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 if and faith in 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 hospital, 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 hospital 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 hospital to patient and vice versa High quality is maintained only if all of the following are achieved:

1. Hospital 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 hospital 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 hospital 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 hospital-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 hospital and undergoes weekly screening by NHCHWs for any danger signs and, is immediately referred to the hospital 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 hospital 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 hospital 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 hospital

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 hospital

    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 hospital on the status of the patient

    5. If patient is not getting better, then referring the patient back to the hospital 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 hospital

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

    1. Getting to the hospital

    2. Services provided by the hospital (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. Hospital operation hours and emphasizing the need to get there during registration time

    6. The composition of hospital-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.

OVERALL VISION FOR OPERATION AND EXPANSION

STAGE 1: Initial Stage: Outreach [graduated]

Rationale:

• follow-up of patients treated at the central hospital, encouraging patients treated for pneumonia, abscess, malnutrition, etc. to return to the hospital as requested by the clinical team.
• detection of pregnancy and recruitment of patients to attend antenatal care visits at the hospital.
• detection of malnutrition using a simple survey that includes a color-coded band that measures mid-upper-arm-circumference
• referring of patients to the hospital for vaccination

History of Activities:

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 

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

Rationale:

• 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 hospital 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-hospital care and refer patients back to hospital if conditions do not improve even after treatment (c) to collect feedback from the community and patients about hospital services and staff and rooms for improvement

Added Trainings:

STAGE 3: Long-term Stage: Triage and Treatment

Rationale

• implementation of a basic triage and treatment protocol to manage non-critical issues symptomatically and refer ill patients to the hospital
• 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

Additional Roles and Responsibilities for Stage 3: