CHWs

Page history last edited by sanjay 1 mo ago

 

Community health workers provide us with an opportunity to engage community members otherwise divorced from the former health system, learn more about health risks and potential interventions, and provide home-based care.

 

  1. Scope and Rationale
  2. Program Purpose and Goals:
  3. NHCHW Supervision and Monitoring
      1. Structure of Supervision
        1. ii.      NHCHW Supervisor
      2. Measuring Outcomes
    1. RAPID EVALUTION OF STAGES 1 AND 2
    2. OVERALL VISION FOR OPERATION AND EXPANSION
      1. STAGE 1: Initial Stage: Outreach [graduated]
        1. Rationale:
        2. History of Activities:
      2. STAGE 2: Middle-term Stage: Adherence Support [in progress]
        1. Rationale:
        2. Added Trainings:
      3. STAGE 3: Long-term Stage: Triage and Treatment
        1. Rationale
        2. Additional Roles and Responsibilities for Stage 3:
    3. REFERENCES AND SIDE-NOTES

     

    Scope and Rationale

    In remote and impoverished areas, community health workers (CHWs; alternately, village health workers or accompagnateurs) play critical roles in ensuring timely access to essential medical care. The needs for CHWs arise from the following challenges of healthcare delivery in these areas:

    • limited roads that make it difficult to transport sick patients
    • high prevalence of chronic diseases that require long-term medication adherence, such as HIV and tuberculosis
    • lack of awareness and faith about modern medical care
    • social challenges in accessing existing healthcare services, particularly for women and other marginalized groups
    • infeasibility of recruiting and paying highly trained healthcare personnel
    • challenges in follow-up of diseases treated at central clinics owing to distance

    To meet these challenges, CHWs are trained in a stepwise fashion, in which they first are deployed as outreach workers who solely act to recruit and refer patients to the central clinics. Their clinical capacity will gradually grow over time to include adherence support for patients evaluated and followed up at the clinic, and then further increased to include triage and treatment. 

     

    Program Purpose and Goals:

     

    The main purposes of NHCHW pilot are as follows:

     

    1.       Providing high quality care, as comparable to that of one available in a US hospital, in Achham by bridging the gap between the clinic and community-based medical care. There are variables, from physical, to social to economic, that are present between what patient hears or receives from the clinical staff and what he or she actually understands and does once he or she is back in the community. NHCHWs, who live in the patients’ community, can act as the link to relay the information from clinic to patient and vice versa High quality is maintained only if all of the following are achieved:

    1. Clinic staff follows all protocols and guideline
    2. Patient is given, understands and utilizes counseling properly
    3. Patient is treated with dignity and respect
    4. Staff is routinely trained if gaps exist
    5. If any issues are seen in any of the above, a prompt solution is sought and applied by the manager

     

    2.      Performing the following tasks:

     

    1. For cases such as ANC, PNC, malnutrition, TB/HIV DOTS (category 1 visit), NHCHWs must visit the patient at certain frequencies as assigned by the NHCHW supervisor.

    2.  For general OPD patient follow-ups (category 2 visit), normally NHCHWs must visit the patient only once after the name is given.

    3. For general community surveillance (category 3 visit), NHCHWs must visit every single household and screen patients for any illness and refer them to the clinic accordingly. Each house must be visited and screened at least two times a month. If settlements are closer by each household may be seen by CHW more than that frequency.

    4. For surveys and non-medical tasks (category 4 visit), NHCHWs must assist with any surveys and work as a liaison for Nyaya to their communities

    5. Every Tuesday, NHCHWs visit the clinic and meet with CHW supervisor to discuss issues, receive the list of new OPD-follow ups, ANC/PNC., and updates on TB or HIV DOTS and transfer the data they have collected to the NHCHW supervisor, who places them in a clinic-community linker EMR system.

     

    3.      Improving child and maternal health by achieving the following targets:

     

    1. No pregnant woman in NHCHWs’ catchment area unnecessarily dies from pregnancy or pregnancy related complications including abortion complications, delivery complications or any other preventable causes.

    2. While pregnant, woman is properly counseled by the clinic and undergoes weekly screening by NHCHWs for any danger signs and, is immediately referred to the clinic if any such signs are observed.

    3. While pregnant, woman receives and takes proper amount of iron, gets anti-helminthis medicine and gets TT shots

    4. For delivery, woman knows to come to the clinic and doesn’t use harmful traditional methods

    5. For abortion, woman knows what her options are and knows the dangers involved with home-made/ayurvedic abortion techniques

    6. For family planning, people in the community not only about family planning methods but are also comfortable and actually use the methods

    7. After delivery, woman (and father) knows how to properly take care of the baby, counseling on breastfeeding and nutrition, childhood illnesses, vaccinations and other items are thoroughly discussed. ANM supervising delivery then lists patient name for CHW follow-up

    8. No child in NHCHWs’ catchment area unnecessarily dies after or during birth

    9. Mother receives proper clinic counseling and re-iteration and test of knowledge by NHCHW

    10. All children receive vaccinations in time and have their child health record

    11. If a childhood illness is detected, NHCHWs promptly refer the patient to the clinic

    12. Growth monitoring is performed during routine neonatal visit

    13. Ensure that specific case patients receive community-based follow-up to assist with following activities:

      1. To re-iterate, simplify or clarify information and instructions counseled by the clinic

      2. To check if patient is actually following medicine regiment

      3. To investigate socio-economic issues that might hinder patient’s progress

      4. To relay information back to the clinic on the status of the patient

      5. If patient is not getting better, then referring the patient back to the clinic for a follow-up care

    14. DOTS: Provide DOTS therapy to TB patients in the community

    15. Screen every household for illness and refer to the clinic

    16. Spread the information about Nyaya Clinic and what services are available. Everyone in NHCHWs catchment area knows about Nyaya Clinic including the following information:

      1. Getting to the clinic

      2. Services provided by the clinic (Lab-tests, Ultrasound tests, 24 hour Delivery, ANC, TB, HIV tests)

      3. Services are provided for free

      4. Cases for which medicines are not given

      5. Clinic operation hours and emphasizing the need to get there during registration time

      6. The composition of clinic-staff

      7. The role of NHCHWs

      8. The qualification of doctor - people generally call anyone who can hold a packet of medicine a doctor. In such scenario, CHWs have become crucial in describing to the community the types of doctors and the one in Nyaya Health is the most experienced (with 7 years of education) as compared to private medical workers who have less than 1.5 yrs of training in medicine and run private medicals as business than for the benefit of patients

      9. How medicines work - people also generally tend to believe that if medicines don't cure their health problem, the medicine is useless. Despite doctors'/pharmacist's counseling on how/when to take medicines, patients still tend to have this belief. Hence, the role of CHWs is even more important in explaining the need to continue taking medicines as per doctors' advice.

     

    NHCHW Supervision and Monitoring

     

    Structure of Supervision

     

    i.      NHCHW Program Coordinator

         1.       Who: Executive director or Program Director of Nyaya Health who oversees the overall functioning of the program
         2.       Duties:
                   a.      Guide the overall NHCHW program
                   b.      Make arrangement of necessary resources such as salary, publicity materials, data recording registers and other logistics
                   c.       Obtain data from CHW Supervisor and communicate with the INGO team
                   d.      Make executive decisions in setting the pace and direction of the program
                   e.      Arranges necessary trainings and educational opportunities
         3.       Meetings:
                   a.       Meets regularly with CHW Supervisor and if necessary with CHWs
                   b.      Performs occasional field visits for evaluation and monitoring
                  

    ii.      NHCHW Supervisor

         1.       Who: ANM, with previous experience of working with communities in Achham and who can form a good relationship with                 CHWs and keep them motivated
         2.       Duties:
                   a.      Attend every CHW meeting
                   b.      Host the CHW meetings
                   c.      Collect data from CHWs and put them in SBMC EMR (as applicable)
                   d.      Provide OPD, ANC, PNC, TB, Malnutrition followup patient list to CHWs during the meetings
                   e.      Implement all the programs and activities with CHW
                   f.       Field visits during evaluation and other special activities
                   g.      Obtain feedbacks from CHWs and relay them to the NHCHW Program Coordinator
         3.       Meetings:
                    a.      Currently every week meetings with CHWs
                    b.      Performs occasional field visits and monitors CHW work
     

     

     

    DATA MANAGEMENT STRUCTURE

     

    CHWs collect the following data in the community:  

    General Data:

    ·         Total people seen each day
    ·         Total house visited each day
    ·         Total patients referred each day
    ·         Total ORS distributed each day
    ·         Total OPD Followup done each day
    ·         Total ANC Followup done each day
    ·         Total PNC Followup done each day
     
    ANC Data
    ·         If still pregnant –
    o   Danger signs, if any seen
    o   If pregnant lady has run out of iron pills
    o   Referred or not
    ·         If already delivered (without notice to/outside Nyaya Health)
    o   Date of delivery
    o   Location of delivery (healthpost/home/medical…)
    o   Qualification of person supervising delivery (doc, ANM, MCHW, HA/AHW, others)
    o   Mother’s condition
    o   Child’s condition
     
     PNC Data
    ·         Danger signs in child
    ·         Danger signs in mother
    ·         Is child malnourished?
    ·         Referred?
     
    OPD Followup
    ·         Is patient taking meds regularly?
    ·         Health outcome
    ·         Feedback about doctor
    ·         Feedback about staff
    ·         Suggestions for improvement
     
    - This data is then entered by ANM into the computer. Logbooks correspond with the SBMC EMR (please see the access form and tables)
    - Then ANM uses ANC, PNC and OPD followup queries to create a list of patients that need to be followed up
    -  Theses names and the IP number are then given to the CHWs
    -   These data are then collected the following week (on Tuesday) during the CHW meeting

     

    Measuring Outcomes

     
    The outcomes should be straightforward to collect and analyze, including: 
    - Recruiting pregnant patients into clinical care
    - Retaining pregnant women in antenatal care
    - Conducting deliveries at hospital
    - Screening for severe acute malnutrition (SAM)
    - Retaining malnourished children on treatment
     
     

    RAPID EVALUTION OF STAGES 1 AND 2

     
    These are the main action steps necessary to improve and enhance the current services provided by NHCHWs and to transition to Stage 3:

     

     

    A.      NHCHW Skill Improvement

    1. Train CHWs on how to provide proper knowledge about doctors
      1. There are two types of doctors: one 7yr educated doctor (MBBS); 1.5-3 yrs educated doctor (HA, AHW)
      2. The doctor at NH is the only 7yr educated doctor in whole Achham
      3. Getting 7-yr educated doctor to check you up alone is a really big thing because if you were to do it in other places, they will charge you more than Rs.200 and you would also have to pay for medicines. But at NH, not only will you get to see a 7yr educated doctor but also high quality free medicines funded by an American NGO.
      4. The doctors in private medicals are running business and what do people do in business? Make money. So they might sell medicines that will not do anything to you but only waste your money. NH is not a business. This is social organization/NGO working in Achham to address the health needs.
    2. Train CHWs on how to get a proper post-clinic follow up
      1. Responsibility of the clinical staff is to check the patient and give him or her diagnosis, advice and medicines. CHWs’ responsibility starts after the patient comes back into the community. This is when CHW needs to do the following tasks –

                                                                   i.      Once CHW receives OPD follow-up list, the CHW visits the patient and asks the following questions –

    1.       What illness/disease did the doctor say you have?

    2.       Did the doctor prescribe you medicines?

    a.       If yes, did you get those prescribed meds from the clinic pharmacy or from outside?

    3.       Have you been taking those meds? How many times a day are you taking them? Does that follow doctor’s order? How regularly have you been taking the meds (note down in the CHW Register in OPD Follow up Form)

    4.       Same as (3) some patients do not follow doctor’s order of dietary restrictions. If patients do not follow that how can they expect to get cured?

    a.       If the patient is not regularly taking meds as advised by the doctor or following advice of dietary restrictions and other suggestions, then convince the person to adhere –

                                                                                                                                           i.      For a seedling to grow into a plant, you need to water it regularly and for some time. If you just water today and not tomorrow, it will wither away and never be a plant. Same is true with medicines ability to treat diseases and illness. If you do not take regularly or for recommended time, then it’s useless. You will never be cured.

                                                                                                                                         ii.      Do you think 7yr educated doctor will give you advice just for no reason. Pilot knows how to fly airplane after learning for 4/5 years. Doctor also studies for 7 years to find diseases and treat them.

                                                                 ii.      If patient had just come back from a higher health facility and is on medication, CHW should take the same approach in convincing patients about following doctors order and medicine intake.

    1. Make sure everyone in CHWs catchment areas knows about the hours of operation
    2. Make sure everyone knows about the services
      1. Lab: The best lab and resources in whole Far-western region…
      2. Pregnancy and delivery: services provided anytime, any day
    3. Develop strategies for CHW to explain the medicine dispense protocol
      1. Medicines are disbursed to those patients
      2. The priorities –

                                                                   i.      Cure disease

    1.       Ex: pneumonia

    2.       Ex: Diarrhea

    3.       Reducing the severity of certain diseases such as COPD and Diabetes

                                                                 ii.      How it changes the health outcome

                                                                iii.      Acute injuries

    1.       Ex: trauma and burns 

     

    1. Educational Training/refreshers
      1. Pregnancy/Delivery related

                                                                   i.      Dangers with delivery at higher age

                                                                 ii.      Dangers with delivery at home

                                                                iii.      Basic medical education about complications related to pregnancy and pregnancy in general conducted by an ANM or doc

    1.       Ability to convince mothers to use clinic/ANM for delivery

    a.       Using this particular case as an example… examples are better than pure lecture

    b.      Relay information about complications… I was amazed by Satya ji’s description of pregnancy to locals using simple language and imagery… we need to use more of such approach

    1. APD

                                                                   i.      CB to gather more information and ways to increase knowledge among CHWs for about APD and its prevention or control/treatment at community level

    1. Worm Meds

                                                                   i.      CB to gather more information about possibility of giving worm meds through CHWs… deworming campaigns, any ongoing projects that NH can coordinate with

    1. Refresher

                                                                   i.      Diarrhea

    1. New trainings –

                                                                   i.      ARI

    1.       Need to Speak with Sailendra Sir to get ARI equipment

                                                                 ii.      APD

    1.       More information to CHWs about APD and counseling

                                                                iii.      Pregnancy/Delivery – more in depth education

                                                               iv.      First AID

    1. Test kits available, will arrange the training shortly 

     

    1. Having CHWs or someone accompany the patients if a case is serious or arrange with/find someone in the community to bring the patient down to the clinic
    2. Getting a system by which CHWs can also take meds to the patient if the latter is incapable to come to the clinic in his/her own.
    3. Discuss the feasibility and appropriateness of giving a very few medicine if the person needs to get it from the medical; but may cause more problems such as patient only taking the given medicine and never buying additional, recommended quantity from private pharmacies.

     

     

    B.      NHCHW Supervision and Monitoring

    1. Structure of Supervision

                                                                  i.      NHCHW Program Coordinator

    1.       Who: Executive director or program director of Nyaya Health who oversees the overall functioning of the program

    2.       Duties:

    a.       Guide the overall NHCHW program

    b.      Make arrangement of necessary resources such as salary, publicity materials, data recording registers and other logistics

    c.       Obtain data from CHW Supervisor and communicate with the INGO team

    d.      Make executive decisions in setting the pace and direction of the program

    e.      Arranges necessary trainings and educational opportunities

    3.       Meetings:

    a.       Meets regularly with CHW Supervisor and if necessary with CHWs

    b.      Performs occasional field visits for evaluation and monitoring

                                                                ii.      NHCHW Supervisor

    1.       Who: ANM, with previous experience of working with communities in Achham and who can form good relationship with CHWs and keep them motivated

    2.       Duties:

    a.       Attend every CHW meeting

    b.      Host the CHW meetings

    c.       Collect data from CHWs and put them in SBMC EMR (as applicable)

    d.      Provide OPD, ANC, PNC, TB, Malnutrition followup patient list to CHWs during the meetings

    e.      Implement all the programs and activities with CHW

    f.        Field visits during evaluation and other special activities

    g.       Obtain feedbacks from CHWs and relay them to the NHCHW Program Coordinator

    3.       Meetings:

    a.       Currently every week meetings with CHWs

    b.      Performs occasional field visits and monitors CHW work

     

    C.      NHCHW Data Entry and Management

     

     

    The previously designed data management (please see NHCHW Program Plan in Evernote) procedures had faced several challenges in implementation. Some of the challenges include –

    v  At data systems level –

    o   Collecting some redundant data

    o   Difficulty of collection of certain data

    o   Sometimes too time-consuming to inquire about certain data from patient

    o   Unnecessary information columns in the logbook

    o   No clean mechanism to transfer data from CHW to CHW supervisor

    o   Incomplete Access form for collecting data in SBMC EMR; the form also had a few bugs and asked for some redundant information

    o   Incomplete Access queries with bugs; OPD followup query fine, ANC had few bugs, PNC nonfunctional

    o   No proper link between clinic and community data or information collected

    v  At CHW level –

    o   CHWs not understanding what and how to enter in the CHW logbook

    o   CHWs not entering or not caring to enter data properly

    o   CHWs entering incomplete data

    v  At CHW-supervisor level –

    o   ANM untrained at entering data into EMR because of the lack of a stable system for data entry

    o   Lack of time of program director for transferring data from the previous week; difficulty to allocate time for data entry during weekly CHW meeting

    o   Complete dependency of CHW data management on expat program director and limited or no role of ANM

    o   Lack of proper ownership by ANM leading to an unsustainable program depends on expat Nepali-speaking volunteer to coordinate

    v  Monitoring and Use of collected data

    o   Because of the improper and incomplete data entry (and also the short duration of the pilot), data collected has been largely not-useful for making quantitative programmatic evaluation

    o   Focus should be more on what data are “useful.” Usefulness is defined as follows:

    §  Useful for knowing the health outcomes of the patients seen by clinic and CHWs

    §  Useful for making sure that each women is properly followed up during pregnancy, delivery and post-partum and each newborn is properly followed up after birth for signs of illness, malnutrition and for receiving of immunizations

    §  Useful for providing proper link between clinic and what happens in community. For example, with ANC, the ANC patient if delivers at home, should be counseled and monitored properly to ensure proper health of both the newborn and the mother

    §  Useful for internal recordkeeping and grant writing

    §  Useful for monitoring accountability of CHWs and making sure they are actually doing work

     

     

    Given the above listed problems with previous data management system, the following changes need to be made:

     

     

    v  Data Management structure

    o   CHWs collect the following data in the community

    §  General Data:

    ·         Total people seen each day

    ·         Total house visited each day

    ·         Total patients referred each day

    ·         Total ORS distributed each day

    ·         Total OPD Followup done each day

    ·         Total ANC Followup done each day

    ·         Total PNC Followup done each day

    §  ANC Data

    ·         If still pregnant –

    o   Danger signs, if any seen

    o   If pregnant lady has run out of iron pills

    o   Referred or not

    ·         If already delivered (without notice to/outside Nyaya Health)

    o   Date of delivery

    o   Location of delivery (healthpost/home/medical…)

    o   Qualification of person supervising delivery (doc, ANM, MCHW, HA/AHW, others)

    o   Mother’s condition

    o   Child’s condition

    §  PNC Data

    ·         Danger signs in child

    ·         Danger signs in mother

    ·         Is child malnourished?

    ·         Referred?

    §  OPD Followup

    ·         Is patient taking meds regularly?

    ·         Health outcome

    ·         Feedback about doctor

    ·         Feedback about staff

    ·         Suggestions for improvement

    v  This data is then entered by ANM into the computer. Logbooks correspond with the SBMC EMR (please see the access form and tables)

    v  Then ANM uses ANC, PNC and OPD followup queries to create a list of patients that need to be followed up

    v  This names and the IP number are then given to the CHWs

    v  These data are then collected the following week (on Tuesday) during the CHW meeting

     

     

    D.      Public Health Outreach and Activities

     

     

    • Toilet construction in Siddheswor/Ridikot… what’s the status… from CARE if they have any plans on expanding to these areas. CB to contact CARE
    • Malnutrition: Look at DACAU’s report/data or through UNICEF (Mohan ji) to find information about Malnutrition rates in the communities and ways to expand in those areas to provide necessary support

     

     

    E.       SOCIAL and ECONOMIC DEVELOPMENT PROJECTS

    a.       Microfinance methods… more understanding CHWs need to bring from the community and discuss at the meeting and during community meetings

    b.      Discuss with SEVAK Nepal to find more information about their efforts [CB had first meeting; second meeting scheduled to discuss the details and for CHW expansion]

    c.       Discuss with Women Development Group/Committee to understand what programs they have

    d.      Review DHO’s document on loans for mothers

    e.      Review District Development Paper

    f.    Coordinate with other NGOs to learn what has been done and how Nyaya can make best use of its resources for community development

     
     
     
      

    OVERALL VISION FOR OPERATION AND EXPANSION

     

    STAGE 1: Initial Stage: Outreach [graduated]

     

    Rationale:

     
    Given that CHWs in the beginning are untrained in medicine, the first step is to help to utilize them as local outreach workers. This serves to familiarize them with working with patients and to develop some rapport and respect within their local communities. The activities at this stage include:
    • follow-up of patients treated at the central clinic, encouraging patients treated for pneumonia, abscess, malnutrition, etc. to return to the clinic as requested by the clinical team.
    • detection of pregnancy and recruitment of patients to attend antenatal care visits at the clinic.
    • detection of malnutrition using a simple survey that includes a color-coded band that measures mid-upper-arm-circumference
    • referring of patients to the clinic for vaccination
    Note that during this stage, the CHW needs no medical skills since all she is doing is encouraging patients to follow up at the clinic. She does need to understand the mission of the clinic and why medical services are important. Though she may not be able to communicate by voice-phone with the clinic (owing to limited communications infrastructure), she needs to report to the clinic once a week to update her list of patients and discuss any issues. For many CHWs, this will involve 2-4 hours of walking to reach the central clinic.
     

    History of Activities:

     

    1. Hiring of the initial CHWs
    CHWs were hired by using the following selection protocol:
    1) Request for nomination of candidates -
    - Letters are sent to Aama Samuha (Mother's Group) to nominate candidates from potential Wards for expansion
    - The announcement for vacancies are also announced over local newspaper and over the radio
    2) Training and selection
    - a two day training is provided 
    - interaction and communication skills are assessed
    - a written exam is administered
    - selection is made based on communication skills and written exam
     
    2. Trainings that have been conducted
     
    1. Introduction to Nyaya Health – 10 min 
    2. Introduction to Each Other– 20 min 
    3. What is community health – 30 min 
    4. Defining the CHW Role – 30 min 
    5. Antenatal Care – 45 min
    6. Deliveries and Postpartum Care – 45 min
    7. Breastfeeding – 1 hour 
    8. Vaccinations – 20 minutes 
    9. Basic IMCI – 30 minutes 
    10. Family Planning – 1 hour
    11. Nutrition – 1 hour 
    12. HIV – 1 hour 
    13. Tuberculosis – 1 hour 
    14. Home Visits – 1 hour 
        15.  Review and wrap-up – 1 hour 
     
    3. Roles and responsibilities of CHWs
    a) Conducting Household Health Survey
    CHWs visited every household in their target region, introducing themselves as Nyaya's CHWs, informing patients about the high-quality, free care at Nyaya's clinic, and conducting a short survey to learn about family profile, death in the last year, health of children and pregnant women and family planning of every family. They also looked for signs of malnourishment and danger signs and referring patients to the clinic.
    b) Dehydration program
    CHWs also looked for signs of dehydration in children, distributed Oral Rehydrating Salts (ORS) for free and showed mothers how to safely prepare this life-saving solution. 
    c) Outreach workers: informing about Nyaya Health, services available and composition of staff
    d) Malnutrition detection
     
     

    STAGE 2: Middle-term Stage: Adherence Support [in progress]

     

    Rationale:

    The next stage is to involve a slightly higher layering on of clinical capacity that should include some clinical knowledge. The activities at this stage include:
    • providing directly observed or modified directly observed therapy for tuberculosis and HIV
    • providing weekly follow-up of chronic diseases such as congestive heart failure or COPD
    • providing weekly follow-up of antenatal patients for adhering to antenatal vitamins and for screening for complications and any clinical or psychosocial issues
    • providing weekly follow-up to clinic patients (a) to make sure patients are taking medicines regularly and perform CHW counseling if they are non-compliant (b) to relay back information about the change in patients' health status and condition post-clinic care and refer patients back to clinic if conditions do not improve even after treatment (c) to collect feedback from the community and patients about clinic services and staff and rooms for improvement
     

    Added Trainings:

     
    1. Maternal and Child Health
     
    Trainings were given with special focus on-
    -review of pregnancy
    -danger signs in pregnancy
    -performing ANC in community
    -review of delivery
    -following up on ANC patients using a form given to patients during ANC visits
     
    -safe delivery
    -danger signs
    -abortion complications
    -following up on deliveries using a form given to patients during ANC visits
     
    - performing PNC in community
    - identifying danger signs in mothers
    - following up on PNC patients using a form given to patients during ANC visits
    - identifying danger signs in neonatal
    - malnutrition and childhood illness monitoring in neonatal upto the age of 1 yr
    - following up on vaccinations and knowing about child health record
     
    2. TB-DOTS
     
    - symptoms for identifying TB
    - using TB Card to note medication intake by patients
    - performing DOTs
    - identifying side-effects of TB drugs
    - safety and precautions 
     
    3. Malnutrition Review
     
    - review of on-going method of using UMAC readings
    - using RUTF-Sarbottam Pitho (Nutritous flour)
     
    4. OPD Follow-up Training
     
    - communicating with patients about -
      - how to ask questions about medication intake and how to interpret the response
      - status of their health condition post-clinic care
      - collecting feedbacks about doctor, staff and services
      - suggestion for improvement
     
    5. Data Collection and using CHW Register Book
     
    Continous training was performed during each meeting to improve and adjust CHW Register Book to make it practical and feasible for CHW and also for also overall program evaluation and monitoring.
     
    Steps towards Stage 3:
    1. Make sure CHWs are capable of proper followup of OPD, ANC, PNC, malnutrition and TB patients
    2. Make sure CHWs are cabable of properly using CHW Register Book
    3. Make sure CHWs have continued good relationship and stand in the community
     
     

    STAGE 3: Long-term Stage: Triage and Treatment

     

    Rationale

    This third stage involves the CHW functioning as a true, albeit still limited, paramedic that undertakes the following activities:
    • implementation of a basic triage and treatment protocol to manage non-critical issues symptomatically and refer ill patients to the clinic
    • performance of the integrated management of childhood illness
    • execution of basic first aid in the field
    • follow-up of symptomatic postpartum patients
    • follow-up of newborns and administration of vaccinations
    In this stage, it is critical that the communications infrastructure has been improved to allow for real-time voice discussions between the CHW and the central clinic.
    Eventually, the overall goal is to have a CHW that engages patients in the medical system, assists them with adhering to prescribed therapies, and provides some level of basic medical services.
     

    Additional Roles and Responsibilities for Stage 3:

    The following additional roles and responsibilities are to be added to existing CHWs who have graduated from stages 1 and 2:
     
    1. First Aid
    2. ARI drug distribution
    3. APD counseling
    4. Basic Triage and referral from the community with enhanced medical
    5. Administration of Vaccinations
    6. Pneumonia diagnosis and referral
    7. HIV DOTS
    8. Iron distribution 
    9. Malnutrition: CHW-based treatment 
     
     
     
     
     

    REFERENCES AND SIDE-NOTES

     
    Some key issues identified in prior CHW programs (see review in references below):
    -ensuring that CHWs have a curative role, not only a follow-up/disease detection role, so that they are respected in the community
    -ensuring timely payment of CHWs
    -maintaining senior CHWs for long-term retention (younger persons tend to leave)
    -ensuring that CHWs have adequate and regular supervision, and that supervisors have detailed knowledge of their role
    -preventing role conflict by having CHWs have a discrete job from other health providers, e.g., being focused on home-based interventions
    -that CHWs are rarely successful at mobilizing communities, but that already mobilized communities tend to have the most successful CHW programs
    -that CHWs have been most successful in: maternal health (repro and contraception), identifying and treating PNA, and malaria/tb/hiv
    -try to allow community both to choose CHWs and that CHWs come from community they are serving
    -to have checklists and exams during CHW trainings, with phases of training to 'graduate'
    -ideally 1 CHW per 150 households
     
     
    References
    A comprehensive review of the data and evidence regarding the use and limitations of community healthcare worker programs.
    PIH has put up an amazing portal about their two-decades-long experience with CHWS:
    We will be heavily using and adapting their resources.
    Good resource of training materials for CHWs:
    CHW related resources:
    WHO integrated management of illnesses modules:
    WHO global workforce alliance webpage
    WHO workforce in healthcare shortage report (may 2008):
    Female Community Health Volunteers Resources
    Excellent article on FCHVs in Nepal: http://www.nepalitimes.com/issue/371/Nation/14071
    Current CHW-focused Grants (see foldershare): WB, newaid, SAARC TB, Downs
    OLD NOTES
    Tasks
    Nepal Team
    Hiring FCHVs:
    • speak with DHO (District Health Officer) about policies to hire FCHVs (Female Community Health Volunteers)
    • any restrictions to pay FCHVs?
    • will we be "sharing" them with the government or are they no longer considered government workers?
    • clarify that we will be hiring only one, not to replace the VHWs but to be our liaison in each village)
    • How are other organizations utilizing FCHVs?
    • If there are any restrictions on hiring them, try to get a list of former FCHVs.
    After getting to Achham
    From Dr. Sedain:
    • Names and contact and years in the position of all FCHVs in the region.
    • Recommendations for any FCHVs in villages surrounding Sanfe; share details of our plans to hire FCHVs as CHWs.
    • reconfirm logistics around hiring/sharing FCHVs.
    • Obtain training materials used by the DHO of FCHVs and VHWs
    Selection and Hiring
    1 per village, hire 10 CHWs in the first round after publicizing in the villages and a local newspaper (sudur sandesh). If only hiring FCHVs, can do focused publicity and invite them to apply.
    Qualifications: (in addition to our regular requirements for passion to serve) at least 2 years working as FCHW, experience in deliveries and MCH, able to read and write Nepali, preferably member of dalit family.
    Roles and Responsibilities
    • Will serve the communities they live in by providing primary care, making referrals of high risk and complicated cases.
    • Will aggressively conduct outreach to marginalized and vulnerable populations like pregnant women, dalits and the poorest in their communities.
    • Will very likely be complemented by a TBA (Traditional Birth Attendant) per villages.
    Training
    Training manual is being developed by nyaya. Training will be conducted by physician with assistance from other members of the staff (see foldershare Clinic DocumentsCHWsTraining Modules for draft of the modules, mainly based on PIH)
    • After selections are finalized, call a meeting for needs assessment.
    • Training will not reiterate what they receive from the government but will use a skills-based curriculum and include suggestions generated from the needs-assessment session.
    • Emphasize the importance of documenting every patient encounter for performance measurement and to identify weaknesses in the process (training, lack of supplies, skills of the CHWs, other challenges they may encounter)
    • References:
    Monitoring and Support
    Biweekly meetings at the clinic in the first few months, can rotate in every village thereafter. Meetings will focus on challenges and successes in: conducting outreach, providing care, availability of supplies, documenting patient encounters, and open ended discussions on what are the challenges and what has worked.
    Site visits by Nyaya staff at least once in the first two months for every CHW to provide support and general monitoring.
    This section will be flushed out later
    Current situation:
    Nepali government's presence in villages: 1 Village Health Worker is assigned to every VDC (Village Development Committee). This is a paid position, usually held by a male. Our experience has shown that they are usually absent from the VDCs. Most of the outreach and especially maternal and child health is conducted by the Female Community Health Volunteers.
    FCHVs are often celebrated and we think are underutilized and we should focus on providing them support (monetary, supplies and other support)
    **Training, ****Monitoring and Evaluation
    Currently, FCHVs receive a 2-week training that is mainly knowledge/theory-based. Every 6 months, they receive a 2-day "refresher" course. We will develop training modules that will not only impart knowledge but also equip them with skills needed to conduct outreach, find patients, interact with patients, document those interactions like a clinic chart and get their feedback to guide the training process. Look at bibhav's downs application for some ideas and background on evaluating effectiveness of CHWs in providing care/conducting outreach.
    Incentive Structures
    There have been multiple demands that FCHVs should not be take from granted and be cotinually denied payment for the sake of keeping the model "sustainable". In addition to paying the CHWs, we will need to research other incentives: respect in the community, a strong supply system so they will not suffer from lacking essential supplies and failing to provide treatment, connecting them to the clinic and to each other etc.
    A key aspect of keeping the CHWs engaged is having regular meetings to keep them engaged. Jamkheds had these at the clinic; we might do some combination of clinic-center meetings (say every month or bimonthly) interspersed with rotating meetings at each CHW's village. In addition to having regular meetings, we will find innovative applications of technological tools like wi-fi phones to keep the CHWs connected to the clinic and each other.
    We will need to continue research on other models that have worked and think creatively on what will work in Achham. Please share links and resources here with comments.
    WHO's recent incentives for health workers statement: http://www.who.int/workforcealliance/news/incentives-guidelines/en/index.html
    Continuous Quality Improvement
    Evaluation will yield data that will be fed to a CQI system that will consist of CHWs, clinical staff and the clinical management board. The group's goal will be creating indicators to measure performace and using that data to identify which parts of the process can be improved to maximize performance on those indicators.
    bibhav working on this. will implement during the summer. email him if interested. **

     

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