Addressing Critical Knowledge Gaps in Newborn Health

The real comrades

Aricle published in Nepal's Republica online. By Bibek Bhandari.

Laxmi Sharma flips through her notebook: The song she wrote looks like scrambled words in scratched lines but in reality it mirrors the state of Nepal’s maternal and child healthcare, mainly in farfetched districts like her own Damachaur Village in Salyan.

“I didn’t know anything, like I had to get checked, take pills and have immunizations during my pregnancy and deliver my baby at a health facility,” said Sharma who was married at 15 and had her first child the following year. “Now I know it. I want to make women aware of that. And I’m just doing that.”

Sharma has been working as a Female Community Health Volunteer (FCHV) for 12 years now. Dressed in a green sari, the official uniform, red blouse and red beads – the last item being the mark of a married woman – she walks from one house to another in the area she covers. Her responsibilities, among many, include spreading awareness on maternal health and nutrition, family planning, administering polio and vitamin A drops, and asking women to visit their closest health facilities for antenatal checkups and delivery.

Also, they are asked to do follow-ups after delivery on the third, seventh and 29th days to check on the newborn.

Despite the decade-long Maoist insurgency that stalled Nepal’s development and infrastructural growth and even in the most intense stage of the conflict, people like Sharma have facilitated the improvement of the health sector from community level. She is one of the estimated 50,000 FCHVs nationwide who have dedicated themselves to service without any monetary benefits.

Nepal’s maternal and child healthcare has made a significant progress in recent years.

According to UNICEF, the under-five mortality rate has slumped from 142 in 1990 to 48 in 2009. As per UNICEF’s 2009 report titled “The State of World’s Children,” Nepal ranks 62 out of 192 countries and the 2009 data for the annual number of under-five death stands at 34,000. The latest data also underscores a 73% fall in maternal mortality rates—from 850 per 100,000 live births in 1990 to an estimated 229 in 2010. And FCHVs are seen as key players in the progress.

But the FCHVs are doing more than just working toward safer motherhood and child care.

In Marke Village’s Ward 8 in Salyan, some five hours’ drive from Damachaur through the dusty and winding trails, Mithu BK makes a swift ten-minute walk from her two-story house overlooking the Sisne Himal range, through a grove of orange trees under a clear blue sky, for a follow-up examination for pneumonia. She sits with the sick child and his mother, takes out the timer and checks the child’s diaphragm. She then compares the child’s breathing with the chart FCHVs are given so they can give them antibiotics or refer them to hospital if it is out of their reach.

“The child is fine,” she looked at the mother and smiled as the child was resenting BK’s examination.

BK, who has been an FCHV for 20 years, reflected the changes in healthcare, especially relating to pregnancy and childbirth.

She listed: “People were illiterate and unaware then of cases regarding pneumonia; children died of dehydration during diarrhea; there were deliveries at home, no immunizations, and women used to die delivering at home.”

But she said the situation has changed and women don’t shy away from visiting hospitals for deliveries. And also, it is the FCHVs who visit women to advise and check when they find about their pregnancy.

“Now they also come to us for everything,” BK said. Every FCHV’s house has a signboard with their names and a visual representation with four rings for the illiterate. The four circles signify that FCHVs have covered from wards to Village Development Committees to districts and the nation at large.

The FCHV program initiated by the Ministry of Health and Population and supported by USAID in 1988 was implemented to improve community participation and outreach of health promotion through local women working voluntarily. The program called for one volunteer per ward, and the national implementation of the program was completed in 1992. In the mid-90s, additional FCHVs were recruited in 28 districts according to population-based ratio.

FCHVs initially are given an 18-day training in two phases. The initial training they receive make them “health promoters” while further and additional trainings on antenatal and neonatal practices and pneumonia establish themselves as “health providers.”

Programs, such as Community-Based Newborn Care Package implemented by Nepal Family Health Program and funded by USAID, have started training programs in Salyan recently. Santosh Neupane, field officer in Salyan, said FCHVs are the “key elements of this program” as they are already working in the communities. The major objective of the program is to make FCHVs efficient in child and maternal care with proper trainings. In 2010, a major chunk of the budget, US$ 203,800 for FCHV programs and trainings came from the American agency.

Apart from trainings, at community level, women sit together, share information and suggest to-be and new mothers on safe motherhood and childcare.

At Marke Ward 1, Amrica KC, FCHV for the area, heads the monthly 30-minute Aama Samuha (Mother’s Group), meeting, an open forum for women. It is through this group that FCHVs are appointed in the community.

In KC’s courtyard, some 25 women, some pregnant and some with their newborn, gathered that day. Flipping through the chart book, KC demonstrated hand washing techniques, proper diet during pregnancy and decoded the myths and traditional practices during and after delivery.

“So what should you do?” she asked the group, showing a picture of a pregnant woman.

“You need to go to the health post for checkups,” a woman voiced. “Immunizations,” said another. “You shouldn’t deliver at home, and if you were to, there should be skilled medical personnel,” added another woman.

Over time, through proper mobilization of FCHVs as a channel of communication, locals have started using the health facilities more often, and they are well-informed about safer motherhood. Such publicity prompted Bhumisara Pariyar to make a day’s trek to visit the sub-health post in Marke. The 21-year-old mother of two was oblivious to the fact that she had to take immunizations and pills and go to the hospital for birthing. After coming into contact to local FCHVs and auxiliary nursing midwives, she made it to the nearest health facility to deliver her third child from her village of Kalimati.

Gorakh Bahadur Thapa, senior auxiliary health worker who has been stationed in Marke for 12 years, noted that there has been a marked rise in people visiting the health facility. The sub-health post started its service from a small room of the VDC building. Today, it’s a one-storey building that prioritizes maternity services, among others. Thapa credits the FCHVs to be “pillars in raising the health standards” in the area.

According to the annual reports of Demographic Health Survey, a total of 12,677 Acute Respiratory Illness (ARI) cases were treated by FCHVs in 2065/66 BS (2008/09) in Salyan district whereas only 4,859 cases were treated by FCHVs in the year 2064/65 (2007/08). Similarly, 51% of total ARI cases were seen by FCHVs in the year 2065/66 which was only 36% in FY 2064/65.

“They identify the health problems in the area and refer to us when they can’t help,” he said of the relationship between FCHVs and the health facilities. “Also, they have been active in making people aware of antenatal and neonatal issues.”

The district hospital in Khalanga, established in 1987, has also seen marked improvements when it comes to deliveries. A chart outside the Out Patient Department lists the names of women, the times they have visited for examination during their pregnancy and post-delivery periods, along with remarks such as “regular” and “irregular.”

Dr Uma Shankar Chaudhary, district health officer, informed that the hospital records about 25 to 30 deliveries every month, a rise by 20% compared to previous years, which he said is a good sign toward the improvement of women’s health.

In September, Nepal received the Millennium Development Award for outstanding national leadership, commitment and progress toward achievement of Millennium Development Goal (MDG) on “Improved Maternal Health,” and with this ongoing pace in the health sector at the community, local and national levels, officials claim that the Tier 5 goal for MDG can be achieved. The Tier 5 goal is to reduce the under-five mortality rate by two thirds, between 1990 and 2015, and reduce maternal mortality rate by three quarters, between 1990 and 2015.

“I think we’re an integral part of the process,” confidently remarked Chitra Sunar, an FCHV in Marke Ward 4 though she did not know about the MDGs. “We’re doing this because we feel it’s necessary to serve and empower our community.”

And it is the sentiment of selfless service that keeps a nationwide army of some 50,000 FCHVs dedicated to their job. For most of them, it is not about money but the benefits to others.

“They respect us in the community,” Sunar, an FCHV for seven years, said. “Our community looks at us as health service providers.”

For Sharma from Damachaur, she wants the current generation of women to take the benefits of the facilities she did not have access to in her time, and know about issues no one told her then.

However, on a realistic note, the volunteers don’t hesitate to mention the lack of money. Though they are volunteers, they hope about benefits apart from the Rs 200 allowance they get during trainings and polio and vitamin A campaigns. The government, in terms of benefits, has announced a plan that upon retirement, the FCHVs would be entitled to Rs 10,000 for their services.

Thus to empower FCHVs financially and also motivate them, the FCHV Endowment Fund was introduced in 2001. Damachaur’s fund totals Rs 128,000 and FCHVs like Sharma have made full use of the assistance.

She took a loan of Rs 30,000 to open a utensils shop at Damchaur marketplace. Today, she has fully paid the loan with interests.

“Women have invested money from the fund to buy cattle, open shops and farms,” said Sharma who currently is the chairperson of Damachaur’s FCHV Endowment Fund. “The interest is 20% less than what others offer. It’s 12% per annum.”

Margaret Bailey, USAID’s director for international communications, and who was in Salyan to assess the FCHV program, said the “dedication and commitment of the volunteers in every location with necessary trainings has been able to provide strong essentials to serve their community.”

Bailey, who has also worked in Pakistan, thinks of the similarities of the programs—like the Lady Health Workers in Pakistan—that comes down to commitment and strength of women who are implementing these programs to make a difference from grassroot level.

UNICEF’s “The State of World’s Children” also credits Nepal as an example. The report states that a randomized study in rural Nepal shows that the collaboration between trained community health workers with skilled health personnel to provide care to mothers, newborns and children have reduced neonatal mortality rate by 30%. Salyan is just an example of how FCHVs are revolutionizing Nepal’s healthcare from a community level. On a national level, with programs as such, thousands of mothers and children could be saved.

And a similar notion is expressed in Sharma’s song. Her lines voice the concerns, and suggest solutions and accentuate the roles of FCHVs to save the lives of mothers and children.

She sings:
Shishu saathma chha
Tyo shishulai ruwaune ki hasaune
timarai haathma chha
Sutkeri byatha lagyo, swasthya sanstha jaun, daksha swasthyakarmibata sewa pau
Shishu janminchha, swasthya janminchha
Shishu aama dubaiko swastyahalai herinchha
Yo Nepalma ek ganthama teen dekhi char jana samma nawa shishuko mrityu hunchha, hera na
Aba mrityu nahos, mahila swastyha sewakko sandeshle tyo dar ghatdai jaos
Aba mahila swasthya sewakko kaamle tyo dar ghatdai jaos
Mrityu nahos, mahila swasthya swayamsewakko sandeshle tyo dar ghatdai jaos.

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