Nepal: Nepal Earthquake

 

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 25^th 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 25^th, 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 20^th of September and the building will be completed by the 30^th 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.
• 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 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 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:

1. 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

2. 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:

1. 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.
 

2. 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.
 

3. 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 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:

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.
• 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.  
 
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:

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.

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.

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 139^th 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 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.   
 
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.
 
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
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.