These are the main action steps necessary to improve and enhance the current services provided by NHCHWs and to transition to Stage 3: [Comments within square brackets in blue represent the status of recommendation implementation.]

 

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.
   5. [Addressed and discussed during the meetings; During evaluation period, CHW Program Director and CHWs addressed groups of community members to provide right information about doctors and their qualifications. CHWs were also trained to respond to patients beliefs.]
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 hospital 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.

                                    [These issues were thoroughly discussed in data entry refreshers during weekly meetings. The condition of patients who were under CHW followup were now reviewed each week during weekly meetings and data were entered in the database. If patients were not doing well, the doc was consulted and CHWs were instructed on how to care or bring the patient to the hospital.]

 

3. Make sure everyone in CHWs catchment areas knows about the hours of operation
4. 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
5. 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 

[CHWs were trained on using inhalers, about condom use. An ARI training was prepared for using electronic timers to measure respiration rates of children to detect and refer pneumonia. However, because of the complexity of the technology of previously purchased timers, the training was postponed until simpler version of timers (those used by UNICEF) could be procured. Weekly meeting also involved going over a diseases and conditions that were more prevalent in their communities at that time. See trainings section for more details on what trainings were given during each CHW meetings.]

 

6. Educational Training/refreshers
   1. Pregnancy/Delivery related [Performed]

                                                               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 hospital/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

                                                               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

                                                               i.      CB to gather more information about possibility of giving worm meds through CHWs… deworming campaigns, any ongoing projects that NH can coordinate with [Incomplete as of Aug09]

                                                               i.      Diarrhea [Performed multiple times, more recently during diarrheal outbreaks in Achham and neighboring districts in July09.]

                                                               i.      ARI

1.       Need to Speak with Sailendra Sir to get ARI equipment [Never came through, need to request again]

                                                             ii.      APD

1.       More information to CHWs about APD and counseling [Incomplete as of Aug09]

                                                            iii.      Pregnancy/Deliver- more in depth education [Partially performed: further recommendations to perform more thorough review when volunteer doctor is around.]

                                                           iv.      First AID

1. Test kits available [Performed, trained and now they are carrying their boxes while visiting patients] 

 

7. 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 hospital [Discussed during weekly meetings. In fact, many cases were brought to the hospital because of direct persuasion and accompany of CHW, particularly involving malnutrition, ARI, TB, retained placenta and complicated delivery]
8. Getting a system by which CHWs can also take meds to the patient if the latter is incapable to come to the hospital in his/her own. [TB DOTS implemented in Mastamandu; Sarbottam pitho delivered to a child whose parents were in no capacity come back to the hospital after initial diagnosis at the hospital. Distribution of condoms]
9. Discuss the feasibility and appropriateness of giving a very few medicine if the person needs to get it from a private pharmacy; 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

                                                              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 hospital 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 hospital 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 hospital 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 [On hold, had meetings with several local NGOs working on anti-poverty program including SEVAK.)

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] [Both meetings performed. Expansion on Hold. CB identified villages that are most needy in terms of socioeconomic status and access to health resources. This database will be useful for guiding future expansion.]

c.       Discuss with Women Development Group/Committee to understand what programs they have [Spoke with SNEHA, women's HIV/AIDS advocacy and rehabilitation agency; program has phased out.]

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