior Technical Advisor in International Institute of Science and Technology in Virginia , USA . He provides technical assistance to Cambodia , India , Ethiopia etc. to implement community-based health and nutrition projects. He has developed different models in implementing community-based programs.