Posted by Ranju Sharma
Nyaya volunteer Ranju Sharma recounts a day she spent in the summer of 2009 with two of Nyaya’s CHWs
Achham had recently had the first few rainfalls of this year’s monsoon when we went for a community visit with two of Nyaya Health Community Health Workers (CHWs). The day was not an ideal depiction of a typical day for a CHW. This year, monsoon started late in Achham and following a rainy day, family members of almost every household were out working in the fields. Most of the houses in the villages were empty – we met only a few children and old women at their houses, however we met people from most of the households while they were working in the fields or carrying out their daily chores such as fetching water or washing at the communal water sources, or collecting fodder for their cattle.
The CHWs said that during monsoon, which is the planting season in Nepal, the families leave home as early as dawn and return after dusk, so it is hard to collect data from every household every visit. Typically, every week the CHWs are responsible for completing a general surveillance of each household in the communities they are assigned to. Each week, they are expected to report data giving a picture of the basic health status of their respective communities.
For general health surveillance, CHWs monitor for illness in their communities, they note the type and duration of sickness, inquire if any medical attention has been given, and encourage ill patients to visit the hospital accordingly. CHWs also monitor pregnancies in the community and ensure that the pregnant women are advised about ANC (Antenatal Checkup) and PNC (Postnatal Checkup) visits. They ensure that the parents are aware of the different immunizations their children require, and encourage them to get their children immunized. CHWs also screen children for the signs of malnutrition and encourage parents to take the child to the hospital when necessary. Other major duties of CHWs is follow up for patients who have been recently seen in the hospital, to check if the patient is taking the medicines correctly, inquire about their continued health status, and collect feedback on the doctor/staff and comments/suggestions for improvement of service provision. For patients with tuberculosis, CHWs also provide DOTS (Directly Observed Treatment Strategy) – the medical treatment process to cure tuberculosis – in their assigned communities. Another major responsibility for Nyaya’s CHW program is the distribution of ORS (Oral Rehydration Solution) packets to patients suffering from diarrhea. ORS is a mixture of salt that helps the body retain water, and can be lifesaving for patients suffering from diarrheal illness. As diarrhea is a common disease in these communities, especially in the monsoon, distribution and teaching of proper utilization of ORS by the CHWs is an effective way to prevent death from dehydration due to diarrhea.
The day of our visit, we visited all the villages that two of our CHWs would normally cover in a week’s time because we aimed to get an overview of how they conducted their work. As all Nyaya CHWs live in or around the communities they work with, every household is well acquainted with their CHW. Upon meeting community members, CHWs conversed informally with them, asking after the health of each person in their household. In some instances, when the CHW knew that the person was ill on their previous visit, they asked if there had been any improvement and if they sought any kind of medical attention in the interim.
During our visit, we came across a few cases of diarrhea, a case of fever, two pregnant women, and a few recent mothers requiring post-natal care visits. Of all the people we met, most had positive responses to CHW services and the potential of using the hospital’s services when necessary. However, others were apathetic to CHW efforts and stated they had no interest in walking a few hours to the hospital when there was no guarantee of them being fully treated. A few older women we met – who were suffering from asthma – complained that the medicine that they were given previously had not worked, so why should they return again? Asthma is one of the most commonly observed diseases in rural Nepal, mainly in the older population, and due in large part to indoor cooking stoves that cause significant air pollution. The commonly prescribed drugs for asthma are administered using inhalers. Inhalers are difficult for many of Nyaya’s patients as the large majority of our population is illiterate – if they are not properly counseled on the right way to use the inhalers, the drugs aren’t effective at all. The women we met had previously visited Nyaya’s SanfeBagar Clinic (which operated prior to the opening of Bayalpata Hospital), and had received the inhalers there. The CHWs told us it was likely that the women had received no relief from the inhalers because they were using them improperly.
Unfortunately, even though the CHWs tried to explain this to the women, and encouraged them to visit the hospital again, they replied they wouldn’t walk so many hours to get medicine that might not work again. Instead, they suggested the CHWs bring them the medicine. This suggestion was quite common as it meant the patient wouldn’t have to travel themselves to the hospital. However, as CHWs are not trained health professionals, they are unable to distribute medications in the community. The role of the CHW is instead to ensure that medications are being used in an effective manner, and to refer patients to the hospital in the case that further medication is required. Some community members understand this limitation of the CHWs, however it can be extremely difficult to make others understand why distributing medications is not as simple as distributing ORS (which has no side effects or danger of overdose). Following this visit, the CHWs were trained on the usage of inhalers so that they could properly counsel asthmatic patients in their community.
Nyaya’s CHWs are a means of outreach to the community served by Bayalpata hospital. They act as a bridge connecting Nyaya Health to the community; CHWs both monitor their communities for health problems, and also teach their fellow community members about the health services available to them. It has been a little more than a year since the Nyaya CHW program began. Even in this short time period, the CHW program has played an important role in ensuring effective usage of Nyaya Health’s services. However, there are still great challenges to overcome, many lessons to be learned and vast possibilities of improvement and modification. As Nyaya grows, and expands our services, our CHWs will be a critical component in ensuring our programs are rooted in the community, and responsive to their needs.