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Field Notes

Female Community  Volunteers Save Children from Pneumonia Deaths in Nepal

Chitra Kumal knows the pain of losing a child. When her daughter, Sunita, was 15 months old, she developed a respiratory infection that quickly progressed into pneumonia. With no health facilities in her Nepalese village, Kumal depended on the advice and treatment of a traditional healer or shaman. After just three days of fever, fast breathing and chest indrawing, her only daughter died.

Unfortunately, Kumal is not alone. Pneumonia is a leading cause of mortality in children under-five in Nepal. A 1991 national survey found an under-five mortality rate of 121 per 1,000 nationally, and the exceedingly high rate of 147 per 1,000 in rural Nepal. The Ministry of Health at that time estimated the proportion of deaths due to pneumonia was between 30 to 40 percent.

When Kumal was given the opportunity to help others in her community, she eagerly volunteered to be trained as a Female Community Health Volunteer (FCHV). FCHVs are local women, selected by their communities and trained by the ministry of health to promote healthy behaviors and provide selected health services in their villages.

Female Community Health Volunteers are part of a larger cadre of Community Health Workers (CHWs), which includes include Village Health Workers and Maternal and Child Health Workers. Community health workers can provide high-dose vitamin A capsule supplementation semi-annually to children, treat diarrhea with oral rehydration solution (ORS) and zinc, and are trained to refer seriously ill children to health facilities. The community-based pneumonia initiative, which was launched in 1995, was based on Nepal-specific research which showed that community-based management of pneumonia could decrease child mortality.

Because a large proportion of the FCHVs were illiterate, there was initial concern among some senior government officials about allowing them to treat children with pneumonia using antibiotics. A government policy was then developed to guide an initial pilot program to evaluate this approach in four districts, comparing “treatment” and “referral” models.

A formal evaluation of this program in 1997 revealed that FCHVs were able to deliver high-quality pneumonia case management in their communities. Moreover, in districts where FCHVs were allowed to provide the antibiotic, twice as many children suffering from pneumonia were identified and treated. Therefore, on the recommendation of the evaluation team, the ministry of health adopted a plan for cautious expansion of the “treatment” model.

The program merged with Community-based Integrated Management of Childhood Illness (CB-IMCI) in 1999, and community-based management of pneumonia has since remained a strong core component. Access to care has increased, especially in more remote villages and districts. In most communities, treatment is provided free of charge. This ensures equity, with more disadvantaged members of society able to access care for childhood pneumonia.

Giving the responsibility for pneumonia treatment to community health workers on such a large national scale was pioneered in Nepal. To make this possible, John Snow, Inc., which has been integral to all program activities since the inception of the community-based pneumonia initiative, participated in a technical group, led by the ministry of health and including all partners – UNICEF, USAID, WHO and nongovernmental organizations working in health – to guide the program activities.

To initiate community-based pneumonia treatment, FCHVs receive community-based IMCI training. CHWs are trained to determine if a child has pneumonia by using a specially-designed timer to count the respiratory rate. They also learn how to dispense cotrimoxazole, an antibiotic used to treat “pneumonia only” cases. Review meetings are used to refresh their knowledge and to collect data from their registers. The community-level training also includes a traditional healers’ orientation, to encourage them to promptly refer pneumonia cases to the nearest FCHV or health facility.

To inform each village about the new role of FCHVs, community orientation meetings are held and the FCHV is supported by health facility staff to examine sick children and share her knowledge about pneumonia. Community stakeholders are encouraged to identify ways to support their FCHVs.

The results of this approach have been dramatic. Community-based pneumonia treatment has doubled the total number of cases treated as compared to districts with facility-based treatment only. The program has been phased in over 14 years and now 80 percent of Nepal’s under-five population has access to pneumonia treatment. The government is committed to complete nationwide coverage within the next two years. Over the past 15 years, under-five mortality has been reduced to 614 per 1,000 live births and community-based pneumonia treatment has contributed to this significant decline.

The presence of the established FCHV cadre in Nepal facilitated implementation of a successful community-based pneumonia treatment program. The cadre was already recognized and accepted in the communities and gained considerable status by treating pneumonia. Many FCHVs had personally experienced loss of a child to pneumonia, making them highly motivated to identify and treat cases. Other countries could benefit from a similar approach, utilizing community-based outreach workers, to reduce the high mortality burden from pneumonia.

For more information, visit John Snow, Inc.

REFERENCES

1. Family Planning and Health Survey. Kathmandu: Family Planning and Maternal Child Health Division, Planning, Research and Evaluation Section, Ministry of Health; 1991.
2. WHO/UNICEF/USAID Assessment of the ARI Strengthening Program, 1997
3. FCHV Survey 2006
4. Nepal Demographic and Health Survey 2006. Nepal: Ministry of Health and Population, New ERA and Macro International Inc.; 2007.