Posted by Shefali Oza
Given the remote location of many households in Achham, our community health workers (CHWs) represent a critical bridge to the community. CHWs are primarily responsible for providing health education, conducting general surveillance, and visiting patients who require follow-up. The lack of roads and communication networks, which make this program an important step in improving population-level health indicators, also result in management difficulties that require innovative solutions.
For example, our current CHWs live up to two hours away from Bayalpata Hospital by foot. Thus, we have structured the program so they come to the hospital once a week for a feedback meeting. During this time we can evaluate their work, provide them with patient information for the next week’s follow-up visits, and conduct weekly training courses on a range of diseases and patient education topics. Because there are no cellphones, landlines, or community-wide internet structures in Achham, it is difficult to efficiently contact the CHWs during the rest of the week.
A well-designed program needs oversight in order to guarantee that desired results are being achieved efficiently. Numerous programs throughout the world – ranging from within governments to international organizations to local NGOs – have demonstrated the waste of precious time, resources, and opportunities that can result from a lack of such oversight, no matter how great the original idea was. Thus, over the coming months, we are aiming to develop innovative strategies that can bypass the transportation and communication challenges present in Achham and allow us to effectively monitor and evaluate the work of our CHWs.
Here we share an example of an aspect of the CHW program requiring oversight and a proposed solution. Due to the difficult terrain and lack of roads, patients sometimes do not return to the hospital for follow-up, which can be dangerous for a number of conditions. Each week, the CHWs are given a list of patients in their catchment area whose illnesses require follow-up. One of the main responsibilities of our CHWs is to visit such patients and counsel them to return to Bayalpata Hospital if their condition is not improving. During the visit, they record basic data on the patient’s condition that can then be evaluated at the hospital.
We are currently piloting a basic “ticket” system that will allow us to confirm that our CHWs are actually performing these patient visits. When patients comes to the outpatient department at Bayalpata Hospital, they are seen by one of our doctors or health assistants. Each healthcare provider has been trained on a list detailing the conditions requiring CHW follow-up and the names of the CHW catchment wards. When a patient is seen who meets these criteria, a “ticket” is attached to the medical record that the patient takes home. At the following CHW meeting, the names of all patients with such tickets are given to the relevant CHWs. The CHWs then collect the tickets from the patients during the home-based follow-up visit that week and return the tickets to the hospital at the next CHW meeting.
We will assess the effectiveness of this simple oversight system in the coming 1-2 months and post an update about our experiences. While not completely full-proof, this method is relatively easy to implement and is not time intensive for medical staff, patients, or management. Outpatient visits generally only require one follow-up visit; in order to collect the ticket the CHW will have to see the patient at least once. We are working to develop alternative oversight mechanisms for conditions that require more than once weekly follow-up, as oversight through this ticket-based system can be more easily bypassed in such scenarios.
As always, we welcome your thoughts and suggestions on ways we can improve our services.