SAMMAN. Newsletter. INSIDE Project brief Continuum of care Proven tools and approaches Project achievement Success stories Staffs update

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1 Towards the Healthy Communities SAMMAN Volume I March 2013 Newsletter Strengthening Approaches for Maximizing Maternal Neonatal and Reproductive Health From the desk of Area Programme Manager INSIDE Project brief Continuum of care Proven tools and approaches Project achievement Success stories Staffs update It is my pride to say, CARE Nepal with its long engagement in the region and having had a dedication to improving the health of women and children, has been working with the community since 27 year in this region. We have been working with multiple programs specifically through health for reducing maternal, child and infant mortality and achieving universal access to basic health services to the rural part of the community. We have been endeavoring with this Strengthening Approaches for Maximizing Maternal Neonatal and Reproductive Health (SAMMAN) Project to renew our dedication in three districts of far-west (Kailali, Dadeldhura and Doti) with the generous support from Glaxo Smith Kline (GSK), UK and CARE UK. The program, has dreamt to bring a broader agreement and understanding on the different innovations of the CARE s previous health programs in the region to improve maternal, family and child health, promoting prevention, care and support to HIV and AIDS infected and affected people including access to quality, affordable health systems and services and embarking more new with this Project. We have learnt that focus on technical interventions alone is not enough. Barriers to improving maternal, family and child health includes limited availability and quality of health information and services; and gender, cultural and social norms and acceptability; cost and distance which has been reducing utilization even when services exist. But we have yet to be able to create an equitable society and give due rights and recognition to traditionally weak and poor people with a critical strategy to address many of these barriers; is ownership and meaningful engagement of the service seeker and the citizens, particularly the marginalized and the deprived community for basic health services. We, CARE in far-west continually striving to integrate our contribution into our maternal, neonatal and reproductive health efforts. This issue of newsletter is an attempt to explain how we have been working with a variety of actors in the program areas, including GoN/MoHP, D/PHOs, VDCs, HFOMCs, FCHVs and partners/community based organizations- to develop a participatory common process that fosters increased access to and utilization of maternal, neonatal and reproductive health. R. Sharan Pyakurel Area Program Manager, CARE Nepal Regional Field Office, Dhangadhi Celebrating 35 th Years in Nepal

2 2 SAMMAN Newsletter From the Team Project has established strong coordination mechanism from centre to the community It gives me an immense pleasure to present our joint efforts in the form of Newsletter Towards Healthy Community. CARE Nepal is going to celebrate its 35th Anniversary establishing itself as a strong international development partners with palpable presence in every strata of the society in Nepal. The Strengthening Approaches for Maximizing Maternal. Neonatal and Reproductive Health (SAMMAN) Project is a continuation of CARE Nepal s previous efforts for maternal and child health in the country. In far-western development region the project is being implemented in Doti, Kailali and Dadeldhura focusing integrated maternal, neonatal and child health (MNCH) programme from July 2012 to June 2015 with the financial support from UK based agency, Glaxo Smith Kline. The goal of the project is to improve maternal and neonatal health outcomes by strengthening and increasing effectiveness of frontline health workers and increasing service access and utilization. The project has established a strong coordination mechanism from centre to the community with high level of commitment from all stakeholders. Major technical interventions on maternal neonatal and child health are being implemented by respective District Public Health Offices in close coordination and leadership of Department Health Services under Ministry of Health and Population. Similarly, the community mobilization related activities are being implemented smoothly through local NGO partners. On the occasion of CARE Nepal s 35th Anniversary, I would like to thank all the Public Health Managers, Health Workers, Female Community Health Volunteers, Civil Society Members, beneficiaries and other concerned stakeholders for their great contribution and collaboration making our efforts more visible and sustainable. Nirmala Sharma Health Programme Coordinator, CARE Nepal SAMMAN Project: The Strengthening Approaches for Maximizing Maternal, Neonatal and Reproductive Health (SAMMAN) project is built on two existing Maternal Neonatal and Child Health (MNCH) projects (one of which included GSK supported CRADLE project) in Doti and Kailali and has been expanded to one new district, Dadeldhura, to implement and strengthen integrated MNCH programming from July 2012 to June CARE International in Nepal is working closely in collaboration with national, regional and District Health Offices and local district level partners to enhance skills of Health Workers, facilitate effective supervision, and strengthen community support and health care systems so that Health Workers can more effectively deliver high quality services for informed communities who are actively engaged in seeking appropriate care and achieving positive health outcomes. The key aim of the project is to improve maternal and neonatal health outcomes by strengthening and increasing effectiveness of frontline Health Workers (HWs) to positively impact MNCH goals. Similarly, project objectives are to increase capacity of Health Workers at community level; enhance effectiveness of community health systems; enhance effectiveness of community mobilization; and leverage learning on how to improve HWs effectiveness to increase impact on MNCH. The major technical interventions of the project are Community Based Newborn Care Program (CB-NCP) in Dadeldhura, Family Planning (FP) in Doti, Calcium pilot and safe motherhood in Kailali along with significant efforts on Community Based Management of Childhood Illness (CB IMCI), Infection Prevention (IP), Birthing Centre (BC) strengthening, capacity building of Health Facility Operation and Management Committee (HFOMC) and HIV/AIDS in all three districts. These are mostly being led by District Public Health Offices (D/PHO). More on it, Community Health Score Board (CHSB) for good governance, service quality and accountability; Self Applied Technique for Quality Health (SATH) to facilitate Mothers Group for Health (MG- H), empower mothers and monitor service utilization and health awareness raising activities for behavior change communication and advocacy are the major activities for community mobilization. The technical interventions are implemented in close coordination with D/PHOs and the community awareness and education, empowerment and mobilization part is implemented through local NGOs. The CARE Nepal, Country Office plays role to ensure the project s planning; achievements and learning are being shared with Chind Health Division (CHD), Family Health Division (FHD),

3 SAMMAN Newsletter 3 In a Nutshell Madan R. Bhatta Monitoring, Evaluation and Advocacy Specialist, CARE Nepal, SAMMAN Program Association of International NGOs in Nepal (AIN) and other stakeholders through different Technical Working Group (TWG) and sub-committees. Similarly, it also ensures national policy and strategy is followed at the project level. So far, these coordination and network mechanism has helped to connect the project with national level efforts on MNCH. Focusing continuum of care on MNCH across time, place and person Thousands of women still lack access to skilled care during pregnancy, child birth and newborn care in Nepal. So the special joy that mother and their families feel at childbirth is often overshadowed by the life-threatening risks both at mother and child in this very part of the region. Too often, the miracle of new life is transformed into a painful struggle for survival. The Maternal Mortality Ratio (MMR) of 229 per 100,000 live births, ranging from 153 to 301 by district was found in Nepal in The figure for those aged over 35 was considerably higher (962 per 100,000 live births). It also revealed significant differences between ethnic groups, with higher rates among Muslims, Terai/ Madhesi and Dalits 1. Thus, saving hundreds of women, newborns, and children who die each year from preventable causes presents a formidable challenge. Creating a MNCH continuum of care can result in considerable progress toward achieving these goals. A continuum of care lend one voice to the interconnected fields of maternal, newborn, and child health and helps to ensure that the needs of each group are included in policies and programs. The continuum of care reflects lessons learned from evidence and experience in maternal, newborn and child health during recent time. In the past, safe motherhood and child survival program often operated separately, leaving disconnections in care that affected both mothers and newborns. Delivering specific interventions in the continuum has multiple benefits. It is the way to address maternal, newborn and child morbidity and mortality having number of similar and interrelated structural causes. These causes include cultural barriers, food insecurity, female illiteracy, early pregnancy and poor birth outcomes, low birth weights; inadequate feeding practices, lack of hygiene and access to safe water or adequate sanitation; exclusion from access to health and nutrition services as a result of culture, poverty, geographic or political marginalization; and poorly resourced, unresponsive and culturally inappropriate health services. Thus, 1 Nepal Demographic Health Survey,2011. linking interventions in packages can balance the demand and supply side and increase their efficiency and cost-effectiveness. SAMMAN project is focusing on continuum of care addressing the multiple causes of maternal and newborn mortality and morbidity through various interventions. The project is working in collaboration with national, regional and district health offices and local NGO partners to strengthen government district health system. The project is strengthening the capacity of local health institutions through equipments support and renovations, capacity building trainings and orientations to health workers and volunteers. Similarly, project is generating demands for quality maternal and child health care services through awareness raising activities and focused educational workshops and interactions like orientations of community groups on different aspects of maternal and child health, campaigns against different forms of violence against women, strengthening MG-H to increase service utilization and empower women using SATH, community interface meetings for service quality, good governance and accountability using CHSB etc at grass root level of the community (demand side). The models of continuum of care that is adopted by the project are as below: 1. Continuum of care across the time for maternal, newborn and child health 2. Continuum of care across service providers and health institutions Celebrating 35 th Years in Nepal

4 4 SAMMAN Newsletter The quality of care that both mother and newborn receive during pregnancy, at delivery, and in the early postnatal period is essential to ensuring women remain healthy and that children get a strong start 2. Many stillbirths and newborn deaths could be averted if more women were in good health, well-nourished, and received quality care during pregnancy, labor and delivery, and if both mother and newborn received appropriate care in the postpartum period 3. Though the project has progressed with GSK continued support, it also has been working through mobilizing resources from CARE s other projects, sustainability of such efforts is a challenge. The dual approach adapted by the project facilitates effective supervision and monitoring as it builds community s knowledge base and capacity leading to strengthened community health care and support systems so that community level health workers can more effectively deliver high quality services to informed communities whose members are actively engaged in seeking appropriate health care. Reaching out to poor and hard to reach through health promotion approaches Self Applied Technique for Quality Health (SATH) MG-H is the pillar for sustainable health outcomes at community and household level. In order to ensure regularity of MG-H meeting at each community, and enhance their basic knowledge and understanding on Maternal and Neonatal Health issues, their own responsibilities, and their rights to obtain basic services from health providers, a community mobilization tool was developed as SATH. This self supporting substantial community mobilization tool is being implemented by CARE Nepal in selected communities of far western region of the country. This technique for greater community involvement regularizes MG-H meeting and eventually making it meaningful. It puts pressure on mother for changing their behavior in the community using the Behavior Change Communication (BCC) Strategy. On the basis of learning and experience from the previous Child Survival Projects, and other health programs (e.g. NFHP), a mixture of various quality assurance tools (e.g. REFLECT, Partnership Defined Quality (PDQ), Social Mapping/RRA) were used to design SATH. 4 Presently, CARE Nepal s SAMMAN Project has been implementing SATH in Doti, Kailali and Dadeldhura districts through three local partners in close coordination with respective District (Public) Health Offices (D/PHOs). Community Health Score Board (CHSB) To ensure social accountability mechanism (demand-driven and operate from the bottom-up) and participatory monitoring & evaluation (the monitoring of service delivery by communities) even at very grass root level, project is implementing CHSB. The objectives of CHSB is to make unheard voices heard, increase public awareness, and by so doing generate collective action and bottom-up pressure against poor service delivery. It also provides public health managers an opportunity to track immediate outcomes, take mid-course corrective measures and bring in strategic re-orientation. 2 Anne Tinker et al., A Continuum of Care to Save Newborn Lives, The Lancet Neonatal Survival Series, No. 3 March 2005). 3 Anne Tinker, Safe Motherhood is a Vital Social and Economic Investment (paper delivered at Technical Consultation on Safe Motherhood, Colombo, Sri Lanka, Oct , 1997) 4 Annual Report, the CRADLE Support Project, CARE International in Nepal, 2009.

5 SAMMAN Newsletter 5 and under five children; mainstream decentralization; promote responsive and accountable health service providers and ensuring sustainability. Pregnancy Outcome Surveillance System (POSS) and Sharing Back to Community CHSB is a community based monitoring tool that is a hybrid of the techniques of social audit, Different Participatory Rural Appraisal (PRA) techniques and citizen report cards. It uses community as its unit of analysis, and focuses on monitoring at the local health facility level. It facilitates the monitoring and performance evaluation of public health services, especially on MNCH, by the community themselves. Since it is a grassroots process, it is useful in a rural setting. A critical feature of the CHSB process is that there must be a definite and almost immediate feedback mechanism in built in the execution. This is done by means of an interface meeting between the users and health service providers. Using a methodology of soliciting user perceptions on quality, efficiency and transparency it helps to track of inputs; monitor quality of services; generate benchmark performance criteria that can be used in resource allocation and budget decisions; compare performance across health facilities; generate a direct feedback mechanism between providers and users; build a local capacity and strengthen citizen voice and community empowerment; focus on the poor, vulnerable and socially excluded mothers POSS is a system of collecting vital maternal and neonatal mortality information from community members through Verbal Autopsy (VA) that is carried out by trained health worker. POSS is one of the innovations of previous USAID supported CRADLE Project. SAMMAN project is scaling up POSS into one more districts, Dadeldhura. POSS is integrated with the government HMIS system for reporting mortality and allows for further investigation into the causes of mortality and then for educating community members as to how changes in their behaviour could result in a reduction in maternal and neonate mortality which is called sharing back to the community. Sharing back to the community ensures that the community realizes their health seeking behavior and understands ways within the community to address the health problems. It is expected to positively influence the community people to reduce neonate and maternal mortality. Sharing of the findings of the verbal autopsy by developing case study have been an effective method to sensitize community people in different settings. Celebrating 35 th Years in Nepal

6 6 SAMMAN Newsletter Our Achievements Improving Quality of Care at Birthing Centers (BCs) through Infection Prevention Training Project trained 70 health workers from 24 birthing centers in Doti on infection prevention for quality of care. CARE Nepal with financial support from GSK provided essential equipments to those BCs previously. 325 participants) and 3 in Kailali (with more than 400 participants) to address the issues of accountability and health governance improving health care delivery system and community participation at Village Development Committee (VDC) level. Strengthening District Monitoring and Supervision System on Child Health Project trained 142 Female Community Health Workers (FCHVs) and 37 health workers working in 13 health institutions on CB IMCI through supportive supervision, on site coaching and intensive monitoring. The focused areas of supervision and monitoring were Pneumonia, Diarrhea, Malaria, Measles and Malnutrition among under five children. HFOMC members, health workers, women, poor, vulnerable and disadvantaged janjaties were participated in the interface to score the delivery of public services such as access of health services; quality and responsiveness of the service providers; regularity of meetings of MG-H and HFOMC; situation of Gender Based Violence (GBV); cultural barriers existing and usage of toilet in their community. Targets were determined for the upcoming review of CHSB in six months and health workers committed to improve the quality of care especially on maternal and child health. Affirmative commitments were also obtained from HFOMC to improve the health status of the VDC. Addressing the Accountability and Governance Issues Through CHSB Project implemented CHSB in 4 health institutions in Doti (reaching to more than 500 participants), 3 in Dadeldhura (with Improving Capacity of Local HFOMC Project enhanced the capacity of 769 VDC level stakeholders from 38 health facilities from project districts on local resource mobilization and good governance through one day orientation

7 SAMMAN Newsletter 7 workshop. Majority of the participants were HFOMCs members, political leaders, teachers, FCHVs and NGO/CBOs members. Joint Program Monitoring Visit from Ministry of Health and Population Project is conducting joint program monitoring visits in presence of senior officials from Ministry of Health and Population, CARE Nepal Central Office, Kathmandu, CARE USA, and Regional Health Directorate (RHD). The focused areas of visit were SATH, CHSB, BC and POSS/VA. The visits were so productive from the perspective of wider sharing and creating enabling environment for scaling up. After these trainings, the PES have been referring pregnant mothers for ANC care and institutional delivery. Hence there is rise in service utilization in the health facilities. Strengthening MG-H through Self Applied Technique for Quality Health (SATH) Project scaled up SATH into eight new MG-H reaching hundreds of women and children. It has been noticed that service utilization on MNCH has increased; emergency fund has been provided and mobilized for MNH; MG-H has been regularized and Poor Vulnerable Socially Excluded (PVSE) mothers were mainstreamed for MNCH services at the ward level. Behavior Change Communication through Peer Educators & Supporters (PES) Four days training was provided to 512 PES (277 females and 235 males) on Sexual and Reproductive Health, Maternal and Neonatal Health ((SRHMNH) and HIV/AIDS from different HIV Prone VDCs of Project districts. They are expected to build enabling environment at ward level for HIV/AIDS and MNCH program, support MG-H, mobilize community and motivate people for service utilization. During the period, project reached to more than 6562 individuals with BCC messages in selected VDCs. (Fig below) Scaling Community Based Newborn Care Program (CBNCP) in Dadeldhura After successful implementation of CBNCP in Doti during pilot phase, CARE Nepal with financial support from GSK is implementing the revised package in Dadeldhura. CB NCP package is now under scale up phase. With the support from CHD, 4 master trainers on CB NCP were developed; district level planning was done and District Development Committee (DDC) level stakeholders were oriented about the programme. Celebrating 35 th Years in Nepal

8 8 SAMMAN Newsletter In the district level planning, 25 persons including the district Public Health Administrator (PHA), district supervisors and RHD participated in the event whereas in the DDC orientation 39 persons including Chief District Officer (CDO) and Local Development Officer (LDO) participated in the orientation. All stakeholders appreciated CARE and D/PHO for bringing proven intervention for child survival and committed to support CB NCP. Training on Use of the Government Priority Medicine, Chlorhexidine In Kailali, project facilitated the Chlorohexidine orientation (Chlorohexidine prevents newborn sepsis and is applied in newborn s umbilical cord) to health workers and nursing staffs of Seti Zonal Hospital. After the event, 3000 tubes of chlorhexidine were also distributed to the hospital. It was found that the rate of sepsis among neonate in the hospital has been drastically reduced after this training. Support Orientation to Health Service Providers and Volunteers Orientation was provided to 113 HWs and 438 FCHVs on Family Planning, Maternal Neonatal and Child Health (FPMNCH) and HIV/AIDS in selected VDCs of project districts. These refreshers are expected to uplift the spirit of health workers in service delivery and keep them motivated. Assessing Birthing Centers, Basic Emergency Obstatric Care (BEOC) and Comprehensive Emergency Obstatric Care (CEOC) Sites for Wvidence Based Support Project is continuously assessing the status of BCs including BEOC/CEOC for service quality and coverage. 25 of the birthing centers were found having inadequate equipments and management problems in three districts. Project will support those BCs with necessary equipments and orientation sessions to HFOMCs. Strengthening Birthing Centers through Skilled Birth Attendants (SBA) Project trained 12 health workers on SBA training (60 days) in close coordination with National Health Training Centre (NHTC) with the facilitation of Seti Zonal Hospital. After the training the participants committed to provide quality MNCH services at their respective BCs. Strengthening Evidence Based Intervention through POSS Sharing back to the community was done in Khailad VDC where two maternal deaths and four neonatal deaths were reported. 40 participants including the deceased family participated in the event. The hindering factors that caused the death and could be prevented were discussed and commitment was obtained to seek for the services delivered through the local public health facilities. This intervention involving the participation of community people is expected to positively influence them for health service utilization and hence they realize the benefits of services rendered in the health facilities. Major up coming events Doti Kailali Dadeldhura FP training CB IMCI Intensive CB NCP Training monitoring BC and CEOC strengthening Calcium Pilot SATH/CHSB/POSS Orientation CB NCP review CHSB and SATH scale up POSS/VA and Sharing back to community Community awareness raising and capacity building campaigns BC and CEOC strengthening and IP training CHSB and SATH scale up POSS/VA and Sharing back to community Community awareness raising and capacity building campaigns BC and CEOC strengthening CHSB and SATH scale up Community awareness raising and capacity building campaigns Operational studies Operational studies Operational studies Misoprostal orientation Program Team in coordination with District Program Coordinator s of FAYA Nepal, SOURCE Nepal and NNDSWO)

9 SAMMAN Newsletter 9 Collective Effort Makes a Difference - Dr. Narendra Khanal, Tikapur Hospital, Kailali I am working here since 2 years. When I first came here, I was not satisfied with the management of the hospital. Most of the cases were referred, usually to Kohalpur Medical Hospital, Nepalgunj and three ambulances were providing regular service to transport the clients and patients. I suffered a lot as the hospital didn t even provide suture needle holder at that time for a minor treatment. I didn t loose hope instead I felt that I should do something for the hospital and started my mission to bridge the gap. For this, my journey started from good coordination with local community, district public health office and central departments. I am happy to say today that the 90 percent cases admitted here are being managed locally. With the support from all like minded persons and organizations, we have been able to fulfill our requirements even within a short time period. And I am very delighted for the achievements of the hospital so far. I appreciate the positive attitude of all the staffs working in this hospital. Apart from the collective efforts, it would not have been possible to make a difference in this short span of time. Moreover, most of the community peoples are well aware about the primary health care services provided by the hospital. I have a team of dedicated staffs and supportive management committee. KOICA, a Korean organization has started to work with us particularly in infrastructure development. CARE Nepal has been providing equipments and we hope this will be continued in the future as well. We have a dream to upgrade this hospital to an equipped teaching hospital. Nevertheless, there is need of health awareness campaigns especially health education programs in freed labor camp sites I would also like to reminiscence that with the collective effort this hospital which was Primary Health Care Centre (PHCC) earlier was upgraded into district hospital. When it was just PHCC there was nothing about Operation Theatre (OT). I usually used to buy some essential commodities for minor operation myself and provided the services. But now, with the support from FHD and CARE International in Nepal, we were able to provide more advanced services since past couple of months. Now, from the level of obstetric first aid we have been able to transform maternal and neonatal health services initially to BEOC and then CEOC. CARE Nepal with financial support from GSK (Glasko Smith Cline) who provided OT table, OT light, warmer, Delivery table etc from where our journey of OT service has been started. Additionally, Nepal Red Cross Society, Tikapur is providing blood and we are providing transfusion service locally. in Tikapur area. For service quality, we still need equipments and support from Government of Nepal (GoN) and external partners. This hospital could be a community referral hospital for gynae and obstetric care for the future if support from GSK/CARE like organization continues. I would say, we are saving the lives of hundreds of peple with possible quality health care services from our level especially on maternal and child health. We are managing complicated cases locally. Seeing the happy faces of people in Tikapur area is the great achievement for us. This all is made possible merely because of our collective efforts. I personally would like to thank SAMMAN team/care Nepal and the generous support of GSK UK in the areas of promoting maternal and child health. Celebrating 35 th Years in Nepal

10 10 SAMMAN Newsletter FROM THE DISTRICT HEALTH MANAGERS CARE Nepal s support in Doti district is noteworthy - Mr. Mahendra Dhoj Adhikari Sr. PHA, District Health Office, Doti the goal of government and non-government organizations should meet Mrs. Rita Bhandari Joshi Sr. PHA, District Health Office, Dadeldhura CARE s remarkable presence is an asset for us Jay Bahadur Karki Sr. PHA, District Health Office, Kailali CARE is one of the foremost organizations actively working in the district throughout these years. Complementing the previous efforts of CARE Nepal to improve the maternal and child health situation of Doti, SAMMAN project adds to its endeavor wherein the family planning component is added in this project. If we assess the situation of family planning services utilization in the district, it is still exasperating. Some of the hindering factors for which are inaccessibility, unavailability, lack of awareness, illiteracy, poverty etc. SAMMAN project has various community level family planning interventions which I believe will add on to our efforts to improvise the situation. In order to make the activities of SAMMAN more effective in the upcoming days, we expect CARE s continued support for increasing quality of care at birthing centres, sustaining the established birthing centres, provide infection prevention training to all the health workers, support to CB IMCI/NCP program and capacity building of the health workers by providing them training on Intra- Uterine Contraceptive Device (IUCD)/Implant to increase access and utilization of family planning services. In health sector, the non-governmental organizations facilitate to fill in the resource gap where the government cannot fully contribute. The coordination between the public and private sector helps to bridge the gap thus ensuring that coverage of the health services is throughout. The maternal and child health and reproductive health indicator of Dadeldhura is good as compared to other districts. However, we still should continue strengthening the birthing centers supporting them with birthing equipments and supplies and promoting quality service. The interventions brought forward through SAMMAN/GSKII project will definitely help to improve the situation reaching to grass root beneficiaries. For maternal and child health, there should be social change to address this. Mother health should be the priority of the family taking in account of her nutrition and psychosocial aspects. Also, we have birthing centers which provide 24 hour delivery service to its clients. But I believe considering the geographical terrain of the region if we could work on the concept of Birthing Hut then the maternal health can ensured as people have place to stay in immediately after delivery. Lastly, in any sector the goal of government and nongovernmental organizations should meet through healthy coordination ensuring no duplicity in the work and with the same resources we can have wider coverage of the program. I have been in this district since 18 month as a District Public Health Administrator. I found that public health activities are going well with better harmony among like minded organizations. Maternal and child health program is one of the priority one programs (P1) of Government of Nepal. In recent years with the support from organizations like CARE Nepal MNCH program has better impact at community level. Marginalized and poor people are getting services from local health facilities, birthing centers are in increasing trend, people s awareness level has been increased, institutional delivery has been increased, antenatal care service is also increased. I would like to acknowledge the support of FHD, CARE s CRADLE Support project and GSK funded SAMMAN project and other NGOs and INGOs working in RH field for joining hands with us. As I know, CARE is like emergency medicine to address the gaps that we are facing now as in the past and we want to strengthen our partnership further to a optimum level through this GSK funded project. Further, technical and financial support to sustain the continuum of care is crucial at this point of time. Lastly, I would like to thank CARE Nepal for its remarkable presence as an asset since long in this part of the country.

11 SAMMAN Newsletter 11 Situation of HIV and AIDS in SAMMAN Intervention Districts POEM Dabal Bhat, VDC Sectretary Bhumirajmandu recites poem Community Health Score Board in Our VDC in community interface program Community Health Score Board in our VDC Installation of Community Health Score Board in the VDC Sanguine populace feels appeal of quality health service Presence of DHO and CARE in the VDC Overjoyed people here are appreciating a. Service information Service Type Dadeldhura Doti Kailali Region STI Centre HTC Centre ART centre PMTCT Centre CCC/CHBC site CD4 centre Blood transfusion centre Drop In Centers Prevention service 13 VDCs 38 VDCs 19 VDCs CARE Nepal SAMMAN Intervention 10 VDCs 10 VDCs 10 VDCs 30 VDCs b. Status of HIV and AIDS Description Dadeldhura Doti Kailali Region HIV +ve cases Cases under ART Death Reached through Counseling % of +ve among counseled Death Total alive cases Source: Regional Health Directorate, Dipayal, Doti From Himal to the Terai, CARE Nepal is working Up to now the volume of support is overwhelming Good governance is all that we desire for Yet the political pain we are bound up to endure Anticipate social inclusion everywhere, without it is misdeed The people suffer and so the village cries instead Power ought to be imparted to those deprived Welcoming good governance everyone smiles Preventing from HIV /AIDS in Nepal Guiding Principles 1. Universal Access of Prevention, Treatment, Care and Support services for all people on equitable basis 2. Decentralized, integrated, multi-sectoral and interdisciplinary engagement 3. Evidence-informed planning and programming 4. Health System Strengthening and Community System Strengthening 5. Service delivery based on the principle of Primary Heath Care Approach 6. Equity and Human Rights 7. Gender mainstreaming 8. GIPA Principle Celebrating 35 th Years in Nepal

12 12 SAMMAN Newsletter Advocacy Campaigns Against Gender Based Violence For CARE Nepal, International Women Day (IWD) has become an occasion to celebrate the significant progress and raise the voice from oppressed community where people (mostly women and children) are suffering from discrimination and violence often at workplace, families and relatives. To mark 103 rd IWD, project continued its practice by reaching to thousands of people through different advocacy campaigns at centre, region, district and VDC level. Community level activities were focused on women s reproductive rights, women s rights, girl s education; gender based violence (Chaupadi Pratha). The theme of the day was A promise is a promise: Time for action to end violence against women. Mass rally, candle light, speech, dances, song competition, interaction with mothers group promoting locally available foods to pregnant women, recently delivered mothers, their mothers in law and husbands are the major actors of the events conducted. Some events in the occasion of International Women s Day Shova Gurung MNH Officer, SAMMAN Project, CARE Nepal

13 SAMMAN Newsletter 13 SUCCESS STORIES KMC saves newborn lives Amrita Nepali, a resident of Mudegaun VDC Ward No 7 of Doti, was married while she was 15 years of age. Her family owns a limited land which was not adequate for her family. The produced food is enough only for a month. So, the family members work as labor to solve the day-to-day hand to mouth problem. Her husband has gone to India for labor work soon after she became pregnant which was only a year after her marriage. She visited health facility 3 times for antenatal checkup at nearby health facility. She took iron tablets and TT vaccine as per the suggestion of health workers. Unfortunately, during the 35 th week of her pregnancy, she got unbearable pain at mid night. There was no one in her family to lend support during her throbbing labour pain and the health facility was at a distance so she couldn t gather courage to go there without her family member. Finally, she remained with that agonizing pain for couple of hours in the home and gave birth to a female baby with the support from a relative. Seeing the baby we were puzzled as she (the baby) was such very lean and thin. But she is big and healthy now her relative said. The baby had breast feeding problems and Amrita took her to nearby health post. Unexpectedly, her weight was found just 850 grams. She was taught about Kangaroo Mother Care (KMC Mayako Angalo in Nepali) by CBNCP trained health workers and applied KMC immediately. She followed the procedure regularly. After 15 days, the baby gained double weight and the weight tripled within a month. Now, she was 2.5 months old and gaining the weight regularly. It was the first baby for whom we started KMC with little confidence. CB NCP training made all this possible said Mr. Prem Kathayat, Incharge, Mudegaun SHP. Amrita, with confidence, is now sharing the importance of KMC to her relatives. If I had visited the health facility in time, things could be better. Thanks God!! My baby is alive now. KMC can save life of low birth weight baby, if consulted trained health workers on time, she said with a smile. Hari Lal Dhakal FP Officer, SAMMAN Celebrating 35 th Years in Nepal

14 14 SAMMAN Newsletter SUCCESS STORIES Practicing to use Bag and Mask during onsite coaching SBA trained ANM Yashoda KC in Delivery Room I got success to save a child My happiness of becoming a mother suddenly turned pale when my baby didn t show any reaction after birth. I was facing serious delivery pain since 15 hours and watching the baby this way that came to this world after my long struggle I was utterly upset. I was consciously observing a sister inserting a small pipe into the mouth and then on the nose of my baby. I was curious what she must be doing to my baby but was scared to speak a word. At that moment, all I could do was just lie on the hospital bed and watch her working, still I could see baby was lethargic and did not show any sign of life. Very quickly then, sister used a pumping machine into the mouth of baby. While she was using the machine continuously, my baby started to cry. I was so happy to hear the crying voice This candid view was said by a post natal mother Ms. Amrita Thapa, 20; a resident of Chhatiban VDC-1, Doti. It was first pregnancy of Amrita Thapa. She received three ANC visits and TT vaccination in nearby Sub Health Post (SHP) as per the advice of FCHV, Belu Gurung. With the help of Belu, she was taken to SHP for delivery of her child in the morning of second day of her labor pain. She was given medical support immediately. I was very much worried because it was first birth asphyxia case to be handled independently in my professional career. I used Delee Suction firstly, then used Bag and Mask to give the baby life. The child gave sign of respiration while I used Bag and Mask continuously for about four minutes. Fortunately, my effort did not fail; I was successful to save the child. Said Yashoda KC, a SBA trained ANM of Chhatiban SHP. Belu was also very happy to see the child alive and opined in our onsite coaching visit that, Eventhough it was already late, if Amrita was not taken to health facility in time, anything could have happened. I knew bag and mask can give a life to a child in a critical condition. Man Bahadur Bohara District Programme Coordinator, SOURCE Nepal

15 SAMMAN Newsletter 15 SUCCESS STORIES Her courage to improve maternal health Gauri Nagari belongs to a Dalit family. She was married at a very early age and thus was compelled to quit her education without completing. Because of her boldness and social behavior she was chosen to work as a FCHV by the mothers group of her community. She was always determined to work for improving the health of her community. She was offered to study ANM in Pokhara. She demonstrated her admirable skills and completed the course with exceptional marks. She is then working as an ANM in Barbata SHP, Doti. Gauri Nagari was very excited to hear that she was selected for two months SBA training in Seti Zonal Hospital, Kailali. Soon after her ANM studies, she had been attending deliveries in Barpata SHP but she always had the feeling that if she was SBA trained then it could enhance her delivery skills and she could perform deliveries in a perfect way. SBA training is two months training package intended for health workers to acquaint them with the essential maternal and neonatal health services including early diagnosis and management of complications of both mother and child as a result from pregnancy with hands-on experience in the birthing sites. Amongst the 12 participants who attended SBA training in February March 2013, Gauri was one of the diligent and motivated person through the training. She was eager to learn new skills and expressed her concerns in times of uncertainty. She says There are a lots of women in my community who are deprived of education. I wanted to be a role model for them. It is the matter of willpower and I still believe I have a long way to go. Gauri feels extremely fortunate that she was granted this opportunity to participate in the SBA training that CARE was supporting in coordination with D/PHO and NHTC where she has acquainted herself with the clinical skills of SBA. Gauri has already attended more than 95 normal deliveries but believes now on she is more efficient for the purpose and can handle complicated cases. She had previously attended IP training which was also facilitated by CARE Nepal and expressed that she maintains a sterile delivery room and uses sterile practices while providing services. All these trainings have boosted her spirit to provide delivery services and persistently serve to reduce maternal and neonatal death in her community. Prativa Basnet Research Officer, SAMMAN Project Celebrating 35 th Years in Nepal

16 16 SAMMAN Newsletter SUCCESS STORIES PES mobilization: A golden opportunity I am prepared for institutional delivery Sharada Rokaya is a resident of Malakheti VDC, Kailali. Currently she is working as a Peer Educator/mobilizer in the VDC. She needs to perform all domestic work, look after the livestock, collect firewood and grass for fodder etc. Before being trained as a PE facilitator, she was not aware on the health of mother and child. Mothers in her village did not seek health care services from local health facility. One day she got chance to participate in PES training organized by FAYA Nepal (SAMMAN project) with technical support from D/PHO Kailali and CARE Nepal and financial support from GSK. She learnt about technical aspects of maternal neonatal and child health and HIV and AIDS. She thought she is the luckiest person in the village who got this type of excellent opportunity at her own village. She mobilizes all the PES in the VDC. She is very happy these days because she knows many things about mother and child health including HIV/AIDS. I sincerely thank SAMMAN project that provided me precious and wonderful platform for learning and doing social activities in my own community she said with smiling face. She added I want to suggest all PES not to waste time or misuse this golden opportunity we got and work hard to improve maternal and child health conditions in our village. Prem Raj Joshi, District Project Coordinator, FAYA Nepal I am Punam Saru Magar, 19 years, resident of Alital-4, Dadeldhura. I became pregnant first time and I was very shy to tell about pregnancy initially. I have never been to health post for the check ups. Narendra Thapa (PES of SAMMAN project/nndswo-care-d/pho) shared the information about safe motherhood in Jyoti mother group where I was a member. All the members of the group gathered on a fix date and place and share the information about importance of ANC visit and institutional delivery, danger signs during pregnancy and other health related information. He saw me and advised me to go for ANC visit and told about how to take care during pregnancy, danger signs of pregnancy and so on. As the date of delivery came closer I realized the words he said to me. Then I went for regular ANC checkups and was assured about the positive outcome of the pregnancy. I am fully prepared for institutional delivery and waiting for the date of delivery. I am also providing health related information to the people in the community. Prakriti Pant District Project Coordinator, NNDSWO, Dadeldhura

17 SAMMAN Newsletter 17 SUCCESS STORIES Saving mother and newborn through SATH Phulmati Chaudhary, 23 years, lives in Thapaur VDC, Kailali. She is illiterate and from disadvantaged family. Her husband is a rickshaw puller at Dhangadhi. In the past, her sister in-law delivered two babies at home. One of them was died because of lack of timely care. Her family did not manage for birth preparedness. But strongly refused institutional care. Family members thought, it would be cheaper for them to marry again if she died, rather than paying the costs for institutional delivery. Phulmati herself became pregnant and luckily, local mother group and FCHV heard about her this time. The members of MG-H are implementing SATH program with the support from SAMMAN (FAYA/CARE Nepal/D/PHO Kailali) project. SATH group comprises FCHVs, local mothers, mother-in-laws and PES. The project has also provided an emergency fund of Rs.3000 to the MG-H. They keep records of all the pregnant and delivered women in their area and monitor the service utilization by pregnant mothers through colored TIKA. The SATH mother group in coordination with local FCHV talked with her family members taught them the importance of antenatal care and Institutional delivery, provided emergency fund to cover the transportation costs. As a result, she went to hospital with the help of her family members. At the hospital, she went through caesarean section as it was a complicated case. She got everything free of cost at hospital and got NRs 500 as a safe delivery incentive provided by GoN. She might be in risk if she couldn t seek institutional care. Now, Phulmati and her baby are healthy and happy. Mina Chaudhari, Community Health Facilitator, FAYA Nepal Celebrating 35 th Years in Nepal

18 18 SAMMAN Newsletter SUCCESS STORIES There is no Chhaupadi My name is Bhagrathi Tamrakar, permanent resident of Aalital-3, Dadeldhura. There exist many traditional practices which are harmful (not all traditions are harmful) to us. Chhaupadi is one of them. Chhaupadi is the period in which women in their menstruating period have to live outside their house and are not allowed to be touched by any members of the family and community for 5 to 7 days in a month. I also sleep outside of my house. We are now educated by SAMMAN/CSP of CARE Nepal/NNDSWO/D/PHO about the consequences of Chhaupadi. I along with other 23 women attended a training facilitated by Kamala Nagri and Bhim Bahadur Saud from NNDSWO on various issues like Dalit rights, Human rights, livelihood and health related information. Discussion was also took place on personal hygiene and importance of nutritious food in the mother group meeting (Bandana MG-H) which is usually facilitated by Kamala Bohara, FCHV. We also discussed about importance of ANC and institutional delivery. We, women of the community committed to sleep inside the house during the menstruation period and decided to remove the Chhaupadi (unhealthy small huts) that were used to sleep during menstruation period. We jointly removed those huts and now have started to sleep inside our house. Nothing harmful has happened to us after this moment. I myself cook food during the period. What we have realized is we had done injustice to ourselves for years. But now we all are aware about the health hazards of chhaupadi. We are informing other communities about the harmful effects of chhaupadi. Family members are also supportive now. Bhim Bahadur Saud Community Health Facilitator, NNDSWO

19 SAMMAN Newsletter 19 Activities at a glance Hand washing practice Practicum in resuscitation Kangaroo mother care Neonatal examination Family Planning Workshop, Doti CB-NCP Training to Health Workers, Dadeldhura Mothers' Group Meeting on SATH, Doti Celebrating 35 th Years in Nepal

20 20 SAMMAN Newsletter Staff Update GSK Nepal Country Manager during his field visit CARE Nepal Name Position R. Sharan Pyakurel Area Program Manager Madan R. Bhatta M&EA Specialist Shova Gurung MNH Officer Hari Lal Dhakal FP/RH Officer Prativa Basnet Research Officer Dipti Acharya Finance Officer Lali Jung Kuwar Logistic Assistant Rupa Malasi House Keeper Lal Bdr Oli Driver FP Micro Planning Training, Doti FAYA Nepal, Kailali Prem Raj Joshi Shiva Raj Chaudhary Dhani Ram Chaudhary Mina Chaudhary Dilli Singh Rawal Bhagwati Pariyar Muna Adhikari Ramila Rawal DPC AFA FCHVs from Project districts felicitated in National Level FCHV Day Celebration SOURCE Nepal, Doti Man Bdr Bohara DPC Dipendra Khadka AFO Dil Bdr Dhami Bhajan Malashi Khem Bdr Patali Mahabir Kadayat Indra Singh Karki Laxmi Rawal Ganga Majhi Dhurb Bdr Singh CARE Contact CARE Nepal, Central Office Krishna Galli, Lalitpur P.O. Box: 1661, Phone: Fax: Web: CARE Nepal, Regional Field Office Dhangadhi Phone: Fax: Web: NNDSWO, Dadeldhura Prakriti Pant DPC Kiran Jairu AFO Bhim Bdr Saud Jagadish B.K Ganga Air Ram Dutta Pant Damaru Sarki Basanti Tamrakar SAMMAN project is funded by Glaxo Smith Kline (GSK), UK. The project is being implemented through the CARE Nepal s partnership with NNDSWO Dadeldhura, SOURCE Nepal Doti and FAYA Nepal. Overall leadership and coordination is being provided by the Government of Nepal, Ministry of Health and Population, Department of Health Services, Regional Health Directorate and respective District (Public) Health Offices.