THE ROLE OF FEMALE COMMUNITY HEALTH VOLUNTEERS IN

PROVIDING KEY FAMILY PLANNING SERVICES TO WOMEN IN HARD TO

REACH AREAS ACROSS NEPAL

International Conference on Family Planning Bali, Indonesia January 25-28, 2016 Presenter: Savitha Subramanian Co Authors: Sophia Magalona, Leela Khanal, and Binjwala Shrestha

NEPAL CONTEXT

Total Fertility Rate among women aged 15-49 years is 2.6

Almost one quarter of women give birth by the age of 18; nearly half by 20

Knowledge of contraception is universal Contraceptive Prevalence Rate is 49.7%

Source: DHS 2011

FCHVs IN NEPAL

The Female Community Health Volunteer (FCHV) program was initiated in 1988.

The FCHV program focuses on family planning, maternal/neonatal and child health.

More than 52,000 FCHVs are active across Nepal.

The FCHV program is widely acclaimed for its contribution in reducing child mortality and improving maternal health in the country

PresenterPresentation NotesThe Female Community Health Volunteer (FCHV) program in Nepal, introduced in 1988 by Nepals Ministry of Health and Population (MOHP), was designed to enhance Nepals primary health care network, improve community participation, and expand the outreach of health services. The goal of the FCHV program is to support achievement of national health goals through community involvement in public health activities. FCHVslocal women volunteering at the community level function as a bridge between the government and the community.

Since its introduction, the program has contributed to increasing the rural populations use of modern health services; reducing infant, child, and maternal mortality; and ensuring the prevention and treatment of key diseases. Currently, in addition to providing community-based family planning services, FCHVs contribute to key public health programs for maternal care, sick child care, health and nutrition counseling, vitamin A supplementation/de-worming, and immunization. FCHVs also provide basic health information to women, including information needed during pregnancy. As such, they are critical resources that extend the reach of the public health care system far beyond physical health care facilities, deep into the community.

OBJECTIVES

To conduct a comprehensive national survey across 13 domains focusing on:

To understand how FCHVs perceive their work and factors influencing their motivation for continuing to serve as FCHVs

To understand how stakeholders and communities perceive the role of FCHVs and identify strategies to ensure program sustainability

FCHV socio-demographic

and work profile

Support

received by FCHVs

FCHV

services

PresenterPresentation NotesThe survey was carried out to provide a snapshot of FCHV characteristics, services provided, support received, and FCHV and stakeholder perceptions of the program across geographic and technical areas. It is expected that the results will illuminate strengths and challenges of the current FCHV program and help contribute to policies affecting FCHVs, ultimately enhancing the potential of this cadre and mitigating programmatic limitations.

METHODOLOGY

Quantitative Data Collection

Systematic random sampling with the ward/FCHV as the primary sampling unit in each of the 13 domains

Sample selection stratified by urban and rural wards to ensure adequate representation

Use of PC tablets for data collection and storage using SurveyCTO and Enketo

Total of 4,302 FCHVs interviewed

Qualitative Data Collection

Purposive sampling to include various levels of respondents 12 (rural and urban districts) within 8 of the 13 domains included in the qualitative survey

48 Klls and 34 FGDs with 106 participants

PresenterPresentation NotesCross Sectional Survey

Data collection between August 2014-February 2015

(central-level, district-level, health workers, and health facility management committee members), and FCHVs from rural, urban, remote, and marginalized communities

ANALYSIS

Quantitative Survey

Univariate and bivariate analysis

Results weighted based on the relative size of the districts in the13 domains

Stratified by residence (urban vs. rural), literacy, FCHV age, and time it takes FCHV to reach health facility

Chi-square tests

Qualitative Information

Transcribed and analyzed per protocol

Thematic coding analysis

RESULTS

PresenterPresentation NotesFCHVs are trained to provide the following; results to be presented on the following

Counselling ( group, pair and individual )

Referral to the appropriate health facilities for FP services

Distribution and redistribution of Condoms and Pills

Support to long acting outreach FP services surgical camps

FCHV PROFILE

Average age 41.3 years 67% of FCHVs reported attending school; of these 45%

attended 6th-12th grade 83% of FCHVs were literate 90% of FCHVs were married

59% of FCHVs served > 10 years

96% of FCHVs reported receiving basic training

PresenterPresentation NotesBasic training-18 day training including family planning

FP COUNSELING

PresenterPresentation NotesAll FCHVs were asked if they provided FP services in the three months prior to the survey; 97 percent reported having provided at least some.

Chart1

93

94

99

91

97

99

93

97

98

99

100

99

99

DOMAIN

Percentage of FCHVs

Percentage of FCHVs who reported providing any family planning counseling in the three months prior to the survey

Sheet1

In the last 3 months, provided counseling on family planning for:

Provided any family planning counseling in the 3 months prior to surveybc*

Characteristics

Pregnant womandPostnatal womancdeNewly married couplebcdWoman undergone abortionbcReturnee migrantbcOther adult malebcdeOther adult femalece

Adolescentbc

DENOMINATOR (N)4,3024,302

Domain

Eastern Mountain93886830832222432

Eastern Hill94796920726212129

Eastern Terai999393371750355083

Central Mountain91645830740244672

Central Hill977473251135182953

Central Terai999292191337413774

Western Mountain938476362343254654

Western Hill977170281437455564

Western Terai989489352758554984

Mid-western Hill998782361744336075

Mid-western Terai1009889321947343567

Far-western Hill998674312054384968

Far-western Terai999485322762253444

Literacy

Illiterate958481241235293566

Literate988378291642354463

Age

FP COUNSELING

PresenterPresentation NotesThis counseling was most often provided during contacts with pregnant or postpartum women (83 percent and 79 percent, respectively), although almost two-thirds of FCHVs (63 percent) also reported having provided such counseling to other adult women over that period. On average, only 28 percent of FCHVs reported providing FP counseling to newly married couples, and only 15 percent of FCHVs provided counseling to women who had undergone an abortion. In addition, 41 percent of FCHVs reported providing FP counseling to adolescents, and 34 percent provided FP counseling to returnee migrants. Some regional variation was found in the results.

Not much difference between counseling provided by urban vs. rural FCHVsOther characteristics: Interestingly, only 8 percent of older FCHVs (55+ years) reported providing FP counseling to women following an abortion, compared to 18 percent of younger women (

DISTRIBUTION OF FP COMMODITIES

0

10

20

30

40

50

60

70

80

90

100

Perc

ent o

f FCH

Vs

Domain

Condoms (%) Ever distributed condoms in the3 months prior to survey (n=2664)

Pills (%) Ever distributed pills in the 3 monthsprior to survey (n=2661)

PresenterPresentation NotesAmong FCHVs who had reported on contraceptive distribution in their registers, 68 percent and 67 percent, respectively, reported having distributed condoms and oral contraceptives over the past three months. Proportions varied considerably across domains, with a high proportion of FCHVs reporting this activity in Far Western Terai (condoms 97 percent; pills 83 percent), and a low proportion in Central Mountain (condoms 29 percent; pills 43 percent).

REFERRALS FOR FP SERVICES

45

32

49

3427

41

2723

50

28

45

33

59

0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge o

f FCH

Vs

DOMAIN

Percent of FCHVs who recorded referring couples for family planning services in the three months prior to survey (n=2662)

PresenterPresentation NotesNationally 35% of FCHVs reported providing referrals for couples for family planning

Chart1

45

32

49

34

27

41

27

23

50

28

45

33

59

Couples referred for family planning services in the 3 months prior to survey

DOMAIN

Percentage of FCHVs

Percent of FCHVs who recorded referring couples for family planning services in the three months prior to survey (n=2662)

Sheet1

In the last 3 months, provided counseling on family planning for:

Provided any family planning counseling in the 3 months prior to surveybc*

Characteristics

Pregnant womandPostnatal womancdeNewly married couplebcdWoman undergone abortionbcReturnee migrantbcOther adult malebcdeOther adult femalece

Adolescentbc

DENOMINATOR (N)4,3024,302

Domain

Eastern Mountain93886830832222432

Eastern Hill94796920726212129

Eastern Terai999393371750355083

Central Mountain91645830740244672

Central Hill977473251135182953

Central Terai999292191337413774

Western Mountain938476362343254654

Western Hill977170281437455564

Western Terai989489352758554984

Mid-western Hill998782361744336075

Mid-western Terai1009889321947343567

Far-western Hill998674312054384968

Far-western Terai999485322762253444

Literacy

Illiterate958481241235293566

Literate988378291642354463

Age

REFERRALS FOR FP SERVICES

0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge o

f FCH

Vs

DOMAIN

Percent of FCHVs Reporting Providing Referrals for Sterilization in the Year Prior to the Survey (n=4302)

Women referred for sterilizationin the year prior to survey

Men referred for sterilization inthe year prior to survey

PresenterPresentation NotesNationally, thirty-one percent of FCHVs reported providing referrals for women for sterilization and 45% of FCHVs provided referrals for male sterilizationThirty-one percent of FCHVs reported referring women for sterilization, with the lowest proportion of referrals in Central Terai (11 percent of FCHVs) and the highest in Central Mountain (46 percent). By comparison, 45 percent of FCHVs reported providing referrals for male sterilization, with 64 to 70 percent of FCHVs reporting referrals in Eastern, Central, and Western Terai.

Chart1

2626

3439

1664

4648

4237

1166

4629

3234

3470

4027

2743

3137

3771

Women referred for sterilization in the year prior to survey

Men referred for sterilization in the year prior to survey

DOMAIN

Percentage of FCHVs

Percent of FCHVs Reporting Providing Referrals for Sterilization in the Year Prior to the Survey (n=4302)

Sheet1

In the last 3 months, provided counseling on family planning for:

Provided any family planning counseling in the 3 months prior to surveybc*

Characteristics

Pregnant womandPostnatal womancdeNewly married couplebcdWoman undergone abortionbcReturnee migrantbcOther adult malebcdeOther adult femalece

Adolescentbc

DENOMINATOR (N)4,3024,302

Domain

Eastern Mountain93886830832222432

Eastern Hill94796920726212129

Eastern Terai999393371750355083

Central Mountain91645830740244672

Central Hill977473251135182953

Central Terai999292191337413774

Western Mountain938476362343254654

Western Hill977170281437455564

Western Terai989489352758554984

Mid-western Hill998782361744336075

Mid-western Terai1009889321947343567

Far-western Hill998674312054384968

Far-western Terai999485322762253444

Literacy

Illiterate958481241235293566

Literate988378291642354463

Age

PERCEPTIONS ON FCHVs ROLE IN PROVIDING HEALTH AND FP SERVICES

FCHVs are the eyes and ears of the health programs, because they are working as the main media of the

community problem. They bring all the health problems to health facility. With her information we are organizing the

community health program. KII, AHW

We can discuss with FCHVs openly, we don't feel shame to discuss family

planning, pregnancy. We don't feel easy to outsider in this matter. We are satisfied with FCHV's service. FGD, Community

Beneficiaries

PresenterPresentation NotesCommunity beneficiaries expressed how FCHVs provided leadership for key health services by taking time to discuss topics including FP with families. As a result FCHVs have created an enabling environment where beneficiaries do not shy away from discussing FP. Health workers from facilities stated that FCHVs are a suitable cadre for counseling on FP because they are able to identify clients in the community, and encourage and inform them about the availability of contraceptives. In addition, given that FCHVs are the first source of care for many communities, they are able to refer people to facilities for different FP methods that they are unable to provide. FCHVs also reported accompanying beneficiaries to the clinics for clients who were interested in sterilization.

PERCEPTIONS ON FCHVs ROLE IN PROVIDING HEALTH AND FP SERVICES

FCHV are playing important role to break cultural barrier, because in

remote community women are illiterate and feel shame to visit health facility, especially family planning, ANC and

delivery care.-KII, ANM

Now with help of FCHV child death are prevented. Number of pregnancy also

limited due to promotion of family planning-FGD, Community Beneficiaries

(Remote VDC)

PresenterPresentation NotesCommunity beneficiaries expressed how FCHVs provided leadership for key health services by taking time to discuss topics including FP with families. As a result FCHVs have created an enabling environment where beneficiaries do not shy away from discussing FP. Health workers from facilities stated that FCHVs are a suitable cadre for counseling on FP because they are able to identify clients in the community, and encourage and inform them about the availability of contraceptives. In addition, given that FCHVs are the first source of care for many communities, they are able to refer people to facilities for different FP methods that they are unable to provide. FCHVs also reported accompanying beneficiaries to the clinics for clients who were interested in sterilization.

POLICY IMPLICATIONS The FCHV program needs to be continued and

adapted to meet changing and varying needs

Specific (contextualized) FCHV services vs. blanket approach

Targeting resources to specific high-impact activities by FCHVs (MNCH, FP and Nutrition)

Ensuring regular commodities availability to help increase performance of the FCHVs

Supportive supervision and monitoring mechanism for FCHVs

Additional FCHV training or refresher training

Better record keeping and use of registers is likely to improve service outcomes

PresenterPresentation NotesThe survey findings highlight the important role of FCHVs in providing FP counseling and commodities as they are the bridge between communities and formal health facilities, particularly in rural areas. Results from the survey showed that FCHVs are key health staff in delivering FP services that otherwise might not be available in these areas. In addition, given the strong standing of FCHVs in communities, they are better able to discuss family planning with beneficiaries as they understand the cultural context of these communities given that they are from the same areas. However, there were some geographical variations where FCHVs in some geographic areas seemed to be more active in terms of providing FP counseling and commodities compared to others. Further investigations should identify bottlenecks to FP service delivery and how these can be addressed.

Other findings from the survey highlighted the need for FCHVs to have better supervision, regular supply of commodities, and re-training, all of which apply to family planning services. Availability of health commodities varied. Over half (59 percent) of FCHVs had condoms available on the day of the survey, but the proportion varied across domains. Availability of oral contraceptives averaged58 percent (range: 44 to 79 percent by location). Among FCHVs who lived further away from a healthfacility (>60 minutes), 64 percent were observed to have pills, compared to 52 percent of FCHVs who lived closer (

ACKNOWLEDGEMENTS

Funding USAID

UNICEF Save the Children

Study Implementation Team JSI R&T HERD FHI360

Key Advisors/Stakeholders Department of Health Services,

Nepal Family Health Division, MOH

NHRC

Respondents FCHVs

Key informants - central-level, district-level, health workers, health facility management committee members, and community beneficiaries

PresenterPresentation NotesCross Sectional Survey

Data collection between August 2014-February 2015

(central-level, district-level, health workers, and health facility management committee members), and FCHVs from rural, urban, remote, and marginalized communities

The role of female Community health volunteers in providing key family planning services to women in hard to reach areas across nepalSlide Number 2Slide Number 3Slide Number 4Slide Number 5Slide Number 6Slide Number 7Slide Number 8Slide Number 9Slide Number 10Slide Number 11Slide Number 12Slide Number 13Slide Number 14Slide Number 15Slide Number 16Slide Number 17