An assessment of the sustainable cost recovery program.

Research Report.

Executive Summary; A sustainable cost recovery program began in 20 Morang Village Development Committees (VDCs) on August, 2001, with its District Public Health Office (DPHO) support and Nepal Family Health Program (NFHP)/Biratnagar Field Office collaboration. From September through November 2003, an NFHP consultant, aided by NFHP/Biratnagar, conducted an assessment of this program. The study objectives were 1) To determine the extent to which cost recovery has been implemented and 2) To determine and provide recommendations to overcome difficulties. Activities included interviewing those involved in the program-Female Community Health Volunteers (FCHVs), Caretakers and Health Facility (HF) staff. Their input helped formulate recommendations for program expansion to other VDCs. The uniqueness of the program is it uses the established Community Drug Program (CDP) to sell cotrimoxazole-P tablets to families with children diagnosed with pneumonia. Previously, such programs had FCHVs buying cotrimoxazole -P tablets from a set of authorized dealers in Siraha District model4 . FCHVs, MCHWs and VHWs buy cotrimoxazole-P and sell at the same price under the CDP. The CDP program aims to make Nepal self-dependent in buying drugs at affordable prices and in sufficient quantities. A total of 19 HFs, 78 FCHVs and 112 caretakers were interviewed. Interviews supervised by NFHP consultant or NFHP/Biratnagar, used standardized pre-tested questionnaires. Ninety-one percent of FCHVs charged a fee for cotrimoxazole-P tablets. Reviewing their 10 most recent patients, 61% of caretakers had repaid the FCHV, 20% had been given cotrimoxazole-P tablets without cost and 19% had yet to repay. A total of 65% FCHVs were not aware the HF would compensate them for cotrimoxazole -P tablets given free. Of the remaining 35% that knew, 74% had not made claims. Needed are more awareness programs to improve communication between the HF and FCHVs. Ninety-seven percent of FCHVs reported receiving resupply from HFs, 97% visited the HF themselves for resupply, 63% reported VHWs and MCHWs provided resupply and 41% reported sending someone else. A total of 79% of FCHVs had no resupply problems. Of the remaining 19%, 40% had at least 20 cotrimoxazole-P tablets in stock at the time of the interview, 60% who indicated no resupply problems had at least 20 cotrimoxazole -P tablets. FCHV resupply problems are not good indicators as to how many cotrimoxazoleP tablets FCHVs have. A total of 95% of FCHVs reported creating awareness programs in Mothers Group Meetings (MGMs) to promote the program and 92% reported had personal meetings with community members. Regarding community support, 95% reported that MGMs provided full support, 51% received VDC support and 42% reported receiving VDC chairman support. VDC support to FCHVs varied. Some provided dress, some did not; some provided a monthly stipend and paid FCHVs for working on special program days, some did not. Consistent support was 90% of VDCs (18 of 20) provided snacks during to FCHV meetings with HF staff. In determining successes, 85% of FCHVs reported that this program would succeed if implemented in other VDCs, 10% did not know and 5% said the program would not succeed. Results indicate FCHVs deliver primary goods in the program. Difficulties during the onset must be corrected before implementation in other VDCs. Common problems that include difficulty claiming credit or not knowing how to treat poor communities need to be thoroughly addressed. A total of 99% of caretakers that were interviewed were mothers. A majority went to FCHVs (100%) or HFs (71%) for child illnesses. Average walking distance to the nearest HF was 46 minutes versus 7 to the nearest FCHV. FCHV proximity to caretakers and ability to provide community-based health services to children is important. All 100% caretakers knew the FCHV and 89% knew her by her full name. A majority (99%) were satisfied with the FCHVs treatment of their child for pneumonia. The average visits per caretaker was 2.25 within the last 3 months. A majority was well educated on services the FCHV provided. Caretakers were equally educated on danger signs of pneumonia. These encouraging results reinforce the important role of FCHVs and their high regard by the community. A large majority (96%) of caretakers reported the FCHV informed them they had to pay for cotrimoxazole -P tablets. Most (84%) were aware FCHVs bought more cotrimoxazoleP with this money. There was a large inconsistency in amounts charged by FCHVs for cotrimoxazole -P tablets. Another problem according to FCHVs and HF staff was caretakers taking credit, then not paying the FCHV. For children under 1 year old, 73% of caretakers, paid Rs 12 or less; 27% paid more; 51% paid in cash; and 49% had had yet to repay. For children over 1 and under 5 years old, 94% paid Rs 17 or less and 6% paid more. However 62% of had yet to repay. Only 38% repaid the full amount in cash. Eighty two percent were happy to pay and felt it was a good thing to do. This indicates the majority are aware of the program benefits and if problems such as recovering credit and consistent charges are resolved the program will flourish. A total of 95% (18 of 19) of HFs reported selling cotrimoxazole-P when treating children under 5 years old for pneumonia. Only 10 reported bringing cotrimoxazole -P through the CDP. Six HFs used free government cotrimoxazole-P tablets and 3 bought from medical shops. Eighty five percent sold at 50 paisa per tablet, 5% sold at 40 paisa, 5% sold at 25 paisa and 5% provided tablets for free. Although these rates are more consistent than rates charged by FCHVs, all must be made consistent to eliminate any complaints. Of 19 HFs, 15 held promotional campaigns to raise awareness about the program. Of these, 68% were conducted at during MGMs. Only 11 HFs provided Rs 5,000 it had initially promised at the onset of the program. Of HFs that provided this money 27% had used it for FCHV development. Of problems encountered, 79% of HFs reported difficulty gaining community support for the program. Needed are more effective awareness programs before starting the program, to convince the community it will benefit them and therefore enable the program to meet its goals. HF staff from Eastern VDCs in Morang (Bhatigaj, Dainya, Bardanga, Sijuwa, Jhurkiya and Dainya) also reported the presence of roaming doctors (often referred to as quacks) who treat children using intravenous antibiotics. Belief that these doctors (quacks) are better than FCHVs or HFs runs high in the community. A majority (95%) of HF staff reported the Community Health Management Committee (CHMC), which helps decide procurement showed favorable attitudes toward the program. There seemed to be no problems when the CHMC was dissolved about a year ago; 79% of HF staff reported no problems. Regarding varied charges by HFs for cotrimoxazole-P tablets, 68% had a 100% payment record, 16% had partial payments and 16% received no payment. When asked about the major difficulties encountered by CHWs, 74% reported giving credit. Only 5% CHWs reported difficulties coming to HFs to buy cotrimoxazole -P tablets. This again shows inconsistencies of payments. Based on study findings, these recommendations are proposed: · Expand cautiously to all VDCs in Morang District. · Eliminate free government supply of cotrimoxazole -P tablets so the community must raise money to buy more cotrimoxazole -P tablets for pneumonia treatment. · Inform all FCHVs and HFs the fixed price of cotrimoxazole-P tablets in all areas where the program has been implemented. This price should be lower than the market price so FCHVs and caretakers need not buy from India or private medical shops · Inform caretakers of fixed selling price for caretakers. Make sure HFs regularly monitor this. · Ensure more consistent VDC support to FCHVs through providing FCHV dress, more training programs and pay them for working in special program days. · Enable creation of awareness programs by the community before launching the program. MGM seems to be a good way because it receives much community support. · Control unwarranted roaming doctors (quacks) in VDCs in eastern of Morang District. · Get all VDCs to pay Rs 5,000 so that Rs 10,000 can be deposited as the FCHV development fund. Don't let this fund sit idle. · Create more efficient ways for FCHVs to obtain payment on credit from caretakers.

· Continue to assess the impact of cost recovery on the availability of cotrimoxazole-P in communities.