Total
Time born BCG Measles DPT & OPV Hepatitis B Remarks
I" I"
Fiscal year 1 991 1 37 137/137 961105 133/135 I 33/1 3S 1001105 132113S 1281135 961105
{Oct.l 99 I·Sept.l 992) 100% 91 .4% 98.5% 98.5% 95.2% 97.8% 94.8% 91.4% · 4 moved oul
- 28 were discharged due 10 Ihe new health centre was buill
Fiscal year 1 992 98 98/98 92195 98/98 93/95 "13/95 98/98 93/95 93/95 - 3 moved ouI (Oct. I992-Sept. I993) 100% 96.1% 100% 97.8% 97.8% 100% 97.8% 97.8%
Fiscal year 1993 I I I 1 1 111 1 1 1 1 111 1 1 1 1 111 1 1 1 1 111 1 1 1081108 1 1 111 1 1 1 10/1 1 1 10511 OB - 3 moved ouI (Oct. l 993-Sept l 994) 100% 100% 100% 100% 100% 100% 99. 1 % 97.2%
This finding was in contrast to the figure of
75%
coverage calculated for these two villages by the district health office. This was because the district health office used the expected target group as a denominator. The number of the target group was calculated from multiplying the total village population by a national birth rate.Unbelievably (from my perspective), they asked me to put
75%
in the pamphlet thoughI
discussed with them that my data could be traced back for reliability.
I
assured them thatthey had done their best. They had every right to claim this credit instead of being
labelled with such a low productivity rate. Besides, knowing the real situation would
help them to plan their activities appropriately. The high immunisation coverage indicated people understood the need and brought their children for immunisation, thus this activity should be left for systemic routine monitoring and they could concentrate their efforts to work out other problems.
I
also suggested that the annual plan of health centre activities was not used properly.The plan showed routine activities rather than being used to guide the actual activities and for evaluation as it should be. For instance, activities for communicable disease control were put under the general term "communicable disease control" and activities
what specific activities should be identified accordingly. For example, if dengue fever was determined as a priority problem, then distributing ABATE would be required every three months. However, my suggestions were not accepted and no change was made. No reason was given, they told me "never mind, just leave it like that".
4. CPHCC Activities
The policy of establishing Community Primary Health Care Centres (CPHCC) was launched in
1 992
to provide an office for the VHV and a centre for other PHC activities. Criteria for setting up CPHCC were that there was a place available, the centre must carry out some PHC activities, and the health workers had to supervise to the VHV at least once a month.In villages A and B, two CPHCC were set up in the houses of the VHV heads in each village and the only activity was as a drug depot. Drugs supplied by the health centre were put in the drug depots, in spite of the failure of the drug revolving fund some years ago. The result was as expected; villagers hardly used the drug depot service. After establishing good relationships with them, I asked the health workers why they had not discontinued the drug depot. I had already checked with the supervision team and the answer was confirmed that a wide range of activities were possible to fit community needs and problems. To my question, the health workers answered "Just leave it there, it is already set up and won't be good to give up". I understood very well that once it was established it was counted as a quantitative success although it did not work. The VHV themselves did not agree with setting up drug depots, but their response to my question was "it was the health workers who wanted us to do it".
The required monthly supervision was recorded to demonstrate that it had been done regularly, and the VHV in villages A and B signed on the form that they received supervision. But in fact it was just a monthly meeting held at the health centre and it was just a repetition of what the health workers heard in their monthly meeting in the district
5.
The Non-Communicable Disease Control Programme
In May
1 995,
the health centre was informed that the provincial health office had set up a Non-Communicable Disease Control Programme. The progranune focused on three major diseases: diabetes, hypertension, and cervical cancer. This programme was to becarried out during March-September
1 995.
The stated aims of the programme were case finding, health education and disease prevention. A problem arose because each disease had its own target group; for the first two diseases the target groups were people over forty and obese, or those who had family history of such diseases, whilst the target group for the latter was married women aged1 5-44
years (see also chapter six).This programme created extra work for the health workers who were already
overburdened. The screening and health education activities for diabetes and hypertension were carried out by arranging mobile services for one day in each village. The villagers were informed via the village broadcast system a few days before the mobile team moved to that specific village. For cervical cancer screening, they had to pool health workers in the same zone rotating to help in each health centre to do cervical smears. Then the number of clients examined were summarised and reported to the district health office.
I shared with them my opinion of some aspects of this programme. First, such a report
was not adequate to give a real picture of disease prevalence in each village, since it covered only those who turned up on those days, but not about the rest who did present. Besides, it reported the absolute number of clients being screened rather than disease prevalence which would enable them to make comparisons between times, villages and diseases. The disease prevalence was calculated as the percentage of people who had the disease out of the total target population. My point was that the target population for each group was essential background information; it was necessary to set up a system of keeping and updating this data. But this was beyond their ability to decide, and perhaps too difficult for them to handle, both to think about this issue or establishing the updated system.
Second, for me this project could actually provide only case fmding rather than health education or disease prevention as was stated in the proposal. I questioned the
appropriateness of the latter two activities at this stage when clients did not yet have a confirmed diagnosis. In addition, health workers would rather spend time case finding from which they could benefit when being evaluated.
Practically, these types of activities could possibly be integrated into routine work with much less time and manpower spent. For instance in detecting cases of diabetes and hypertension, the most important information which should be provided was clear criteria for each disease for the health workers. With these criteria it would be easy for them to monitor, and give health education to, the at risk groups. The health worker or VHV knew all the villagers very well, including those who had a family history of the disease, or who were at risk according to the criteria. Furthermore, integrating screening and health education into a routine work basis would enable them to start compiling a list of the at risk group, which could guide follow up services rather than doing snap-shot activities.
6.
Family Folder Census and Working with Village Health Volunteers.
In mid June, the Ministry of Public Health wanted to revise the family folder record; the birthdate of each member was to be added in order to know their exact age. This meant health workers had to do another household survey, and it was required to be finished by the end of June. I asked the health workers what their plan was. They planned to complete it by themselves. In my opinion, the family folder survey would provide very useful baseline data, if only it could be updated regularly. Updating it was a big burden for health workers. On a contrary, it was an easy task for the VHV, since they knew very well what was going on in the area they were responsible for, who was married, pregnant, died or had a baby, and so on. I suggested asking the VHV to do this job and taking this opportunity to inform them how important it was and how to handle it. We discussed it, and my idea was supported. Later on the task was explained to the VHV,
and they were willing to help.
I started by deciding on a definite area for which each VHV was responsible and communicated this to them. After that a copy of the village map with the area coloured for which each VHV was responsible was handed to each of them. After two weeks the health worker who was responsible for village A and I followed up the VHV and
discussed problems with them. Two out of fIfteen VHV in village A, who could not read and write, paid someone to do the task for them, one resigned because she did not have time to carry out the work.
All the family folders were taken back to the health centre, but in my opinion the VHV should keep their original forms; the forms belonged to them and from this record they should be trained to understand the significance and how to update them.
At the end of June the health worker who was responsible for village A had to shift to the district health office. I offered to take her place to work with VHV in village A. I took this opportunity to call a meeting. Hereby I learned how they felt, their attitudes about their roles and responsibilities, and much more.
During the second meeting with VHV in village A, they told me that there was an encephalitis patient in the village who was admitted to the hospital. Consequently, it was suggested that children under
14
years old in the village be vaccinated. Since this vaccine was not in the national immunisation policy, parents had to pay for it. Children were taken to be vaccinated at the hospital in town which was inconvenient for parents. Finally, we were able to give the vaccine at the health centre, which was more convenient for parents and saved time and money for travelling. I assured the VHV that they performed their role perfectly.In the same meeting they complained about illiteracy. A few of them admitted that they could not read and write, although they knew the alphabet. I contacted the organisation responsible, but it was not possible to get this service in the village, thus I decided to do it by myself. The class was held at the health centre, starting from the beginning of July. There was only one student who regularly came to my class, but I still continued doing it. It took a few months for her to learn to read and write the basics, then I told her that she could continue practising herself.