Since the initial days of Nyaya Health, we have struggled to identify a viable strategy for our
community health worker program. Despite a strong vision that community health workers are critical to our work, the program hobbled along for our first two years of existence. During that time, we had four health workers who received a salary but from whom we were unable to get much of any tangible results. Much of the time it was unclear what exactly it was that the health workers were supposed to be doing, and even times when it was unclear who was running the program. These failings were partly due to our inexperience as managers. Much analogous to our broken inverter and battery, we are learning-by-doing how to implement effective oversight mechanisms. More importantly, they have occurred because these sorts of programs, while medically not wholly complicated, can be logistically and socially incredibly complex. As such, they require significant grassroots time to problem-shoot and generate new ideas.
Since the beginning of planning our community health worker program, we have angled to work with the government’s existing network of female community health volunteers (FCHVs). The FCHVs are widely respected throughout the country and form a foundation of the public sector health system. Yet they remain quite under-utilized and under-capacitated. Just as Bayalpata Hospital is a physical infrastructure that we would build off of in helping to strengthen the public sector, so too are the FHCVs. The problem that we faced was trying to figure out how to work with the government to provide the FCHVs monetary incentives. This was critical both so that they would be accountable to us and because significant research has demonstrated that paying health workers improves their effectiveness. Intermittently over the last few years, we would discuss as a team about trying to figure out a way to do this, but made little tangible progress.
Finally, about four months ago, we were able to devise a scheme that was palatable to the government. At its heart is quite simple: in each of the village development committees (VDC, a local municipal structure), we identify the FCHVs and pay them incentives for performing various tasks with us. A VDC-wide community health worker oversee their work and conduct weekly meetings. For the last four months, since the FCHV’s skills are minimal, since it would take a long time to train them on more specific tasks, and since we had to start getting to know them, we have asked them to simply record whom they are seeing in their communities who is sick or pregnant or recently delivered. The community health workers report at the hospital directly to Ranju Sharma, our Program Coordinator.
We currently cover 3 VDCs with 35 FCHVs. Ranjuji coordinates this program. She showed me her data recording sheets and will be analyzing them in greater detail soon. Suffice it to say for now that over the last three months, over six hundred interactions between the FCHVs and members of their communities. While we are as of yet capable of speaking to the tangible value of these interactions, this is at least a foundation. Furthermore, attendance by the FCHVs has been stellar at their weekly meetings; even during the holiday season of Desai/Tihar, they asked that the meetings continue. So we have a base from which to grow.
This month, we are adding on an additional layer: follow-up of patients from Bayalpata Hospital. It is difficult to understate the importance of follow-up to quality medical care; patients are rarely
cured or even helped by a single visit. Yet in an area where 20% of our patients walk over 10 hours just to get to the hospital, follow-up is immensely difficult. To identify patients in need of follow-up, we are placing a check-box on the outpatient, inpatient, and emergency registries where the doctor or health assistant indicates that they feel the patient could benefit. They also indicate the number of days within which the patient should return to the Bayalpata Hospital or a government health post (small clinic, staffed by a moderately trained non-physician health worker). The clinician, being busy seeing up to seventy patients in one day, is not expected to do any more than this. They are not even expected to know which VDCs are currently covered by the program. Additionally, the Program Coordinator goes around each week to identify all patients in the condition-specific programs, such as malnutrition, HIV, TB, pregnancy, and post-partum.
Our Data Manager Deepak Bista then enters the data and hands on a weekly basis a list of names with times to follow-up. The Program Coordinator then distributes these lists to the respective Community Health Worker covering a particular VDC, and the Community Health Worker distributes the list to their FCHVs. The FCHVs are then expected to find the patient and say something to the effect of “The doctor asked that I see you and remind you to come back to the Hospital (or health post).” The FCHV then hands a token to the patient, and the patient is expected to give that to the provider when they go for their visit. That is how we monitor the program.
The fact that our providers are sometimes referring to the health post helps us to move in a direction of collaboration with the government on strengthening the health posts, which is a key strategy for our overall goal of bulwarking the public sector. A health post is one of the core smaller clinics that are found throughout the district; they represent a key public health infrastructure but one that suffers from supply chains shortages and staff absenteeism. We hope that we can demonstrate, via these tokens, that the FCHVs can serve as an effective referral mechanism, and that that can help us to better angle ourselves to support the health posts.
For monitoring, our program is quite simple. Firstly, we track the type of encounter. This is a process measure, as it does not indicate the quality of the encounter. The Program Coordinator tallies this. Secondly, we track the percentage of follow-ups achieved by patients covered by the FCHV program. This is done at registration (without the need to involve the clinicians) and is analyzed in our electronic database via the patient’s ID number. The goal of this is to have a simple, straightforward mechanism of tracking the growth and effectiveness of the program. The Program Coordinator is also expected to provide stories and insights about how the program is working at a qualitative level.
We hope to have developed a foundation, based fundamentally on existing community and governmental resources, from which we can build an effective community health system. Stay tuned for further developments.
Summary of the Program
- Female community health volunteers are a core human infrastructure for the public sector in Achham, yet they need support to be more effective.
- Currently, Nyaya’s program operates in three village development committees, covering thirty-five FCHVs.
- Nyaya hires one community health worker per VDC to oversee the FCHVs.
- Nyaya pays FCHVs financial incentives to do 1) community-based disease detection and 2) to follow-up patients seen at the Hospital and not “forget” patients. Both of these tasks require minimal medical skills but build off their fundamental skill in their villages: knowing everybody and who is sick.
- Their performance on follow-up is monitored through the use of tokens that are given out by the FCHVs to patients and received at the health post or the Bayalpata Hospital that the FCHVs had told them to give.
- Our next steps are: 1) to expand the number of VDCs that we cover, to around 10-12 total and 2) to further train the FCHVs on counseling, triage, and basic management of diseases.
Duncan Maru, MD, PhD is a co-founder and President of Nyaya Health. He is currently a resident in the Internal Medicine – Pediatrics program and fellow in Global Health Equity at Brigham and Women’s Hospital and Children’s Hospital of Boston.