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 (Saraswati Peace School catering the conflict affected, poor, marginalized and earth-quake affected children):

• RMF supported pre-fab house has been installed in the school. Lack of quality education is often accorded to lack of well-qualified teachers in the rural areas. The school has placed three qualified teachers, hired from the Kathmandu area and placed at the school for a good salary. The presence of these teachers is essential to the school, as the standard of the education and children’s performance has been raised after bringing them in. However, school had faced challenges in teachers’ retention due to lack of safe housing facilities. Therefore, this pre-fab house will not only provide safe and quality housing option to the teachers but will also contribute to boost their morale, which has been severely affected due to the earthquake and the following aftershocks. We aim that this support will contribute to the overall improvement of children’s performance at the school.  

 
Prefab Building Construction

• RMF will be taking up a local health clinic in the area from November on. Currently, we are in the process of signing a MOU with the District Health Office for this purpose.

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.
 
The 25th April earthquake in Nepal caused significant damage and destruction to buildings and infrastructure, one of which was the 83 year old building of Nepal Children's Organization (NCO), rendering children in the orphanage homeless once again.
 
After destruction of the orphanage building, younger children have been shifted to a nearby government office while the others have been taken to a children's home in Shifal. The present situation of the children and staff working for them is horrific. They are suffering every day in overcrowded rooms which are occupied not only by children and staff but also by their belongings. Due to inappropriate ventilation systems of the rooms, infants have started suffering from respiratory difficulties. This is causing infants in these locations to be seriously ill. Several of the babies are already in Intensive Care Units at hospitals. Not only infants, children of all ages are suffering from various diseases or other physical and mental health issues due to their appalling living conditions.
 
NCO is planning to construct earthquake resistant houses for about 100 children as safe housing for them is of immediate need. For that, NCO has chosen to build prefabricated houses on 7740 sq ft land. Prefabricated homes are the buildings of choice for the children as they are not only safe and energy saving but also earthquake resistant. And as Kathmandu is active in seismic activity it is recommended to have something lighter and safer to raise the children. Additionally, as time is also a pressing issue, prefabricated houses which are quick to build are a good option.
 
RMF is planning to support NCO with a pre-fab house that will provide shelter for 20 toddlers, currently forced to live under precarious conditions.
 
“Our toddlers' boys now are in the small room sharing the whole thing including caretakers. The room is jam-packed for children to stay and difficult for caretakers to take care of them. In past we used to have a bigger space for each of our toddlers where they have enjoyed their freedom to fullest. We had a separate block for young boys and mothers taking care of them. But because of unimaginable magnitude of earthquake which has hit Nepal has made our children homeless.”  – Director, NCO
 
With the recommendation from engineers and designers, the plan is to construct 1100 sq. feet prefabricated house within the premise of Balmandir. 
 
They have selected this place since it is close to the main access and will not take long for caretakers to rush toddlers to the hospitals or evacuate them in an emergency situation.

The entire construction accountability will be given to the contractor and intended to come to an end of the project by the end of December, 2015.

Area Plan:

RMF to support in the construction of Manaslu House:

Manaslu House is designed for 20 boys and is of 2 floors. Total area of this house will be 1100 sqft. and will consist of 4 rooms, 1 toilet, 1 laundry room and 1 store room.

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

• Performed different medical procedures such as dressing, nebulization etc.
• Assisted Physiotherapist in providing physiotherapy to several liable children
• Monitored vital signs
• Medication done as per the requirement of house mothers, children and other staffs
• First Aid treatment has been given to several children
• Created awareness among housemothers and children regarding sanitation, personal hygiene, and healthy habits etc.
• Helped maintaining sanitation of the organization clean and healthy
• Visited Teaching Hospital frequently for check up and follow up on hospitalized children

RMF Nurses at the NCO with children and housemothers:

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:

• We are providing afternoon meals to 2,064 students from 8 schools.
• Team members at Seven Summits Women have made a trip to Sindhupalchowk. The field trip aimed to carry out needs assessment at the schools. Following the trip, infrastructural support to rebuilding Shree Ganesh Lower Secondary School has been secured and construction works will commence soon.
• One trip carrying major purchases of stationery for children has been transported and will be distributed once the schools will reopen, which has been closed for the festival holidays.
• The team has also carried out consultations with women’s groups who have taken tailoring/ sewing training but haven’t been able to use their skills due to lack of resources and market access. Our plan is to mobilize these women’s groups to prepare school uniforms for the 8 project schools, contributing to their livelihoods as well as helping them enhance their skills.

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, and today has 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.
 
RMF supported the local NGO (Social Action Volunteers- SAV) based at Kanti Children’s Hospital to conduct health camps in one of the earthquake-affected areas in Nuwakot district. In the previous month, RMF had supported the hospital with medicines and medical supplies, among which some of the medicines were also distributed through the health camps with support of 5 doctors from the hospital.
 
Currently, RMF is preparing to support Kanti Children’s Hospital through a longer-term partnership. Currently, the NGO based at Kanti is supporting the hospital through provision of free lodging to the families of ultra poor children inside the hospital premises, providing poor children (around 300 in the in cost-free wards) with nutritious food, coordinating with donors or even purchasing expensive medicines that these children’s families couldn’t afford, organizing trips/ excursions for children at the cancer ward, running entertainment/ play sections for the children to make the hospital more child-friendly, and organizing/ storing blood as and when required. Due to lack of funds, the NGO is going to withdraw their support to these children from very poor economic backgrounds and reduce their activities. They could potentially close down if any support isn’t secured in near future.
 
In this light, RMF is looking into possibilities of continuing these initiations to ensure that these critical services to the children at the only Children’s Hospital in Nepal are continued.
 
Indoor and Outdoor Playrooms supported by SAV:

SAV providing accommodation to the families of the very needy patients at different wards in the hospital:

5. Partnership with MOHP, UNFPA, WHO and GIZ to Foster Midwifery Education in Nepal

Discussions with UNFPA for a partnership to support Professional Midwifery education in Nepal have progressed wherein RMF will be part of the "Collaborative Partnership Agreement for Supporting Midwifery Education and Cadre in Nepal" between Ministry of Health and Population, UNFPA, GIZ and WHO.  RMF is discussing the components of the agreement and is aiming to take up the elements as per our objectives and expertise, especially addressing human resources and infrastructural needs.
 
Background:
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
• Equipment, Skills Lab (dummy/ anatomical models)
• Human resources, faculty development (lack of quality due to limited human resources)

 
 
6. Community Outreach Program to Improve Maternal and Child Healthcare in Nepal

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.

We will be working in close coordination with existing groups in rural settings working to promote public health, such as Female Community Health Volunteers (FCHVs) and Mothers’ Groups.
Through a partnership with the District Department of Women and Child Development, RMF aims to provide capacity building and support to FCHVs to hold monthly community health and nutrition awareness and training sessions, and assist FCHVs to conduct home visits for one-on-one counseling especially regarding maternal health and child nutrition.

RMF will also train and form Community Health Educators (CHEs) Groups, comprising mostly of women and prioritizing those from marginalized communities, to promote maternal and child health at the district and VDC (Village Development Committees) level.

CNEs will aim to 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 (Infant and Young Child Feeding) counseling.

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 ownership. A smaller group from the existing group can be created called ‘Self-Help Group’ which would consist of, FCHVs, RMF CHEs, Health Workers, women leaders in the community and also men’s groups to use MUAC to identify malnutrition in the community. Children that have been screened positive for malnutrition will be enrolled in CMAM services where they can be rehabilitated.

Lack of awareness on existing government subsidies and other incentives has also hindered people from accessing the services. RMF CHEs 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 will 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. 

We are liaising 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 will 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. Our prevention approaches will also include providing local communities with knowledge on how to solve and avoid problems regarding nutrition, hygiene and sanitation, empowering local communities to avoid these problems by themselves. Lessons will be imparted using various audio, video, pictorial and demonstrative (especially for cooking) means.

RMF India has developed a very innovative and advanced approach to engage communities and families with malnourished children, expand reach of the RMF CHEs and increase awareness among the community. Among others, the RMF India team uses mobile phones, through the installation of apps to track cases, assist in counseling families, record keeping, effective monitory, referral mechanisms and likewise. The application on the phone guides CHEs step by step through their interactions with a family, which include audio and visual prompts to help them with advice topics. The information that is collected on the phones is recorded in a nearby remote server. 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 is adopting and tailoring this approach to suit the local needs.

Geographical Coverage

Tentative Timeline:
Start Date: 1^st Week of November, 2015
1.  Inception phase: 3 months
1^st November – 30^th November:

• Finalize budget
• Recruitment of HR for the program including a project manager and a CHE trainer/coordinator who will also be able to train new CHEs, an admin and finance officer and 16 CHEs (2 from and for each VDC)
• Set up District office for the program
• Acquire necessary tools for the program including laptops, mobile phones, stationary, and training and screening materials
• Reach out to district and VDC level administrators and local social workers including DHOs, FCHVs, Mothers’ Groups, Community Users’ Groups, Forest Users’ Groups, OTPs and SCs to inform and brief them about the COP
• Orientation and briefing for the project manager regarding the program and how to train the CHEs and run the monthly community programs at a VDC per month including video screenings
• Carry out a introductory health and hygiene awareness campaign in which RMF Nepal staff will donate RMF schoolbags, health kits and stationary items to 1,000 students at schools in the 8 VDCs of the district.

      1^st December – 31^st January:

• Finalize treatment protocols and triage for SAM children
• Review initial training manuals and modules prepared by UNICEF
• Prepare facilitation and guide manuals and flipbook on health and nutrition
• Orientation and training CHEs on proper hygiene, maternal and child health, screening and action protocols, use of apps on mobile phones to track cases, assist in counseling families, record keeping and referral mechanisms. Discuss admission and discharge criteria for children with SAM
• Initially conduct house to house visits in a large group as a part of the training program
• Train CHEs on how to conduct monthly community nutrition awareness and training sessions including video screenings and cooking demonstrations. Clarification on roles and responsibilities will also be discussed
• Hire  a videographer and a video production manager/editor
• Review how similar programs are conducted in other countries
• Review and analyze the current RMF methodology in a SWOT analysis, decide if it is to improve
• Analyze operations of DHOs, CMAM services such as OTPs and SCs in SWOT analysis and provide suggestions on it, and try to get funding for its upgrades if necessary.

2. Rolling out/implementation: Next 21 months:

• Conduct house to house visits on the 4,451 households of the 8 VDCs, prioritizing households with children under 5 first. Screening will be done to identify malnourished children and CHEs will further advise the family in matters of nutrition, maternal health, sanitation and hygiene, sexual health and family planning. CHEs will refer children with SAM to government centers for treatment and will provide some RUTF for critical cases.
• CHEs will conduct monthly VDC level programs to educate the community about proper nutrition, maternal health, sanitation and hygiene, sexual health and family planning. These programs will be carried out in collaboration with DHOs and FCHVs if they have a strong presence in the VDC, otherwise it will be conducted by CHEs themselves. Video screening starring local role models who have adopted best health practices will be shown along with some nutritious cooking demonstrations.

• Tri-monthly self analysis of the operations and discussions on how to improve the current methodology
• Analysis will be conducted and suggestions offered on how different national level programs like CMAM, IYCF and IMCI programs can be improved and integrated with each other to avoid duplication of services and carry out a unified scale up
• CHEs will conduct visits to DHOs, CMAM, IYCF and IMCI services to help counsel to families present there.

Expected Outcomes:
This program is expected to significantly reduce malnutrition among children under the age of 5 and cause behavior change related to health, nutrition and hygiene through health education in the targeted 8 VDCs, along with improvement in the health services and programs provided to them. The program will also help acutely malnourished children graduate from malnourished status to a healthy status. The program is also expected to improve maternal health, sexual health, and family planning and reduce neonatal and infant mortalities among these communities. Our results will be thoroughly monitored and our methodology will be used to replicate the program and also scale up this pilot program to a national scale.
 
7. Consignment with Medical Supplies and Equipment for District Hospital

RMF is supporting the Government’s District Public Health Office in Kavre – one of the most earthquake-affected districts with medicinal supplies and equipment. This government medical facility caters to underprivileged and marginalized communities in Nepal. 

The consignment is underway and has reached Calcutta port. However, due to current tensions at the Indo-Nepal border, we are exploring alternatives to divert the route and get the shipment with medical items to Nepal.
 
 
8. Current fuel crisis hampering humanitarian aid and longer-term rebuilding efforts in Nepal

The current fuel crisis due to tensions at the Indo-Nepal border area and resulting blockades has led to severe shortages of essential items such as petrol, diesel, cooking gas, and kerosene in Nepal.

After a stalemate of 8 long years, the first ever constitution written by people’s representatives was promulgated on 20^th September 2015 in Nepal. The country, however, remained divided, especially on a few contentious issues on social inclusion and federal demarcation.

Madhesi  (indigenous group based predominantly in the Terai Plains region in Nepal) and Tharu (ethnic group indigenous to Terai) parties opposed the new constitution stating that it curtailed the rights of Madhesis, Tharus, Dalits (so-called-untouchables), Janajatis (indigenous groups) and other marginalised communities. This led to violent protests and political unrest, leading to the deaths of more than 40 protestors, civilians and security officers in various parts of the southern plains. 

Indefinite general strike called by Madhesi parties, amidst curfew, continues to cripple life across the region.  In this context, Nepal’s southern neighbor and major trading partner, India, expressed their dissatisfaction with the constitution, leading to an unofficial ‘trade blockade’ that resulted in acute shortages of basic supplies such as Petrol, Diesel, Kerosene and Cooking Gas in the landlocked country which is recuperating after the recent earthquake. The mountainous geography on the northern side means limited trade routes with China, and almost all trading points were destroyed during the earthquake.

India has however denied placing an embargo on Nepal and has cited security reasons in the border areas for making the trucks and other vehicles carrying essential supplies impassable.  Over 8,000 trucks are said to have been stranded near the Indo-Nepal border.

Following this, the government introduced fuel rationing by only allowing vehicles with odd-number plates to operate on odd days and even ones on even days. In addition, a quota system has also come into effect wherein each vehicle is allocated a certain amount of fuel per week.

Many airlines have temporarily suspended flights to Nepal stating that without refueling at the Nepal’s only International Airport in Kathmandu, they wouldn’t be able to operate. The Jet fuel crisis is likely to deepen in days in come.

The current fuel crisis has especially impacted humanitarian aid efforts in Nepal that began following the devastating earthquakes in April and May. In absence of basic supplies, many organizations are struggling to continue their ongoing efforts of reconstruction and rebuilding in various earthquake-affected areas.

Right after the earthquake, RMF was engaged in providing immediate relief through distribution of food, shelter supplies, water filtration, solar lights and other basic needs to many communities in Sindhupalchok, Kavre, Gorkha and we are currently implementing longer term projects to support health posts and schools in close collaboration with government, INGOs/ NGOs and local stakeholders.
In this light, the ongoing major fuel crisis is hindering the efforts of various international and national development organizations and is impacting the communities recuperating from the recent devastation.

Schools in the valley have begun closing down, as the school authorities aren’t able to provide food and continue their operations due to shortages in cooking gas and fuel for school buses. Many of these children were already studying at the temporary learning centers. More than 16,000 public and private schools were destroyed and thousand more damaged due to the earthquake (UN OCHA, 2015). In Gorkha district alone, 90% of the 500 schools have been destroyed or badly damaged, affecting 75,000 schoolchildren. (Save the Children, 2015)