RURAL HEALTH SERVICES
Power in the Parliament Empowered People at the Button

With mobilization of grassroots level government health infrastructures, Nepal Technical Assistance Group’s (NTAG) technical experts are implementing primary health care programs to prevent the pre-natal and post-natal problems in Sunsari district. Established in various stages of liberal political system, these grassroots level health institutions and their medical staffs are working, hand in hand, with NTAG’s technical experts in Sunsari district reaching out to almost all households in the areas through Take Home Model

By KESHAB POUDEL reporting from Dewanganj, Sunsari

When Raj Kumar Shrestha and other NTAG’s technical experts camping in Kaptangunj village a remote part of Sunsari district, 500 miles south-east of capital were informed that a woman in Ramnagar Bhutia Village has delivered a child, next morning they rushed to the house of the newborn baby taking health workers and para-medical staffs from nearby health post.

Mother and child in Sunsari village : Benefiting from health mapping

Along with his other colleagues, a local Female Community Health Volunteer (FCHV) and a junior medical staff of Ramnagar Bhutia Health Post knocked the door of Shana Khatun, 20, who had been treated for night blindness during her pregnancy. After brief conversation with her parents, the health workers weighed the newborn baby and took a blood sample. They found that the condition of mother and children was normal.

This was not a first case for Shrestha, a health monitor of NTAG, and other government’s paramedics, of visiting the households to check the situation of newborn babies and pregnant women. Shrestha and the team regularly visit and monitor the households with pregnant women. They have already visited almost all households in the area in the last 10 months.

As soon as Lukiyadevi Ram, a resident of Ramgunj Balgachiya village of Sunsari district, 15 kilometers south-west of Biratnagar, an industrial town of eastern Nepal, gave birth to a child, she sent her cousin to Sitagunj Health Post to inform the health supervisors of NTAG working under a take home program implemented to provide post-natal and pre-natal check up in the Ramgunj Balgachiya.

With the support from the government health posts and sub-health posts and local FCHVs, NTAG is currently treating pregnant women with night-blindness, worms and other common diseases in Ramnagar Bhutaha Health Posts, Ramgunj Balgachiya Health Post and Dewanganj Health Posts in southern parts of Sunsari serving more than 100,000 women.

Through the health posts, sub-health posts and FCHVs, NTAG collects information regarding health status of all households in their area including the number of married couple, health status of pregnant women and her health record.

Consulations at the health post : Rural outreach of health services

“We also locate pregnant women through the mobilization of FCHVs but most of the cases are referred to us by health posts where we are given a room to establish lab,” said Shrestha. 

Local health officials, too, agree that the partnership with organization like NTAG helps them to increase their outreach. “Under Take Home Model Pilot program, we are receiving technical as well as other support from NTAG,” said Omprakash Mehata, chief of Chimdi Sub-health post in Sunsari. ”We have seen a lot of change through this partnership program.”

With the implementation of Take Home Model Program, a pilot health program run under the collaboration of University of Arizona and NTAG to provide the basic treatment and medical advise to the pregnant women, the women living in health posts of three areas each of Sunsari and Parsa districts are receiving a special pre-natal and post-natal care.

Supporting the government health posts and sub-health posts, the NTAGs staffs, equipped with some basic medical equipment including Night Vision Threshold Test and microscopy and others, test blood, tools and eyesight of pregnant women under the reference of health posts and sub-health posts. If pregnant women require any medicine, they will be administered free of cost.

In the three southern areas of Sunsari district, health posts and sub-health posts have already mapped the total household and the population of all ages.

“We have already mapped the household in our area,” said B.B. Kattel, chief of the Sitagunj Health Post.” We have records about the different status of households including the number of pregnant women.”

Rural Children : Health is wealth

Similarly, other health posts and sub-health posts have similar kind of record keeping system. Collected by FCHVs working in the area, the information regarding the health status of women helps to provide the pre-natal and post-natal services.

In a country with one of the highest maternal mortality ratio - 740 per 100,000 live births - and high under-five child mortality ratio and where only 11 percent of total births are attended by skilled attendants, such programs reaching every household is significant. According to the work plan for the year 2004/05 of the Department of Health Services, there is a program to initiate treatment of night-blind pregnant women with low dose of vitamin A capsules in selected districts.

According to the Annual Report of Department of Health Services, 2061/2062, NTAG provides logistic support, training, supervision and IEC materials for each new district for two supplementation rounds before passing on the responsibility to the district health staff of the Ministry of Health.

Thanks to the long experience of working in the community along with government’s health professionals, NTAG has developed its own mechanisms and a committed group of experts to carry out any kind of works.

“Our technical experts work under the government health posts and sub-health posts as facilitators,” said Ram Kumar Shrestha, executive director of NTAG. “One of the aims of this program is to save women from maternal complications. We mobilize the government staffs and utilize existing infrastructures to carry out the programs.”

Initiated by the United States Operation Mission (USOM) in 1952, community health system evolved under the Public Health Service Model. “The largest health project during this year period was the $1.1 million Assistance to Public Health Services - the first of many efforts to develop a nationwide delivery system for basic health services,” writes Half-a-Century of Development 1951-2001, the History of U.S. Assistance to Nepal , published by the USAID. Started in 1952 as Local Health Service, the project provided technical advisors, participant training, commodities and local currency support for hospitals, health centers and clinics throughout Nepal .

Empowerment at the Bottom

With the restoration of democracy and opening up of the political system in 1990, Nepal ’s government health network has extended all over the country. From the FCHVs at the bottom of the village to the center, there is a strong network of health throughout the country with a capacity to administer Vitamin A and Polio drops to more than 5 million children regularly.

A healthworker at a health post : Need for more such human resource

The development of health infrastructures and health manpower working in remote villages of Sunsari and Morang districts show that the power in the parliament  has empowered the people at the bottom.

It is not denying the fact that the progress was also made during the Panchayat period. There was Rastriya Panchayat as a parliament - which had nexus at the grassroots democracy. Like in Sunsari, these kinds of health networks are helping to carry out any kinds of health campaign throughout the country.

The decentralization of power from the center to the grassroots level has drastically changed the situation. Like all other sectors, different acts including Local Self Governance Act and Social Service Act, evolved in the last four decades though two different constitution and political systems, encouraged local people to take part in the decision-making.

Despite major changes in the health sector, there are still many things to do to make the local health infrastructure effective. “Inadequate access to health services for rural households and limited community involvement in education, motivation and promotion of basic health services are the major bottlenecks to significantly increasing the efficiency of the Primary Health Care System,” writes annual report of Department of Health Services 2060/61.

To support the extension of existing health network and activate the manpower, the NGOs like NTAG played a key role. “The country has manpower and nationwide health network. What the organization like ours is doing is to energize government health workers and support them in their works,” said Ram Kumar Shrestha, executive director of NTAG, who was recently recognized by international TIME magazine as one of the key global health professional working to make a change in the world.

Health technicians : Monitoring the mothers

Past experiences have shown that only through allocating the power from top to the bottom will bring about drastic change encouraging local communities to take care of themselves. The vacuum created by the absence of elected bodies at the grassroots and parliament at the top has already created problems for the local-based development works.

Take Home Model

Introduced as a pilot program, take home model has shown that it can help to activate the grassroots level health institutions and health workers to monitor and observe conditions of pregnant women and newborn child in their vicinity with all kinds of medical records.

At a time when the government is planning to reduce maternal mortality rate, there is a need to increase services given to the grassroots level. Although it is just running as a pilot program in few health posts, it shows how record of pregnant women can be maintained and how they can be encouraged to visit health posts.

“My first baby was died few hours after my delivery at home. Thanks to the services provided in nearby Sitagunj health post for pregnant women, I get all kinds of pre-natal check up now. My two-months baby – born in Kosi Zonal Hospital , is now perfectly alright,” said Ranjita Khadka, 23. “She is still receiving services given by the NTAG’s Take Home Model Project.”

Among many communities of Sunsari district, it is still a dream to have skilled birth attendants. Most of the births are still attended by family members, neighbors, with only a relatively small number of deliveries assisted by health workers.

Kamala Devi Maghi, 22, a resident of Amaduwa village, is pregnant with third child. Since she has already lost one baby, Maghi, a woman from so-called untouchable caste, does not know whether her third child will survive.

With regular visits to the health posts and NTAG’s clinic for check-up, she is expecting that this time she would give healthy delivery with assistance from trained attendants and post-natal care. “We cannot afford money to go to hospitals and it is very difficult to come to health posts,” said Maghi.

Under Take Home Model Program Maghi like many other women living in the area can receive all kinds of pre-natal and postnatal care. Their problems to have skilled birth attendants, however, are yet to be fulfilled.

According to Nepal Millennium Development Goals progress report 2006, in Nepal over 80 percent of deliveries take place at home. Family members and neighbors, with only one fifth of deliveries attended by health workers, assist most of the births. Birth attended by birth attendants  (doctors, nurses, and auxiliary nurse, midwives) is as low as 10 percent.

Although the number of trained health workers and trained attendants has increased, there is a need to take certain steps to motivate them to visit the sites. “We can benefit a lot from existing health facilities and health care system. We are yet to exploit existing facilities,” said Shrestha.

Sunsari’s model shows how government and NGOs like NTAG’s model is helping to increase services utilizing existing government health services and health manpower and bringing about a lot of change in delivery of health facilities to women and children. This partnership also shows that power in the parliament empowers the people at the bottom.