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                                                         Nepal  Projects                                                                                          Updates  –  August  2015    

 August  2015  

Real  Medicine  Foundation  11700  National  Blvd,  Suite  234  Los  Angeles,  CA  90064  +1.310.820.4502    

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1. Model  Village  Project  (Arupokhari,  Gorkha)    

The  Model  Village  Project  (MVP)  is  a  RMF  pilot  initiative  in  Nepal  that  aims  to  contribute  to  the  improvement  of  education,  health  and  livelihoods  of  the  community  in  Gorkha  through  support  of  the  schools,  health  posts  and  other  community-‐based   institutions.  The  project   is  based   in  Arupokhari,  one  of   the  villages   in  Gorkha,  where  RMF  has   started  supporting   the   reconstruction  and   rehabilitation  of   the  village.  Gorkha  district  was  the  epicenter  of  the  earthquake  where  over  91%  of  houses  have  been  irrevocably  damaged,  along  with  over  95%  of  schools  and  90%  of  health  facilities.  Arupokhari  is  a  remote  village  in  Northern  Gorkha,  which  is  close  to   the   epicenter   of   the   April   25th   Mega   Earthquake.   Out   of   1,350   households,   1,226   houses   have   been  completely  destroyed  in  this  village.      Progress:    

Completed:    

• Three   temporary   structures   have   been   constructed   to   serve   as   classrooms   to   conduct   classes  using  zinc  sheets  and  bamboos  from  the  old  classrooms.    

• One  of  the  old  school  buildings  has  been  repaired  and  retrofitted  using  cement,  pipes  and  iron  trust.    

• An  old  building  was  torn  down  and  rebuilt   from  scratch.  So,   in  totality,   the  students  have  two  permanent  and  three  temporary  structures  as  classrooms.    

• 3  out  of  the  8  computers  in  the  computer  lab  have  been  repaired.  In  absence  of  technicians  in  the  village,  the  local  NGO  has  tied  up  with  Om  Automation  Pvt.  Ltd.  who  will  handle  repair  of  the  equipment  from  here  on  at  minimal  cost.    

• Medium  capacity  UPS  backups  for  the  printers,  computers  and  projectors  have  been  set  in  place  for  the  smooth  running  of  computer  classes.    

• The  base   for   the  new  pre-‐fabricated  house  had  been  completed  on  time  on  August  25th,   right  after  our  field  visit  and  site  identification.    

• The  pre-‐fab  buildings  are  being  built  to  address  the  need  of  a  teachers’  cabin  for  the  residential  teachers   who   have   gone   all   the   way   from   Kathmandu   to   teach   the   students   at   Arupokhari,  Gorkha.  Lack  of  skilled  teachers  has  always  been  a  problem  for  the  school,  especially  because  it  is  an  English-‐medium  school.  So,  teachers  were  hired  from  Kathmandu.  However,  due  to  lack  of  safe  housing  options,  the  turnover  rates  were  high.  This  issue  will  be  solved  with  a  new  pre-‐fab  house,  which  will  prove  beneficial  for  the  long  term  success  of  the  school.    

• The  materials  manufactured  in  the  workshop  by  the  pre-‐fab  company  are  also  ready  and  will  be  transported  to  Gorkha,  once  the  road  blockages  are  cleared.    

• We  anticipate  that  the  construction  workers  of  the  pre-‐fab  company  along  with  all  the  materials  will   get   to   the   site   on   20th   of   September   and   the   building   will   be   completed   by   the   30th   of  September.      

Ongoing:    

• One  of  the  buildings  is  being  retrofitted  with  iron  trust.  Since  the  roads  had  been  blocked  due  to  the  heavy  monsoon,  timely  delivery  of  the  raw  materials  was  a  challenge.    

• Costing  and  feasibility  study  for  a  strong-‐wired  compound  for  the  school  premise  is  being  done.    

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• The  damaged  parts  of  the  computers  have  been  brought  back  to  Kathmandu  for  repair.  If  they  are  not  repairable,  plans  are  in  place  to  buy  new  parts.  Also,  apart  from  the  immobile  desktops,  necessity  of  new  portable  laptops  is  felt.    

• Options   for   a   reliable   backup   power   for   the   entire   school   are   being   looked   upon,   taking   into  account  the  irregular  power  cuts.    

 Classroom  before  and  after  retrofitting  and  repairing:  

 

                         

Ongoing  Retrofitting  and  roofing:  

                     

 

Challenges  Encountered:    

Monsoon  has  hampered  speedy  construction  at  the  school.  The  roads  to  the  school  have  been  blocked  and  tractors  aren’t  available  to  transport  the  materials  from  Gorkha  Bazar  to  the  school  site.  Also,  the  downpour  

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has   caused   problems   in   the   electricity   supply   around   the   village,   which   has   been   challenging   in   terms   of  carrying  out  the  construction  work.      

Heavy  downpour  in  the  region:  

 

 

 

2. Orphanage  Support  and  Support  to  the  Nepal  Children’s  Organisation      

RMF  is  supporting  Nepal  Children’s  Organisation  (NCO)  to  improve  the  current  conditions  of  the  children  at  their  orphanages,  particularly  to  improve  the  health,  nutrition,  sanitation,  and  hygiene  status  of  the  children.    

 

Progress:    

• RMF  nurses  who  are  based  at  their  centers  have  completed  the  following  activities  during  their  first  month  of  placement:  

• Regular  checkup  of  children  living  at  the  orphanages.  • Creating  health  profile  of  142  children.  (For  the  first  time,  a  digitalized  health  profile  of  each  

of  the  children  is  being  prepared,  which  will  not  only  contribute  in  creating  a  new  database  but   will   also   support   the   institution   in   record   keeping,   regular   monitoring   and   tailoring  programmatic  support  according  to  the  individual  needs  of  the  children).      

• Consulting  with  doctors  for  regular  medicine  and  further  treatment  of  children.    • Educating  mothers  in  health  and  sanitation.    • Supporting  caretakers  in  their  jobs.  

 • Dr.  Ron  Polamares,  an  American  psychologist  with  extensive  experience  of  working  with  children  in  

traumatic  situations  gave  presentations  on  resilience  and  conducted  sessions  with  children  and  NCO  staffs  -‐  one  of  a  kind  and  very  first  presentation  on  the  topic  attended  by  the  staffs  and  children  at  NCO.  The  purpose  of  the  program  was  to  introduce  children,  housemothers  and  nurses  to  resilience  

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skills   so   as   to   increase   resilience   capability   and   help   housemothers   and   family   of   NCO   to   provide  better  support  and  care  to  the  children.  The  following  are  details  of  the  2-‐day  session:      

Day  1  

The  venue  was  Brihaspati  Bidhya  Sadan,  Naxal  for  the  first  day  program.  There  were  two  sessions:  

a) Children  group  session  The   training   kick-‐started  with   a   presentation  on   ‘resilience’   –   the   ability   to  move   forward   after  tragedy.     Seven   children,   aged   8   to   10   years,   participated   in   the   children   group   session.   The  following  are  some  of  the  major  points  discussed  in  the  session:  

• Being  friendly  • Believe  in  yourself  • Being  confident  • Feel  comfortable  and  easy  

 b) Staff  group  session  

It  was  a  presentation  about  helping  children  cope,  building  resilience  and  understanding  warning  signs   of   problems.   Fifteen   staffs   participated   in   the   session.   The   following   are   some   of   the  important  points  discussed  during  the  session:  

• How  to  deal  with  children    • How  to  motivate  children  • When  you  yourself  are  happy,  then  only  you  can  make  others  happy.  

Day  2  

The  second  day  program  was  held  at   the  Child  Protection  Home,  Siphal  where  there  were  mainly   three  sessions:  

a. Children  group  session  The  training  was  conducted  by  giving  a  presentation  about  resilience  (the  ability  to  move  forward  after  tragedy).  Twenty  children  from  the  Siphal  Home,  aged  11  to  13  years,  participated.      

b. Teenage  group  session  It   was   also   a   presentation/   informal   discussion   about   resilience,   but   tailored   differently   for  adolescents.   Thirty   children  and  young  adults   from   the  Siphal  Home,   aged  14  years   and  above,  participated  in  the  session.      

c. Staffs  group  session  It  was  a  presentation/   talk   session  about  helping   children   cope,   resilience  and  warning   signs  of  problems.   Eight   staffs,   housemothers   and   nurses   from   the   Siphal   Home   participated   in   the  training.    

Overall,  the  participants  of  the  Resilience  Training  program  expressed  that  this  training  was  very  valuable  and  was  able  to  increase  the  confidence  of  children  and  staff  of  NCO.  It  was  a  very  interactive  session  with  

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children   and   teenagers   asking   many   questions.   Some   of   them   were   very   pertinent,   also   hinting   on  psychosocial  needs  of  the  children,  such  as:      

• Why  sometime  one  wants  to  die?    • Why  we  feel  lonely  and  scared?    • What  are  the  factors  required  to  be  brilliant?    • Why  we  are  very  angry  at  times  with  others?  

 Many  important  questions  were  also  asked  by  the  staffs  and  housemothers,  such  as:    

• Why  are  we  so  scared  and  troubled  after  earthquake?    • How  can  we  identify  problems  faced  by  the  children?    •  

Dr.  Ron  wrapped  up  the  session  with  a  very  positive  message  that  “If  we  think  positive,  positive  things  will  happen.”    

Training  Sessions:  

     

     

 

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 3. Rebuilding  and  long-‐term  Support  to  Schools  and  Model  Village  in  Sindhupalchowk      Real  Medicine  Foundation  has  partnered  with  Seven  Summits  Women  and  White  Girl  In  Nepal  to  reconstruct  schools,   health   posts   and   other   damaged   public   structures   in   Bhotenamlang,   Sindhupalchowk   to   provide  immediate   relief   and   long-‐term   support   to   the   people   of   Sindhupalchowk   district,   one   of   the   areas,  significantly  affected  by  the  earthquake.      

 Progress:    

• Providing  afternoon  meals  to  2,064  students  from  8  schools  have  commenced.  Food  and  necessary  supplies  were   transported   to   the   area   and   local   staffs,   including   cooks  were   hired   to   prepare   the  nutritious  meals.  

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• Stationary  and  other  necessary  items,  such  as  school  bags,  water  bottles,  tiffin  boxes  were  purchased  which  will  be  distributed  to  the  children  in  the  schools.    

• We  are   in   the   process   of   hiring   teachers   from  Kathmandu   to   be   placed   in   these   schools.   So   as   to  ensure   quality   education,   a   dire   need   in   the   area,   we   are   looking   for   at   least   one   to   two   year  placements  of  the  teachers  in  these  schools.    

• We’ve  started  the  recruitment  process  for  the  role  of  an  additional  Project  Manager  to  oversee  this  particular  RMF  project.    

 

               

4.  Support  to  Kanti  Children’s  Hospital  –  The  Only  Referral  Level  Children’s  Hospital  of  Nepal

Kanti  Children’s  Hospital  is  the  only  government  referral  level  Children’s  Hospital  of  Nepal.  The  hospital  was  established  in  1963  as  a  general  hospital  with  50  beds,  which  today  have  a  capacity  of  320  beds.  The  hospital  treats   children   up   to   the   age   of   14   from   all   over   the   country,   a   total   target   population   of   13-‐14   million  children.   Following   the   earthquake,   where   parts   of   hospital   building  were   damaged,   there   is   in   general   a  need  for  equipment  and  capacity  building  for  better  health  service  delivery.    

 In   conjunction  with  Convoy  of  Hope,  RMF  supported  Kanti  Children’s  Hospital  with  medicines  and  medical  supplies   worth   over   $408,000.   A   ceremony   was   organized   wherein   RMF   Nepal   Programme   Coordinator,  Barsha  Dharel,  handed  over  the  donated  items  to  the  Hospital  Representative.        When  the  shipment  arrived,  the  doctors  at  the  Kanti  Hospital  selected  suitable  medicines  for  their  respective  wards.   In   consultation  with   the   doctors,   administrative   in-‐charge   and   other   relevant  medical   personnel,   a  distribution   plan   was   prepared   wherein   it   was   decided   that   items   useful   for   Kanti   Hospital   would   be  distributed  within  their  various  departments.  Following  that,  medicines  related  to  maternal  health  care  were  handed  over   to   the  Maternity  Wards   in  other  hospitals.   Boxes  of  other  necessary   items,   especially   topical  skin  ointments,  were  distributed  by  one  of  the  doctors  at  an  old  age  home.  Furthermore,  health  camps  are  also  being  planned  to  get  some  of  the  medicines  distributed  in  rural  areas.        

 

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Reorganizing  the  medicines  to  be  distributed  as  per  the  Hospital  needs:    

           

 

Assistant  Director  at  Kanti  Hospital  selecting  necessary  medicines  for  his  department  and  suggesting  best  way  of  distributing  medicines  to  other  departments  and  hospitals:    

     

 

 

 

 

Official  Handover  Ceremony:    

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5. Partnership  with  MOHP,  UNFPA,  WHO  and  GIZ  to  foster  Midwifery  education  in  Nepal  

Discussions   are   underway   with   UNFPA   for   a   partnership   to   support   Professional   Midwifery   education   in  Nepal.  A  draft  "Collaborative  Partnership  Agreement  for  supporting  Midwifery  Education  and  Cadre  in  Nepal"  is  ready  and  is  likely  to  be  signed  very  soon  with  the  Ministry  of  Health  and  Population.      After   the   earthquake,   up   to   90%   of   health   facilities   in   many   rural   areas   are   known   to   be   damaged   or  destroyed.   For   example,   in   Rasuwa   district,   up   to   78%   of   district   health   facilities   are   reported   to   be  completely  demolished,  and  only  two  health  posts  remain  functional.  Hospitals  in  district  capitals,   including  Kathmandu,  have  been  overwhelmed,  medical  supplies  severely  depleted  and  capacities  overstretched.  Out  of  a  total  of  352  birthing  centers,  115  were  totally  damaged  and  137  partially  damaged.  Overall,  the  April  25  earthquake  affected  some  8  million  people,  including  2  million  women  of  reproductive  age  and  over  126,000  pregnant  women.    

Even  before  the  earthquake,  out  of  an  estimated  total  population  of  27.5  million,  23  million  (84%)  were  living  in  rural  areas  and  7.4  million  (27%)  were  women  of  reproductive  age  in  2012;  the  total  fertility  rate  was  2.3.  By  2030,  the  population  is  projected  to  increase  by  20%  to  32.9  million.    

To   achieve   universal   access   to   sexual,   reproductive,  maternal   and   newborn   care,  midwifery   services  must  respond   to   0.9  million   pregnancies   per   annum  by   2030,   85%  of   these   in   rural   settings.   The   health   system  implications   include   how   best   to   configure   and   equitably   deploy   the   sexual,   reproductive,   maternal   and  newborn   health   (SRMNH)  workforce   to   cover   at   least   70.2  million   antenatal   visits,   10.9  million   births   and  43.7   million   post-‐partum/postnatal   visits   between   2012   and   2030.   (UNFPA,   2014)   There   is   a   dearth   of  professional  midwives  to  cater  to  the  current  and  growing  need;  their  roles  will  be  instrumental  in  improving  maternal  and  child  health  in  rural  areas.

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In   this   context,   a   MOU   has   been   signed   between   4   universities   by   UNFPA   and   MOHP,   which   includes  introducing   Midwifery   education   as   a   different   faculty   in   their   universities   as   a   professionally   accredited  course.  Likewise,  a  draft  Bachelor's  degree  curriculum  on  Midwifery  has  been  drafted  and  will  be  tailored  by  the   universities   to   suit   their   interests   and   this   curriculum   will   be   approved   by   the   NNC   (Nepal   Nursing  Council).  Some  of  the  pressing  needs  of  the  universities  are  as  listed  below  and  the  areas  where  RMF  would  be  supporting  is  also  under  discussion:    

 • Infrastructure  Development,  i.e.  hostel  facility,  classrooms  • Skills  Lab  (dummy/  anatomical  models)  • Faculty  (lack  of  quality  due  to  limited  human  resources)  

 

 

 

6. Visit   to   Lumbini   by   RMF   Nepal   Programme   Coordinator   to   assess   potential  partnership   in   Lumbini   for   future   support,   especially   in   the   areas   of   girls’  education  

RMF   Nepal’s   Programme   Coordinator   traveled   to   Lumbini   in   South-‐Western   plains   to   visit   the   women’s  college   and   assess   the   suitability   and   consider   a   potential   partnership   in   the   area  with   the   local   NGO   on  supporting  women’s  education.    

 

       

 

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7. Community  Outreach  Program  

RMF  Nepal   is   in   the   process   of   establishing   a   Community   Outreach   Program   in   Kavrepalanchowk,   Central  Region,  an  area  with  high  maternal  and  child  mortality  rates,  and  poor  health  quality  that  also  has  been  one  of   the   areas   seriously   affected   by   the   recent   earthquake   and   is   considered   a   high   priority   area   by   the  Government  of  Nepal.  Kavrepalanchowk  has  a  population  of  381,937.   Illiteracy  rate:  27.39%;  among  them,  69.31%  women.  Children  born  alive  in  the  last  12  months  (2011):  3,841  (Male:  1,964;  Female:  1,453)    

     

Background  

Even   though  notable  progress  has  been  made   in   the   last   few  years,  particularly   to   improve  maternal-‐child  health,   significant   gaps   still   remain,   particularly   in   providing   quality   health   care   to   the   rural   populations.  According  to  WHO,  Nepal’s  maternal  mortality  ratio  is  among  the  highest  in  Asia  with  280/100,000  live  births  (WHO,  2010).  With  the  average  Nepalese   living  to  65.8  years,  Nepal   ranked  139th   in   life  expectancy  rate   in  the  world   (WHO,   2010).   Similarly,   under-‐five   infant  mortality   is   estimated   at   50   per   1,000   live   births   and  Human  Development  Index  (HDI)  in  2010  was  0.428,  ranking  Nepal  141  out  of  172  countries.  The  number  of  midwives   per   1,000   live   births   is   4   and   the   lifetime   risk   of   death   for   pregnant  women   is   1   in   80.   (UNFPA,  2010)    A  measure  of  acute  malnutrition  was  estimated  at  11%  in  2011.  Currently  Severe  Acute  Malnutrition  (SAM)  affects  2.6%  of  children  under  five  years  of  age  (UNICEF,  2011).  One  in  every  22  Nepalese  children  dies  before  reaching  age  1,  while  one  in  every  19  does  not  survive  to  her  or  his  fifth  birthday.  

Lack  of  quality  health  care  facilities,  constrained  by  limited  government  funding  in  the  already  impoverished  nation;   and   coupled   with   limited   access   and   knowledge   have   impacted   delivery   of   quality   health   care,  especially  to  the  rural  poor.  In  addition,  existing  cultural  barriers,  social  stigma,  deep  social  divide  based  on  

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caste  and  ethnicity,  gender  discriminations,  harmful  cultural  practices  have  an  impact  on  the  overall  health  of  the  people,  especially  women  and  marginalized  communities  who  have   limited  access  to  basic  health  care.  The  agency  of  women  to  exercise  their  sexual  and  reproduction  health  and  rights  (SRHR)  are  also  limited  due  to   the  socio-‐cultural   structures   that  have  detrimental  effect  on   their  overall  health  and  well-‐being.    Nearly  half   (49   percent)   of   women   of   reproductive   age  marry   before   the   age   of   18.     Of   them,   16   percent   were  married  before  the  age  of  15  and  the  adolescent  fertility  rate  is  71  per  1,000  women.  (National  Demography  and  Health  Survey  (NDHS),  2011)  

Government  has  devised  National  Nutrition  Policy  and  Strategy  to  promote  community  nutrition  and  plans  to  implement   Integrated  Management  of  Acute  Malnutrition  of   Infant   less   than  6  months   (IMAMI).  However  despite   government’s   commitments,   there   is   a   lack   of   adequate   GoN   resources   being   devoted   to  strengthening  nutrition  services.  

Some   statistics   suggest   that   stunting   of   children   under   five   is   37   percent,   underweight   prevalence   is   30  percent   and   wasting   prevalence   11   percent.   According   to   the   Nepal   Multiple   Indicator   Cluster   Survey  (NMICS)   2014   Key   Findings   of   UNICEF,   only   half   of   the  women   (56   percent)   had   a   skilled   birth   attendant  during  delivery.    

On  the  other  hand,  Nepal's  HIV  prevalence  has  not  changed  much  over  the   last   five  years;   it  has  remained  within  0.3-‐0.2  percent.  The  estimated  HIV  prevalence  among  15-‐49  years   is  0.23  percent  in  2013.  With  this  level   of   HIV   infection,   there   are   approximately   40,720   people   living   with   HIV   in   Nepal.   Although   HIV  prevalence  has  not  changed  much,  the  country  has  achieved  reduction  in  the  number  of  new  infections,  from  8,039  new  infections  annually  in  2000  to  1,408  in  2013.  

The  three-‐year  interim  development  plan  (2007/2008-‐2010/2011),  accepted  the  global  principle  of  health  as  a   fundamental   right.   Among   others,   the   plan   set   out   to   meet   specific   objectives   such   as   increasing   the  percentage  of  family  planning  users,  increasing  the  percentage  of  women  receiving  maternity  services  from  health  workers,  and  reducing  the  TFR,  MMR,  and  infant  and  child  mortality  rates.    

One  of  the  Millennium  Development  Goals  (MDGs)  for  Nepal  is  to  increase  the  contraceptive  prevalence  rate  (CPR)   to  67  percent  by  2015,  however,  modern  contraceptive  use  has  not   increased   in   the  past   five  years.  (NDHS,  2011)  The  SRH  of  women,  particularly  adolescent  girls  are  exacerbated  by  cultural  practices  such  as  child   marriage,   resulting   in   early   pregnancy,   witchcraft   accusations,   gender   discrimination,   resulting   in  malnourishment   of   the   girl   child,   lack   of   education,   especially   for   girls   which   has   a   domino   effect   on   the  health  of  her  family  and  vice  versa.  For  example,  teenage  pregnancy  and  motherhood  is  a  major  social  and  health   issue   in  Nepal.  17  percent  of  women  age  15-‐19  have  already  had  a  birth  or  are  pregnant  with  their  first  child.  Teenage  pregnancy  is  twice  as  high  in  rural  areas  as  in  urban  areas  (Nepal  Demographic  and  Health  Survey  (NDHS),  2011).    

There   are   various   factors   that   affect   the   maternal   and   child   health   situation   in   Nepal.   Some   key   factors  include:  lack  of  education  and  awareness,  poverty,  lack  of  transportation  facilities  and  access  to  health  care,  geographical   challenges,   poor   health   facilities,   lack   of   awareness,   referrals   and   traditional   beliefs   and  superstitions   such   as   those   in  Dhami,   Jhakri   (shaman/spiritual   doctors).   For   example,   The   jhakri  or  dhami  belief  is  so  deeply  rooted  in  Nepal  that  it  is  common  to  avoid  modern  medication  in  the  remote  villages  as  it  is  believed  that   taking  modern  medication  such  as   injections  make  their  deities  angry  causing  the  death  of  the  sick  person.        

 

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Community  Outreach  Model  

There   already   exists   a   strong   uphold   of   Female   Community   Health   Volunteers   (FCHVs)   in   all   over   Nepal   -‐  48,549  FCHVs  working  in  remote  areas  of  Nepal  and  acting  as  a  bridge  between  government  health  services  and  the  community.  FCHVs  have  played  a  significant  role  in:  the  biannual  distribution  of  vitamin  A  capsules  and   deworming   tablets,   National   Immunization   Days,   distribution   of   family   planning   commodities,   and  treatment  of  diarrhea  with  zinc  and  ORS  with  referral  of  severe  dehydration  cases  to  health  facilities  (HFs).  They  also  provide  community-‐based  treatment  of  pneumonia,  counsel  families  on  the  management  of  acute  respiratory  infections,  and  refer  severe  cases  to  HFs  in  all  75  districts.  With  their  unique  and  close  proximity  to  the  community,  FCHVs  form  the  foundation  of  Nepal’s  community-‐based  primary  health  care  system  and  are   the   key   referral   link   between   health   services   and   community   members.   They   effectively   use   Middle  Upper   Arm  Circumference   (MUAC)   for   screening   and   referral;   and   are   an   integral   part   of   Vaccination   and  Vitamin  A  campaigns  for  mass  screenings.    

However,   these   are   voluntary   roles   and   are   already   overburdened   with   various   programmes.   RMF   can  contribute   to   complement   the   already   existing   efforts   through   the   provision   of   ‘Community   Nutrition  Educators’  (CNEs)  that  would  work  closely  with  existing  groups  in  the  community,  such  as  Mothers’  Groups,  Community  Users’  Groups,  Forest  Users’  Groups,  and  in  particular  FCHVs.    

Through   a   partnership   with   the   District   Department   of  Women   and   Child   Development,   RMF   will   aim   to  provide  capacity  building  and  support  to  FCHVs  to  hold  monthly  community  nutrition  awareness  and  training  sessions,   and   assist   FCHVs   to   conduct   home   visits   for   one-‐on-‐one   counselling   with   the   families   of  malnourished  children.    

They  can  help  address  one  of  the  key  challenges  of  lack  of  referrals  as  well  as  follow-‐up  on  referrals  to  ensure  that   all   identified   severely   malnourished   children   are   admitted   and   that   feeding   and   care   practices   for  moderately  malnourished  children  have  improved  as  per  the  IYCF  counselling.  

Currently,   it   is   noted   that   District   Health   Offices   (DHOs)   are   taking   greater   responsibility   for   community  sensitization;   an   increase   in   community   mobilization   activities   boosted   admissions   to   CMAM   services.  However,   DHOs   require   more   guidance   and   resources   for   outreach   activities.   Major   constraints   to  implementing  home  visits  by  FCHVs  include  overburdening  by  numerous  programmes,  access  and  transport  problems,  and  inadequate  incentives.    

Similarly,   The   National   Medical   Protocol   for   CMAM   promotes   IYCF   (Infant   and   Young   Child   Feeding)  counselling  and  home  based  preparation  of  supplementary  foods.  Systematic  monitoring  of  nutrition  status  changes  is  lacking  and  home  visit  follow  up  is  weak.  Therefore  RMF  CNEs  can  help  address  these  challenges.    

The  project  will  be  guided  through  three  approaches:  Identification,  Treatment,  and  Prevention.    

Following  the   latest  WHO  recommended  method  for  screening   for  malnutrition,  RMF  will   train   the  already  existing   groups   in   the   community  who   have   a   strong   presence   and   can   ensure   community   ownerships.   A  smaller  group  from  the  existing  group  can  be  created  called  ‘Self-‐Help  Group’  which  would  consist  of,  FCHVs,  RMF  CNEs,  Health  Workers,  women  leaders  in  the  community  and  also  men’s  groups  to  use  MUAC  to  identify  malnutrition  in  the  community.  

Lack   of   awareness   on   existing   government   subsidies   and   other   incentives   has   also   hindered   people   from  accessing  the  services.  RMF  CNEs  can  fill  these  gaps  in  the  referral  system  by  making  communities  aware  of  these  services  and  offering  tools  to  facilitate  communication  and  monitor  the  system.  

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RMF  Nepal  can  replicate  a  very  successful  referral  model  used  by  RMF  India.  This  includes  tracking  referrals  using   a   triplicate   referral   form   that   will   provide   a   tracking   method   that   is   both   low   technology   and   low  resource  intensive.      

RMF   can   liaise   with   the   various   government,   non-‐government,   I/NGOs   and   local   stakeholders   for   the  development  of  new  and  tailored  and/or  the  usage  of  existing  resources  to  aware  the  local  community  about  issues  such  as  maternal  nutrition,  hygiene,  and  sanitation.  Through  documentaries/video  presentations,  we  can  also  provide  successful  models/  initiations  in  other  VDCs/  districts.    

Preventive   approaches   will   also   include   participation   of   extended   family,   focus   on   the   most   at-‐risk  moderately  malnourished  children,  and  promoting  greater  access  to  local  weaning  and  complementary  foods.  

RMF  India  has  developed  a  very  innovative  and  advanced  approach  to  engage  communities  and  families  with  malnourished   children,   expand   reach   of   the   RMF   CNEs   and   increase   awareness   among   the   community.  Among  others,  the  RMF  India  team  uses  mobile  phones,  through  the  installation  of  app’s  to  track  cases,  assist  in   counseling   families,   record   keeping,   effective   monitory,   referral   mechanisms   and   likewise.   Moreover,  community-‐based   videos   starring   local   role  models  who   have   adopted   best   health   practices   are   produced  and   screened,  which   encourages   others   in   the   community   to   follow   the   route.   RMF  Nepal   can   adopt   and  tailor  this  approach  to  suit  the  local  needs.    

Geographical  Coverage  

RMF  Nepal  seeks  to  work  in  areas  where  Health  indicators  are  poor,  poverty/illiteracy  is  rife,  inadequacies  of  government  infrastructure  exist  and  there  is  a  lack  of  an  outreach  model.  

The  project  will   be   focused   in   a   rural   setting  and  will   be  based   in  mountain/  hill   area  where  women  have  been  traditionally  marginalized  and  HDI  are  critical.    

Statistics   suggest   that   infant   and   child  mortality   is   higher   in   rural   areas   than   in   urban   areas.   For   example,  infant  mortality  in  rural  areas  is  55  deaths  per  1,000  live  births,  compared  with  38  deaths  per  1,000  live  births  in   urban   areas.   Rural-‐urban   differences   are   also   significant   in   the   case   of   neonatal,   child,   and   under-‐five  mortality  rates.  Moreover,  there  are  wide  differentials  in  infant  and  under-‐five  mortality  by  ecological  zone,  with  under-‐five  mortality  ranging  from  62  deaths  per  1,000  live  births  in  the  terai  zone  to  87  deaths  per  1,000  live  births  in  the  mountain  zone.  (NDHS,  2011)  

As  a  mother’s  education  is  inversely  related  to  a  child’s  risk  of  dying,  the  project  will  be  based  in  areas  where  literacy  rate  for  women  is  low.  NDHS  suggest  that  under-‐five  mortality  among  children  born  to  mothers  with  no  education  (73  deaths  per  1,000  live  births)   is  more  than  double  that  of  children  born  to  mothers  with  a  School   Leaving   Certificate   (SLC)   or   a   higher   level   of   education   (32   deaths   per   1,000   live   births).   It   also  suggests  that  the  risk  of  dying  among  children  below  age  five  gradually  decreases  with  increasing  household  wealth,  from  75  deaths  per  1,000  live  births  in  the  poorest  households  to  36  deaths  per  1,000  live  births  in  the  wealthiest  households.  

Hence,  some  of  the  potential  project  areas  could  be  as  follows:    

Option  1:  Far-‐western  region-‐  Bajhang  District  

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Pros:   Under-‐five  mortality   is   higher   in   the   Far-‐western   and  Mid-‐western   development   regions   than   in   the  other   regions.   Similarly,   infant  mortality   is   highest   in   the   Far-‐western   development   region   (65   deaths   per  1,000  live  births).    

Cons:  Difficult  to  monitor  and  implement  due  to  geographical  inaccessibility.  We  can  work  through  the  local  NGOs  but  regular  updates  could  be  a  challenge  due  to  lack  of  capacity  and  resources.    

District  population:  195,159  

Option  2:  Central  Region-‐  Kavrepalanchowk  

Pros:   Even   though   accessible,   high   maternal   and   child   mortality   rates,   poor   health   quality,   earthquake  affected  area-‐  high  priority  by  the  government.      

Cons:  There  are  other  areas  with  more  pressing  needs.    

At  a  glance:    

District  population:  381,937  

Illiteracy  rate:  27.39%.  Among  them,  69.31%  women  

Children  born  alive  in  the  last  12  months  (2011):  3,841  (Male:    1,964;  Female:  1,453)  

Timeline:    

Inception  phase:  6  months  

Rolling  out/implementation-‐  18  months  

This  would  be  a  pilot  intervention  based  in  few  VDCs  of  a  district,  preferably  in  mountain/  northern  belt  with  limited  government  community  outreach.