Nepal Red Cross Society

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1 Nepal Red Cross Society Community Eye Care and Health Promotion Programme (CEHP) Annual Progress Report January to December 2010 By: Kamal Baral, Programme Director Deependra Chaudhari, Deputy Programme Director and CEHP team CEHP Annual Report (Jan- Dec) 2010 (1) In collaboration with Swiss Red Cross

2 Table of Contents Executive Summary... 4 Context... 7 Project Activities ) Community Eye Care... 7 Cataract Surgical Camp... 8 Primary Eye Care Camp... 8 Services of Community Eye Care Centres... 9 Service of Surgical Centre... 9 Trachoma Prevention and Treatment School Eye Programme Pre-School Eye Programme Low Vision Services Training and Orientation on Primary Eye Care Promotion of Face Washing IEC Activities Self-sufficiency of CECC Expansion of ear care services in the CECCs Quality improvement on eye care KAP Survey on Community Eye Care Cooperation with partners Problems, solutions and recommendations Outlook for 2011 of Eye Care Component ) Water-Sanitation and Primary Health Care...15 Interaction on PHC IEC/BCC Materials Distribution Model Village and Exchange Visit Safe motherhood HFOMC Strengthening Programme Water Project Sanitation Self-reliance of community groups Cooperation with partners/stakeholders Problems, solutions and recommendations Outlook for 2011 of WASH-PHC Component School based HIV Peer Education (PE) Action plan from the schools and follow up Trainings carried out by DCs Information and education Promotion of Safer Sex Behaviour Support to PLHA National Condom Day & World AIDS Day HIV Mainstreaming in other project components Cooperation with partners/stakeholders Problems, solutions and recommendations Outlook for 2011 of HIV component CEHP Annual Report (Jan- Dec) 2010 (2) In collaboration with Swiss Red Cross

3 4) Organizational Development (OD)...30 Need based Support/facilitation for capacity building Training on Resource Mobilization at DCs Publications and information dissemination Website management Human Resource Development Knowledge exchange with other projects Internal capacity building of CEHP staff/knowledge management Capacity building of other organisations (given by CEHP staff) Cooperation with partners/stakeholders Problems, solutions and recommendations Outlook for 2011 of OD component Transversal themes Gender Do no harm HIV mainstreaming Linking relief, rehabilitation and development (LRRD) Good governance Conflict sensitive Programme management...36 Consultants and Visitors...36 Finance...37 Conclusion...37 Contact information: Annex 1: Abbreviations used in the report Annex 2: Volunteers and staffs at CEHP (at the last quarter of the year 2010) Annex 3: Cumulative HIV and AID situation of Nepal Annex 4: Training/workshops/orientations by OD in Annex 5: Fund Raised in CEHP Annual Report (Jan- Dec) 2010 (3) In collaboration with Swiss Red Cross

4 Executive Summary The Community Eye Care and Health Promotion Programme (CEHP) in the Mid-West Region of Nepal contributes to improving the health situation by meeting the needs of the people in the areas of community eye care, primary health care, water and sanitation and prevention of HIV and AIDS, contributing to poverty reduction and to the achievement of the Millennium Development Goals (MDG) of the United Nations. Through the CEHP s programmatic input the partner organisation, the Nepal Red Cross Society (NRCS) and its District Chapters (DCs) in the Mid-West are strengthened in their organisational development. This report elaborates the performance of project activities from January - December of The year 2010 was the last year of the CEHP Phase II ( ). Under the core services of the CEHP, the Community eye care component primarily addresses the reduction of poverty induced blindness through curative, promotive and preventive eye care service in collaboration with various partners. The guiding principle is the global WHO initiative Vision 2020: The Right to Sight. During this period, over 85,000 people received direct eye care services. Curative eye care services were provided for 34,731 patients in four Community Eye Care Centres (CECCs). All four CECCs are continuing a holistic service approach to eye care providing optical devices and medicines in one-stop service delivery. The CECCs are maintaining a high degree of self reliance. The cost recovery of the running costs amounted to 126% 116%, 78% and 59% in Bardia, Surkhet, Dailekh and Jajarkot respectively. The CECCs in Bardia and Surkhet are fully managed by the DCs since The CECC in Surkhet is continuing cataract surgery service on a monthly basis with a visiting ophthalmologist and has operated 385 cases in The CECCs in Dailekh and Jajarkot are also improving their level of cost recovery significantly, even though they have a lower number of patient turnover and need some more years to sustain fully. 1,197 poor patients, who were identified for cataract surgery in the CECCs and in the screening camps, were subsidised through the Swiss Red Cross (SRC) sponsored poor patient fund. They were brought to Nepalgunj for cataract surgery to restore their eye sight. In 7 surgical eye camps in hard to reach areas 4,777 patients were treated and 1,321 major surgeries and 43 minor surgeries were carried out to restore sight of the people from the rural and hilly districts. During this period, the primary eye care mobile camps were conducted in 113 locations; 16,298 patients were treated and health education was provided. 2,880 cataract cases were referred to the CEHP's referral hospital, the Fateh-Bal Eye Hospital (FBEH) and Nepalgunj Medical College (NGMC) for surgery. 78 trachoma surgeries were carried out and 262,410 persons were educated on trachoma prevention. 193 Junior Red Cross circles/schools organised face washing demonstration where 26,053 students joined this activity. Pre-school screening was conducted and 8,420 children were examined. 94 children were found with refractive error, squint, etc. and were referred to the eye hospitals for further management. During this period, 153 teachers were trained and the vision of 15,512 students from 82 schools was screened, 413 students were identified with refractive error (abnormal vision) and other eye anomalies which were referred to the CECCs and FBEH. Additional 1,077 community health workers, Sub/Health Posts In-charge, medicine sellers and traditional healers received primary eye care training or orientation. 72 low vision patients received subsidized optical devices to improve their vision. A Knowledge, Attitude and Practise (KAP) survey on Eye Care programme was carried out by the CEHP in 5 district of Bheri zones. This survey indicated that the eye care service seeking behaviours of the people have significantly improved. However knowledge level on primary eye care still is low thus needs more action and attention to further improve it. Under the Water-Sanitation and Primary Health Care (WatSan & PHC) component, the CEHP is promoting a community-led process to improve health and sanitation in the communities through 238 community groups (CGs). These groups identify health problems in the community and plan, implement and monitor actions to improve their health situation. 12 core facilitators and 28 community facilitators (CFs) carry out information sessions and facilitate the planning and capacity building of the community groups. More than 1,800 sessions on primary health care including demonstration sessions were carried out by the community facilitators. 1,190 action members are in place. Transport system for pregnant women to the health post has been established by 21 groups, and 54 groups have started a revolving fund for safer motherhood in % of all CGs have a functional safe motherhood fund by end of About 120 women used the fund for medicines and transportation to hospitals. Improved hygiene was achieved through the construction of 2,838 latrines by community members. Out of this, 2'026 families have constructed sanitary latrine. CGs have declared CEHP Annual Report (Jan- Dec) 2010 (4) In collaboration with Swiss Red Cross

5 44 communities as Open Defecation Free (ODF) villages organising a formal celebrations with the involvement of neighbouring CGs, GOs and Non-government bodies. 8 villages also have been declared as model village. Access to water was ensured through the completion of 9 new and 2 maintenance of gravity fed water systems (GFWS) and 3 new spring protections in Salyan, Pyuthan and Jumla. Similarly, 11 new hand pumps were installed in Bardia. 3 new spring protections were completed in Salyan. 54 rainwater harvesting jars of liters capacity each were constructed in Pyuthan. The project has continued Health Facility Operation Management Committees (HFOMC) strengthening activity through the implementation of Health Facility Management and Strengthening Programme to enhance the links between Health Service Provider or Health Facility and community to improve the quality services at the sub/health post level. The programme has accomplished orientation, coordination meeting and promotional events under these activities in Jumla, Salyan and Pyuthan districts. HFOMC strengthening activities were supportive to make the members of the HFOMC and the HP in-charges more dutiful, they started review service delivery system and its management in a more regular basis, almost all HPs have started disseminating their services through citizen charter.the health post in Talium in Jumla which remained closed, has significantly improved the service delivery with the same staff members due to the actions of the HFOMC. A KAP study was carried out by external consultant found that the project had significant impact on people to change their sanitation behaviour as now over 90% of the beneficiaries in the programme VDCs wash their hands after defecation and before taking meal. In case of primary diseases, people now go to health institutions rather than traditional healers. The practice of at least 4 time ANC check up is increased during the pregnancy period in the project areas. The practice of taking iron pills, tetanus vaccination and feeding colostrums to babies is also significantly increased. The community groups have undertaken several other activities, e.g. cleaning of footpaths, road works, forestation, building stretchers for transport of people to health posts, improving household hygiene through waste pits and sun-dry stands. Towards the end of the year, all CGs did a self-assessment of their capacity using the capacity assessment tool. 59, 157 and 22 CGs have reached stages 'A' 'B' and towards 'B' status respectively. The HIV prevention and awareness programme in schools has been implemented in 110 follow up schools in 6 districts. Compatibility with the Global Alliance on HIV and AIDS in the programme components has been ensured while planning. This year, institutionalisation of the HIV prevention and awareness programme in schools was further promoted and strengthened. Extensive orientation was carried out in the DCs, Sub-chapters and to the teacher sponsors (TSs) to further boost the volunteers understanding of institutionalisation. The institutionalisation has happened once the schools incorporate HIV activities in annual plan of schools, incorporate HIV activities in the Junior and Youth Red Ross (J/YRCs) annual plan, a system for replacement of graduated peer educators is in place; regular monthly meetings of J/YRCs happen; discussions on queries on a monthly basis are done; J/YRC has their own fund to carry out minimum activities on HIV prevention and regular reporting of the school to the sub-chapter and DC is done. 76 (targeted 60% of 110 schools) follow up schools from 6 programme districts succeeded to institutionalize HIV activities in their schools and the remaining will continue their attempt for institutionalisation with the support of DCs in the coming year. In order to disseminate the changed programme management role of the DC and its network for the implementation of HIV programme, 5 programme district chapters organised an orientation meeting for DC, subchapter and J/YRC leaders. 120 members from 5 districts participated. Volunteers of programme DCs' visited the follow-up schools 138 times to ensure implementation of the activities. As a part of the institutionalization process, School Management Committees (SMC) were also oriented 101 times. All 6 programme DCs organised Planning meeting with the participation of 99 teacher sponsors in the 6 districts. In order to further support the institutionalisation of the programme, 4 Resource mobilization trainings for Teacher Sponsors were conducted in the programme districts where 70 TS participated, so that they could further support the schools/jrc to raise fund for continuing the programme. Many schools generated funds though local fund raising activities to carry out JRC activities and reported funds around Rs. 200,000. The district chapters also carried out 4 Refresher Training of Trainers (ToT) for 106 Teacher Sponsors of the schools. During these trainings, a review of their ongoing activities was done and updated information regarding Anti Retroviral Treatment (ART) and Prevention of Mother to Child Transmission (PMTCT) were also discussed. In order to transfer their knowledge and skills to the other students of each programme schools, the trained Peer Educators (PEs) with the help of trained teacher sponsors carried out CEHP Annual Report (Jan- Dec) 2010 (5) In collaboration with Swiss Red Cross

6 286 interaction sessions on different topics focusing on HIV & AIDS prevention and reproductive health (RH). 3,722 students received information on RH, sexual transmitted infections and HIV & AIDS. The schools also carried out 269 sessions to discuss queries where 7,150 students participated. Altogether 9,014 students received Information, Education and Communication (IEC) materials in the programme districts. The IEC materials focused on life skills, HIV/AIDS and RH. Some materials were related to peer education i.e. peer diary, batch, life skill guidebooks etc. CEHP supplied 5,000 Yuba Chautari (Quarterly publication of NRCS HQS related with queries and issues of HIV & AIDS) to the programme districts. Within the WatSan & PHC programme, the 238 Action Members/groups of HIV and AIDS conducted 266 sessions in the community groups where 5,125 members participated. This year additional 60 practical condom demonstration sessions were also carried out with participation of 1,333 community people. 15 street dramas on the theme of stigma and discrimination towards HIV and AIDS were shown during local events in the programme district and reached 3,626 people. This year the programme further promoted the Greater Involvement of persons living with HIV and AIDS (GIPA), identification of positive cases, de-stigmatisation and linking positive people to existing services and self help groups. 464 persons were referred to Voluntary Counselling and Testing (VCT) centres for testing and 81 PLHAs were financially supported to access CD4 count in Dang or Nepalgunj. 21 PLHAs were linked to the existing support groups in the programme DCs. Life Sharing Skill training for reduction of stigma for PLHAs was conducted in Pyuthan district. 13 PLHAs participated in the trainings. The programme also involved PLHAs in community groups to share their experiences. During this year in Bardia, Jumla, Salyan and Pyuthan, 66 HIV and AIDS sessions were conducted in the community groups involving PLHA. 1,850 people participated. In 39 schools in six districts (Pyuthan, Salyan, Jumla, Rukum, Rolpa and Jajarkot), 2,951 students participated in sessions led by PLHAs. Under Organizational Development (OD), the CEHP helps assessing the organisational capacity of the DCs through a tool called Institutional Capacity Analysis Process (ICAP). Based on the outcome of the 10 parameters through 116 indicators, each DC develops an action plan on how to minimize their weakness and convert their opportunities into strengths. In 2010 the ICAP targeted the subchapters was carried out in 6 subchapters in Bardia and Jumla districts. As per need, CEHP also offers capacity building for resource generation, programme management skill development, proposal writing support, etc. CEHP continued the quarterly publication of the "Chetana" bulletin, sharing success stories and lessons learnt from the communities and DCs among each other, to various stakeholders and to beneficiaries. Since OD is the integral part of the other service components. OD supported the PHC unit in registration of CGs and Water User Committees (WUCs), vision setting of CGs, Sub-chapter strengthening and mobilisation, support to carry out KAP survey, support for ODF declaration and its monitoring and VCA of the CGs. The OD unit also supported the institutionalization process of the HIV programme; facilitated resource mobilization workshops targeting teacher sponsors. The OD team supported eye care unit to review IEC materials, helped writing proposal for the Village Development Committees (VDCs) and District Development Committees (DDCs). The unit also support to carry out various capacities building training programmes, workshops, survey activities, curriculum development of all units. The integration of OD in all project components has been continuously perceived as very positive, enhancing quality and impact of all programme components. The project follows a Monitoring and Evaluation (M&E) framework/guideline that was developed right from the start of this phase. The monthly reporting from the field to the CEHP base and SRC headquarters follows strictly these M&E guidelines. A project review and planning meeting for the next phase from until took place in August 2010 with the participation of all stakeholders Overall the year 2010 can be concluded as very fruitful, where the project met most of the targets and also showed a significant impact on people's health and health related behaviour. This was achieved as a team work of highly motivated professionals, the support of the management and governance and a conducive external working environment. CEHP Annual Report (Jan- Dec) 2010 (6) In collaboration with Swiss Red Cross

7 Context Nepal's topographical beauty and possibly the cultural heritage and practices give a feeling of richness; though it is one of the least developed countries in the South Asia. Nepal Red Cross Society with the financial and technical cooperation of the Swiss Red Cross (SRC) implements the Community Eye Care and Health Promotion Programme (CEHP) in the Mid-West development region of Nepal, promoting improvement of the health status through the implementation of community eye care and health promotion services. This phase of project is commenced from April 2008 till December There is continuing political instability in Nepal and the country remains in the midst of change. The adoption of the new Constitution planned for 28 May 2010 has been extended by one year. Security situation is still considered fragile as general strikes and similar other violent or non-violent events continue. The parliament failed to elect a new prime minister in the sixteenth round of voting on 4 th November 2010 and the constitution drafting process and integration and rehabilitation of Maoist Army Personnel has been severely delayed due to ongoing power struggles amongst the parties. At the local level, indigenous and marginalized peoples organizations are increasingly active, calling for greater access to the state, more accountable decision-making, improved service delivery, an end to discriminatory practices, and more equitable representation. The fragile political situation and the transitional scenario also had an impact on the development sector. This situation also has impact on institutional management, which has made human resource management and volunteer mobilization a challenge. However the security situation is the Mid-West region was better compared to previous years. Project Activities CEHP's core areas of work are community Eye care, Water-Sanitation and PHC, HIV Prevention and OD. Community Eye care, Water-Sanitation and PHC, HIV Prevention delivers their services in terms of preventive, promotive and curative services to the community where as OD works as a cross-cutting issue to all the component and especially to strengthen the capacity of DCs of the Mid-West region. All the projects on the said areas are implemented by the district chapters of the region with the technical input of the project. This report elaborates results, its indicators, analysis of the results and details of the activities carried out in from January to December 2010 each project component. A project review and planning meeting for the next phase from until took place in August 2010 with the participation of all stakeholders. The outlook of the different sections in the report will already relate to activities planned in the next phase. 1) Community Eye Care The CEHP supports the implementation of community eye care activities in 5 districts of Bheri zone (Banke, Bardia, Surkhet, Dailekh and Jajarkot) and 2 districts of Karnali zone (Dolpa and Humla). The community eye care activities primarily address the reduction of poverty induced blindness through curative and preventive eye care in collaboration with various partners. The guiding principle is the global WHO initiative Vision 2020: The Right to Sight. Objective 1: To reduce the avoidable blindness through the provision of curative, promotive and preventive services Result 1.1: Cataract surgical rate increased in Bheri and Karnali zones Indicator: Cataract surgical rate (CSR) progressively increased by 10% per year. Result Analysis: In order to reduce the backlog of cataract blindness and 'operable' cataract, it is necessary to operate each year on at least as many eyes as develop cataract (incidence). The incidence of cataract is estimated 3,200 in the programme area of CEHP and has planned to achieve 2,100 surgeries by the end of CEHP has altogether carried out 2,903 surgeries and additional surgeries were also carried out by stakeholders mainly in the hospitals. The CSR of Bheri zone was 2,978 and 3,670 in 2008 and 2009 respectively compared to 4,818 (23% increased by 2009) in 2010 CEHP Annual Report (Jan- Dec) 2010 (7) In collaboration with Swiss Red Cross

8 Cataract, a blinding eye disease mainly due to older age is the major cause of blindness in Nepal. In order to reduce poverty induced blindness from the programme districts, CEHP carried out various activities like cataract surgical camps in remote locations of the programme districts and mobile screening eye camps to identify and refer blind patients to the nearest eye hospital or to the surgical eye camps. The cataract patients were also identified and referred by the 4 CECCs, managed by the DCs. The programme built the capacity of the school teachers and volunteer in the programme districts to upgrade their skills in identifying and referring eye patients to the appropriate locations. Cataract Surgical Camp 7 cataract surgery camps were conducted in hard to reach areas of Dailekh, Jajarkot, Surkhet and Dolpa districts of Bheri and Karnali. Patients arriving from the neighbouring districts Humla, Mugu, Achham, Bardia and Salyan were also treated. Total of 4'777 patients were treated as out patients, 1'321 major surgeries and 43 minor surgeries were performed to restore their sight. Additional 1'197 patients had cataract surgery at FBEH and Bardia surgical eye camp (supported by Tilganga) and 385 in the Surgi-centre of Surkhet utilising the poor patent's subsidy. Altogether there were 2,903 cataract surgeries in CSR of Bheri and Karnali zone is significantly increased this year as other stakeholders also carried out 4'893 of additional cataract surgeries in the eye hospitals and in the eye camps. Photo: Dr. Dhungel in an eye camp at Jajarkot. Primary Eye Care Camp During this period, the primary eye care mobile camps were conducted in 113 locations. 16'298 patients were treated and health education was provided. 2,820 cataract cases were referred to FBEH and NGMC for surgery. Glaucoma can also cause blindness if it remains untreated. In order to further sensitise people to seek early service to manage glaucoma, CEHP promotes awareness education among people and also refers glaucoma cases from eye camps and CECCs to the eye hospitals for speciality management. 269 cases were referred for this service. Red Cross Work: Restoring of eyesight CEHP Annual Report (Jan- Dec) 2010 (8) In collaboration with Swiss Red Cross

9 Mr. Sher Bahadur Chand, an OA from CEHP had an interview with Mr. Ashe Nepali at Dunai, Dolpa Surgical Eye Camp before and after his cataract surgery. Mr. Ashe was bilateral blind from cataract. Before surgery: Mr. Chand: Since how long you have problem with your eyes? Mr. Ashe: I had eye problems since 3 years but I can not see any thing since the last since 6 months. Mr. Chand: What problems did you face during this period? Mr. Ashe: I had many problems. I couldn't differentiate between day and night, everything was dark for me. I was just like a prisoner at my home. This was a very bad time for me. I had lot of difficulty to go outside in the field for toilet and 3 times I fell down and got injured. My family members were also not very supportive to me. The blindness caused a problem to them. Mr. Chand: How did you reach the eye camp? Mr. Ashe: One of my neighbours told me about the Red Cross eye camp where I could receive free service. He suggested to come for eye check up. When I asked my son to escort me, he did not agree. I was very upset about this and even felt this must be my fate to live like this. It was useless for me to live in such a situation. My neighbour was very kind and convinced my son agree to bring me to Dunai (eye camp location). Mr. Chand: How far is your home village from here (camp location)? Mr. Ashe: Not very far but it took me more than 5 hours to come. My son alone comes in 2-3 hours. For me waking is difficult. See, how I was injured while walking (Mr. Ashe showed his left leg that was slightly injured when he knocked stone). After surgery Mr. Chand: How do you feel now? Mr. Ashe: I am very happy that I came here. The doctor operated on my both eyes and now I can see even very far everything. I can now walk nicely and I will work again at home. I got medicine I even got food from the camp people (Red Cross). Mr. Chand: Would you like others also to come to a Red Cross camp? Mr. Ashe: Yes, of course. I will certainly tell my neighbours about the Red Cross camp when I am back to my village. I am thankful to Red Cross for restoring my sight. Services of Community Eye Care Centres There are four fully operational CECCs located in four districts of Bheri Zone i.e. Bardia, Surkhet, Dailekh and Jajarkot; delivering eye care services at the CECC clinic and in the communities. All centres are actively involved in clinical, preventive and promotional eye care activities. Since January 2009 CEHP has stopped the financial support to the CECCS in Bardia and Surkhet. Both CECCs have independently performed their services under the management of the DC. They have contributed 10% and 20% to the costs of the outreach programme in 2009 and 2010 respectively. During this period, the CECCs provided curative care and health education services to 34,731 new patients against the target of 35,749. Among new patients 12,191 (35%) visited the CECC within 7 days after onset of eye problems. The CECCs also referred 2,927 cataract patients for surgery to FBEH, NGMC and in eye camps. All the CECCs are providing holistic eye care services under one roof with optical fitting and pharmacy and ear care services. Service of Surgical Centre Surkhet surgical centre has been well functioning and providing cataract surgery service by covering its catchment areas of Bheri and Karnali zone. By considering the demand of high volume surgeries, the DC with the advice of CEHP has been exploring the possibilities to develop the Surgi-centre into a Community Eye Hospital. The Government of Nepal (GoN) has already provided about 10,000 square meter of land for the hospital building With the help of NRCS HQs have submitted a proposal to the Indian embassy to obtain funds. CEHP and DDC Surkhet provided technical and financial support to DC to develop construction plans which was submitted to Indian Embassy. Initially, the Indian Embassy gave provisional interest letter to NRCS to come up with a detailed proposal to establish the community eye hospital at Surkhet. Later, not much interest has been found and the CEHP Annual Report (Jan- Dec) 2010 (9) In collaboration with Swiss Red Cross

10 proposal remains undecided. Thus, the DC is extensively looking for fund to develop basic infrastructure for the hospital from other sources. Photo: Cataract operated patients in remote hills. Result 1.2: Prevalence of trachoma (active/blinding) in Surkhet, Dailekh, and Jajarkot districts are reduced and trachoma eliminated as per WHO definition in Banke and Bardia districts. Indicators: Trachoma prevalence reduced to 5% among children below 10 years of age in Banke and Bardia by 2010 Reduction of blinding trachoma by 20% among adults above 30 years of age in Surkhet, Dailekh and Jajarkot by 2010 Result analysis: A prevalence study carried out earlier already shows that the Trachoma (TT) is no more a public health problem in Banke and Bardia as it is reduced to <5% among children <10 years of age. As regard to the status of the blinding trachoma in Surkhet, Dailekh and Jajarkot, a survey was carried out by the Nepal Trachoma Programme (NTP) which indicates that there is no intervention needed in Surkhet as they could not find TT cases in a the survey; in Dailekh and Jajarkot the prevalence was 1.8% and 5.6% respectively in CEHP altogether carried out 270 (78 surgeries in 2010) surgeries during this phase, which is not significant give impact to TT backlog. Trachoma Prevention and Treatment CEHP and CECCs integrate trachoma prevention related health education and awareness promotion activities along with TT surgery services in the eye camps. Bardia and Banke have now less than 5% prevalence of active trachoma. In late 2008, a survey was carried out in Surkhet, Dailekh and Jajarkot by NTP which indicates that the infective/active trachoma is low in these districts; CEHP Annual Report (Jan- Dec) 2010 (10) In collaboration with Swiss Red Cross

11 however the cases of TT are still hidden in the communities and need an especial effort for identification and operation. Due to awareness raised by the project and antibiotic treatment from National Trachoma Programme (NTP) the cases of active trachoma has decreased. During this period, 78 TT surgeries were carried out and 262,410 persons were educated on trachoma prevention. Reduction of blinding trachoma with this number of surgery is insignificant, and more actions are needed to have impact. At the moment, there is no intervention from NTP in Jajarkot. CEHP plans to continue the collaboration with NTP and Lions Clubs International to address the TT backlog there. Result 1.3: Identification and management of blinding eye diseases (childhood blindness, glaucoma, refractive error, and low vision) is improved. Indicators: % of children served in 2009 increased annually by 15% % of glaucoma identified and referred to secondary eye care provider in 2009 increased annually by 15% % of clients identified and received correction of refraction in 2009 increased annually by 15% Result analysis: This year 23,932 children were served by the programme that is a 205% increase compared to 7,837 in glaucoma cases were identified and referred that which is 51% augmented compared to 177 in The eye care team in Bardia CECC could not start refraction service at the community level lacking technical human resource. School Eye Programme The teachers are key actors in the society working with children and youth. Training them on primary eye care helps identifying eye health disorders related to students and children. The teachers usually screen the vision of the students twice a year at the beginning and in the middle of the academic year. The teachers receive necessary IEC materials and Vision Assessment Charts to carry out these activities in the schools. The District Education Offices support the CEHP to carry out this activity. During this period, 8 resource centres were covered with school eye health programme where 15'512 students (children <15) of 82 schools were screened for vision and 413 students were referred for specialist eye care services. Pre-School Eye Programme Prevention of childhood blindness is one of the major components in the Vision 2020: The Right to Sight campaign against blindness. CEHP implements pre-school screening activities to address this need. Primarily this programme makes community people aware that they need to act on prevention of blindness in the early age of children by seeking services from the nearest health centre as soon as possible to make vision rehabilitation possible. The activity is carried out in the communities targeting all children aged between 1-9 years old. A technical team of CEHP examines their eyes thoroughly, provides possible treatment; and gives education and advice on the spot. Those who cannot be served are referred to the nearest CECC or to eye hospitals. 8,420 children in 4 VDCs of Banke and Bardia district were examined. 94 children were found with refractive error, squint, etc. and were referred for specialist services to the nearby FBEH or CECC for further management. Low Vision Services One important component of the Vision 2020 initiative is the service on refractive error and low vision. This service is mainly focused on children of young age, even though other age category also need this service. CECCs and CEHP identified and served for 137 low vision clients/patients. Out of them 19 patients were referred for further investigations. 72 low vision patients received subsidized devices to improve their vision. Information related to low vision was incorporated in the primary eye care training carried out in the programme area. Only a low number of low vision clients were detected even though estimation indicates that the number should be higher. The team needs to look in opportunities and develop strategies to achieve a higher case detection rate. Training and Orientation on Primary Eye Care CEHP integrates eye care service with the existing health care services of the Government of Nepal (GoN). In order to improve access and to promote primary eye care, education and referral of the patients to the eye hospital and centres, the CEHP carried out primary eye care orientation and training to health workers i.e. Sub/Heath Post Incharges (S/HPIs) Maternal and Child Health Workers (MCHWs), Village Health Workers (VHWs) and Female CEHP Annual Report (Jan- Dec) 2010 (11) In collaboration with Swiss Red Cross

12 Community Health Volunteers (FCHVs) under the system of Ministry of Health and Population (MoHP) and teachers under the Ministry of Education (MOE). 153 teachers trained on Primary Eye Care, 619 community health workers i.e. MCHW, VHW and FCHW received orientation on case identification, referral and prevention of blinding diseases.25 Sub/Health Posts in-charge received Basic Eye Care and Refresher Eye Care Training as well. 23 orientation sessions were conducted for 299 medicine sellers. 4 orientation sessions were conducted for 111 traditional healers. Result 1.4: Measures to prevent blinding eye diseases are practised by the community people Indicator: 2/3 of children in Jajarkot, Dailekh and Surkhet wash their face at least 2 times per day by % of persons with eye problems visit a health care facility within 1 week for treatment Result analysis: A KAP survey was carried out by external consultants to evaluate this situation and found that >2/3 of the children in Jajarkot (68%), 96% each in Dailekh and Surkhet wash their face at least 2 times per day. The same study also revealed that 91.41% of persons with eye problems visit a health care facility within 1 week for treatment. Promotion of Face Washing Face washing is the most important approach to prevent transmission of trachoma and other communicable eye diseases. Dissemination of this approach through J/YRCs circle volunteers and eye care volunteers to the community have significant impact. Thus CEHP has carried out extensive orientation on face washing especially in Surkhet, Dailekh and Jajarkot where the prevalence of trachoma is high. 221 JRCs, eye care volunteers, teacher sponsors and teachers were oriented on the importance of face washing in order to initiate this activity at their school. 193 JRCs/schools carried out face washing activities at their school. 26,053 students were reached with face washing education/messages. IEC Activities CEHP also provided 53,200 copies of IEC materials related to trachoma, cataract and other eye messages and broadcasted radio messages 320 times to disseminate preventive measures on trachoma and other eye diseases. Result 1.5: CECCs achieve full self-reliance and/or move towards self reliance; Surkhet and Bardia contribute towards the outreach service. Indicators Bardia and Surkhet CECC achieved 100% financial self reliance by December 2008 Jajarkot CECC recovers 30% of operational costs by 2008, 45% by 2009 and 60% by 2010 Dailekh CECC recovers 50% of the operational costs by 2008, 65% by 2009 and 75% by 2010 Bardia and Surkhet contribute 10% to the outreach programme cost in 2009 and 20% in 2010 Result analysis: All 4 CECCs met the target for achieving the results as indicated. Bardia CECC recovered 126% of its costs during this year; Surkhet recovered 116%, Dailekh 78% and Jajarkot 59%. The CECC of Jajarkot is on border line. Self-sufficiency of CECC All CECCs have improved their performance moving towards self-reliance. Their productivity and income from the services are continuously increasing. The major source of income is from the outpatient services including spectacle and medicine sale. Bardia and Surkhet CECCs are self-managed by the DCs since January Bardia CECC recovered 126% of its costs during this year; Surkhet recovered 116%, Dailekh 78% and Jajarkot 59%. The chapters are seeking support from the local and other agencies to sustain their services. CECC Bardia, Surkhet Dailekh and Jajarkot have succeed to tap resources (Rs: 462,000, 330,000, 87,400 and 200,000) from DDCs, municipality, Ministry of Health (MoH) and VDCs. Each of the CECCs has developed its business plan to achieve more cost recovery. A portable generator was supplied to Dailekh CECC to improve service delivery of the clinic and also to help CEHP Annual Report (Jan- Dec) 2010 (12) In collaboration with Swiss Red Cross

13 maintaining income generation with continuous availability of electricity to run optical dispensing. DC covered 20% of the cost of the generator. Expansion of ear care services in the CECCs All DCs have integrated ear care services within the CECC. Bardia and Surkhet have a separate staff member for this purpose, where as in Dailekh and in Jajarkot, the Ophthalmic Assistant is also trained for the ear care services. The CECCs examined 1,013 ear cases and 47 complicated patients were referred to Bheri Zonal Hospital for further investigation and treatment. In a national eye care planning workshop the Nepal Netra Jhoti Sangh (NNJS) also announced that they would like to integrate this service in their CECCs. Result 1.6: Quality of service is improved. Indicators Clients are satisfied with the services Bio-safety guidelines are followed 85% of cataract surgery have an outcome of VA of 6/18 Result analysis: A client satisfaction survey was carried out in Bardia, Surkhet and Dailekh CECCs. As per the findings of the survey all CECCs are performing more consciously to improve the quality service of CECCs. Jajarkot CECC has average performance and it was not possible to organise client satisfaction survey. Bio-safety guidelines are followed and the follow up of the cataract operated patients has become a routine service. Over 57% of the patients operated had uncorrected vision 6/18 the next day after surgery. It is expected that the visual acuity improves until 6 weeks after surgery. Since access is very difficult, it is often impossible to do further follow-up after 6 weeks and thus the propjet lacks data of final cataract surgery outcome. Quality improvement on eye care In order to improve the eye care services of the CECCs and outreach activities to improve quality and make services more client friendly patient satisfaction surveys are carried out. A questionnaire is used as a regular tool for patient exit interview allowing the beneficiaries to provide their valuable input to improve the service management of the programme. The survey was carried out by Bardia, Surkhet and Dailekh CECCs and also during 4 surgical eye camps. The survey mainly indicated that there is need for further improvement of publicity of the services, reduction of waiting time for the patients, supply of sufficient drinking water, and toilet facility for patient in the eye camps and improved sanitation in the surgical eye camps. The bio-safety guidelines, developed and introduced by SRC in all their eye care programmes, are strictly followed in the eye camps as routine. In each of the surgical eye camps the camp in-charge monitors the bio-safety status filling a check list and the surgeon of the camps verifies and approves it. Bio-safety guideline is also introduced in the CECCs. A periodic monitoring of the status is done by the CEHP eye care team. Additional equipment and instruments were bought to ensure bio-safety standards and to improve the diagnostic quality of the CECC and outreach services. Staff members were also trained to develop and improve their skills to use new equipment (biometry, refraction and portable slit lamp etc.). CEHP has put further effort to improve quality of visual outcome introducing provision of A-scan biometry and has also maintained monitoring of visual outcome of the patients operated at the surgical eye camps as per WHO criteria to the possible extent. KAP Survey on Community Eye Care In order to assess and compare the effectiveness of eye care services, a KAP (Knowledge, Attitude & Practice) survey was conducted in 5 districts of Bheri zone (Surkhet Dailekh, Jajarkot, Banke and Bardia) by an external consultant. It was household survey with 2,770 respondents (male 1,852 and female 918) age between 16 to 60 years. In 2007, a KAP utilising internal resources was also carried out. Some of the finding of the both survey are following. In 2007 people said that the word of mouth (57%) was the most important method to receive information about the eye care, FCHV 31%, where as radio had little significance (27%). The 2010 survey indicates that the Radio (81.5%) is the main and FCHV (46%) is the key person to deliver eye care messages in the community. The monetary reason seems the main reason that people are not reaching the hospital for service uptake, 80% in 2007 and 74% in 2010 said this. A significant impact on face washing behaviour in children was observed. In 2007 only 68.4% of children regularly washed their face where as this increased to 85.6% in CEHP Annual Report (Jan- Dec) 2010 (13) In collaboration with Swiss Red Cross

14 Health service seeking behaviour also improved during this period as eye care services were accessed in 2007 by 57% and in 2010 by 62.5% of the respondents. The 2010 KAP shows that the 91.41% people seek eye care services within a week of onset of eye problem. People's awareness on treatment of blinding disease was also assessed and found that 7.62% people know that Glaucoma can be treated, similarly 24.19% people correctly knew the preventive measure of Night Blindness and 32% said Cataract can be managed through surgery. Cooperation with partners The eye care activities were implemented in close coordination with District Public Health Offices (DPHO), District Education Offices, and District Development committees, Bheri Zonal Hospital, Nepalgunj Medical College, NNJS, Fateh-Bal Eye Hospital, Nepalgunj Eye Hospital, SEVA Foundation, National Trachoma Programme, Tilganga Institute of Ophthalmology, Nepal Eye Hospital Kathmandu, Lions Eye Care Programme, WHO Prevention of Blindness and Deafness, Foundation Eye Care Himalaya. Among them, the Tilganga Institute of Ophthalmology Kathmandu continued their support in supplying the Intraocular Lenses. FBEH and Nepal Eye Hospital Kathmandu provided their ophthalmic surgeon for the CEHP organised eye camps. Doctors from private hospitals also supported the CECC Surkhet for carrying out surgical services. More than 16,298 patients were screened and 2,820 operable cataract cases were referred to surgical eye camps, Surgi-centre Surkhet and FBEH for surgery. Representatives of the eye care team participated in regional and national workshops organised by partners. Surkhet, Jajarkot, Dailekh, Bardia and Dolpa Red Cross chapters received assistance from local organizations and VDCs to organise food and accommodation for the eye camp patients, as well as utensils, beds, firewood, furniture and many other logistics (tents) to make the camps a success. Additionally they provided many volunteers. NRCS Bardia collected around NRS 462,000, Surkhet NRS 330,000, Dailekh, NRS 65,840 Jajarkot NRS 200,000 Dolpa NRS 50,000 and some food grains from district and local level organizations. Problems, solutions and recommendations The security and political situation sometimes affected the productivity of some of the activities such as surgical eye camps and training programme. The Jajarkot eye camp was delayed because of general strike. The patients had difficulty to reach to the eye camp, which led to a low number surgery. In some extent bad weather was also responsible for delay and cancellation of services of hilly areas. Activities in Humla and Dolpa were also delayed due to bad weather and strikes at the airport. The FBEH, a regional eye hospital in Nepalgunj is the referral eye hospital of CEHP and its CECCs. Due to delay on agreeing for the MoU CEHP had to hire eye surgeons from other eye hospitals to carry out few of the eye camps. Following the signing of an agreement in August 2010, two eye camps, one in Dailekh and other one in Surkhet were carried out with the involvement of surgeon from FBEH. After the agreement was signed, referrals were done exclusively to the FBEH only. Outlook for 2011 of Eye Care Component CEHP will continue the eye care activities and services as mentioned above. In accordance to the KAP survey more emphasis will be given to reach the un-reached and promote eye health awareness activities in hilly districts. Depending on the patients flow in the surgical centre of Surkhet, and to clear existing cataract backlog in the Mid West region, an ophthalmologist needs to be recruited to support the surgical case load and to enhance the outreach on cataract cases. Local collaborators shall be more involved and the number of trained eye care volunteers increased. As per commitment of Surkhet DC, the possibility for the establishment of a community eye hospital will be explored. Following the results of the national Rapid Assessment of Avoidable Blindness, an additional service on Childhood blindness, Glaucoma and diabetic retinopathy will be started to serve the needy. To reach the unreached and strengthen referral mechanisms, the CEHP plans to establish Vision Cells (VC) in Primary Health Care Centers of the Government health system. Quality improving measures will be further implemented. DCs will be encouraged to look for more local resources and invest also for improvement of quality services. All Ophthalmic Assistants will receive further practical training to improve technical knowledge and skills on childhood blindness, glaucoma and diabetic retinopathy screening. CEHP Annual Report (Jan- Dec) 2010 (14) In collaboration with Swiss Red Cross

15 The CECCs will continue ear care services and enhance their productivity. The CECCs will receive equipments and instruments to improve their quality of service. CEHP will collaborate with the National Trachoma Program to carryout activities to reduce backlog of blinding trachoma in hilly districts. Essential coordination and collaboration will be done with several eye care stakeholders to increase efficiency and productivity in the eye care services in the working area. 2) Water-Sanitation and Primary Health Care The project component Water-Sanitation and Primary Health Care (WatSan & PHC) is implemented in Bardia, Salyan, Pyuthan and Jumla districts of the Mid-West region. The programme covers 14 VDCs of these 4 districts, i.e. 5 VDCs in Bardia and 3 VDCs each in Salyan, Pyuthan and Jumla districts. Objective 2: To improve the health status of the people by promoting healthy behaviour through local initiatives. Result 2.1: Awareness and practise about health problems at the household level is improved. Indicators: Latrine is regularly used by all household members over 5 years of age. Household members over 5 years of age wash hands with soap/kharani = ash (before and after food and after toilet) in Bardia 70%, Pyuthan 60%, Salyan and Jumla 40%. Result analysis: The programme promoted sanitary latrine as well as pit latrine construction in the VDCs. The endline KAP survey showed that 94%, 94%, 91% and 92% people over 5 years of age use latrine regularly in Bardia, Salyan, Pyuthan and Jumla. 44 communities have declared themselves as Open Defecation Free (ODF) Village in this year. The survey also showed that 72.5%, 100% (?), 91%, 91.5% HH members practice hand-washing with soap before and after food and after toilet in Bardia, Salyan, Pyuthan and Jumla respectively. Interaction on PHC The WatSan & PHC is implemented by a community led approach through social/group mobilization in 238 established community groups (CGs). This process is facilitated at the VDC level by 2 Community facilitators (1 female & 1 male) for each VDC. Each group has nominated action members who are in charge of special health topics. Till now, 1,190 action members and the entire action groups promote healthy life style, safe drinking water, sanitation, HIV and AIDS, safer motherhood; eye and ear care and ensure the implementation of practical actions for change in the community. In order to disseminate Primary Health care (PHC) messages to CGs including action members/action groups (AMs/AGs), the CFs conducted 1,823 times interaction sessions on PHC for 31,609 participants. 331 sessions were carried out in Jumla, 403 sessions in Pyuthan, 288 sessions in Salyan and 801 sessions in Bardia. The sessions mainly focused on safe drinking water and sanitation and hygiene improvement, safe-motherhood promotion, nutrition, HIV & AIDS, substance abuse (tobacco and alcohol), eye and ear care and other primary health care issues determined by the local beneficiaries. The KAP survey in 2010 also revealed that the people from programme VDCs go to health institutions rather than traditional healers. This proves a significant change in behaviour through the input of the project. Interaction with Persons Living with HIV and AIDS (PLHA) has been part of PHC sessions inviting local PLHA as resource persons to the communities. The objective of the sessions is to sensitize community members for getting tested for HIV, reducing stigma and embracing positive people in the community by listening to the story of the PLHA who mostly look healthy and active. 66 such interaction sessions had been carried out and communities were very enthusiastic and active. Many communities had invited the PLHAs into their village. The rate of HIV testing in VCT centers in the districts has increased because of the community awareness. 1 Endline KAP survey of the CEHP programme, DNet Consultants, Kathmandu, August 2010 CEHP Annual Report (Jan- Dec) 2010 (15) In collaboration with Swiss Red Cross

16 The DCs have publicly celebrated the special occasions and days i.e. World Health Day, National Sanitation week, Breast Feeding Week, National Condom Day, World Toilet Day, and World AIDS Day with campaigns and rallies to raise awareness. 19 campaigns were also carried out at community level. During the campaigns and special days, CFs conducted 240 practical demonstration sessions in i.e. ORS preparation, porridge preparation, stretcher construction, utensil stand construction, toilet construction, proper use of condom, etc. to promote healthy behavior and to transfer skills to the community members. IEC/BCC Materials Distribution Health Promotion through Behaviour Change Communication (BCC) plays a vital role to enhance knowledge and skills in particular areas. During campaigns, formal PHC sessions, at casual gatherings for other reasons and at the time of practical sessions the programme distributed 27,084 copies of IEC materials related to safer motherhood, sanitation, safe drinking water, HIV & AIDS, condom use, eye & ear care, alcohol and tobacco abuse etc. to the community members. The different IEC materials (leaflets, pocket calendar, wall calendars, posters and pamphlets) were collected by CEHP and DCs from different organisations such as the District Public Health Office (D-PHO), Nepal Family Health Programme (NFHP), Helping Hands (a NGO), Sub-Helath Post (SHP), Primary Health Centre (PHC), Drinking Water and Sanitation Sub-division Office and the Family Planning Office. Community members awareness about the importance of healthy behaviour is increasing. They even organize health sessions or activities and celebrate various national days to promote and sensitise for healthy behaviour on their own initiative. They are collecting IECs from the local and district level agencies and use them during these events. CEHP also supported DCs to install 14 Billboards in each programme VDC and to broadcast PHC related messages through local FM radios and newspapers during various campaigns. PHC messages were broadcasted 16 times. Model Village and Exchange Visit In order to promote the CGs towards self-reliance, they were encouraged to achieve minimum sets of requirements/indicators, so that they could be called a model village. Criteria for model village are: registration of the CG as Community Based Organisation in the local VDC; existence of a maternal revolving fund, functional transportation system to health service in place; and ODF certification. 8 CG declared their community as model in. 44 villages are already ODF certified. Several other CGs have also fulfilled almost all indicators other than registration which has delayed more CGs to be declared as model village. This process will be further geared up during follow up period next year. During ODF declaration ceremony CGs from neighbouring villages were invited to visit as they can get some ideas and will be encouraged to promote the same in their village. The CG members also visited the model villages of their district and exchanged knowledge about how to induce change. This type of exchange visits have been conducted 32 times in Result 2.2: Safer motherhood awareness and practise improved. Indicators: Pregnant mothers receive 4 times or more ANC by skilled health care providers (Bardia and Jumla 80%, Salyan and Pyuthan 60%) Deliveries conducted by trained attendants are 30% in Bardia, 20% in Salyan and Pyuthan, 15% in Jumla Result analysis: One of the major interventions concerns safer motherhood. The endline KAP survey showed that 81%, 73.2%, 74% and 62% of pregnant mothers received 4 times and more ANC by skilled health care providers and 42%, 20%, 16% and 31% deliveries conducted by trained health workers in Bardia, Salyan, Pyuthan and Jumla respectively. Achievements on these indicators are at satisfactory level. Interestingly, ANC attendance in Jumla is well below target, while deliveries conducted by trained attendant are higher than expected. In average 72.55% pregnant mothers have done more than 4 times ANC check up at a health institution, which is double the national average. Also in terms of institutional deliveries, the project achieved 12 % higher rate than the (national average of 15.8% of delivery cases attended by skilled health workers. Safe motherhood All the 238 Community groups are engaged in safe motherhood. In many communities the action member for safe motherhood is the local FCHV, who also keeps direct link to the health post and sub-health post. The AMs/AGs CEHP Annual Report (Jan- Dec) 2010 (16) In collaboration with Swiss Red Cross

17 provide inputs on health issues and follow up and monitor the pregnant mothers' health behaviour. They visit the relevant families in the village to motivate and advise pregnant mothers and their family members during pregnancy, delivery and after delivery to make them aware about danger signs; encourage 4 times ANC visit, receive tetanus vaccination, go for institutional delivery, have supplementary nutrition and immunize and exclusively breastfeed the new born. According to information gathered from end line KAP survey, in average 72.55% (national average 35.21%) pregnant mothers have done more than 4 times ANC check up at a health institution and in average 27.25% (national average 15.82%) delivery cases were attended by skilled health workers. 21 groups provide a community transport system (provision of stretcher and carrying team) for pregnant mothers to transport pregnant women or sick people to the health post or hospital. 113 Community Groups received information on health service provision of GoN. Only one maternal death in Bardia district is reported during the year 2010 out of 4 programme districts. 54 community groups of the programme districts have started to operate a safer motherhood revolving fund. CGs have savings of NRs. 1,374,828 till December 2010 and about 120 women utilised this fund in 2010 and more than 500 women used it since the inception in They use the fund primarily to support pregnant women for safe delivery. They also support community members to receive care for other serious and urgent health problems. The fund is always provided as loan with nominal interest. The CFs continue to provide updated information on health service provisions of GoN including all subsidy for safe motherhood package so that beneficiaries are aware and can claim their rights at the health post, PHC centre and hospitals. In order to avoid transportation delay, 62 CGs (26 % of all groups) have an organised transport system in place, where the sick person is transported with 4 helpers and a stretcher to the next health facility. HFOMC Strengthening Programme Even though the programme has worked extensively to promote better health, the provision of health services particularly in the rural hilly areas is very poor in Nepal. In order to strengthen communities influence on the provider side, the CEHP is collaborating with the Nepal Family Health Programme (NFHP) to strengthen Health Facilities Operation and Management Committees (HFOMC). The HFOMC is a local body consisting of representatives from the VDC, the health facility, schools, minority groups and social workers. HFOMCs are part of the GoN s health strategy. The HFOMCs shall bridge the gap between health providers and service seekers and facilitate a partnership between community and health facility. The intention is to link CGs and CG members to the HFOMC, or become a HFOMC member, so that the CGs has more direct influence on the improvement of the health services. CEHP has been continuing the HFOMC strengthening programme in WatSan & PHC programme areas since This year, District level coordination meeting for HFOMC strengthening has been carried out in Pyuthan. 3 days VDC level training on HFMSP (Health Facility Management Strengthening Programme) for HFOMC have been carried out in Dharampani, Raspurkot and Chunja VDC of Pyuthan with the participation of the members of concerned HFOMC and the representatives of SC, DC as well as CFs. HFOMC members assessed the institutional capacity and the situation of health facility management and health service themselves. The findings were taken as a baseline of HFOMC. 2 days VDC level review programme on HFMSP (Health Facility Management Strengthening Programme) for HFOMC has been carried out in Lamra and Talium VDC of Jumla and Dharampani and Raspurkot VDC of Pyuthan with the participation of 13, 17, 13, 15 members respectively. During review meeting, HFOMC members reviewed the institutional capacity of health facility and their health services. The annual action plan of HFOMC also was prepared and HFOMC members made a written commitment to maintain the accountability for the good management of the health services. One day sharing meeting under promotional activities of HFMSP was carried out in health facilities of Lamra and Talium VDC of Jumla; Phalawang, Kabhra and Karagithi health facilities of Salyan; Dharampani Health Post and Raspurkot Sub Health Post of Pyuthan with expectation that community people will be aware on health service provisions and the importance of their health as well as motivate HFOMC to work actively and health workers will also be more responsible/accountable. In those gatherings, HFOMC members were introduced, health indicators and services of those health facilities were shared and a plan was also prepared to carry out community level CEHP Annual Report (Jan- Dec) 2010 (17) In collaboration with Swiss Red Cross

18 health related activities. Existing health services provision, role and responsibilities of HFOMC and community members have been disseminated too. There were the participation of respective VDC's stakeholders, representatives of CGs and community member (i.e. 63 in Lamra, 29 in Talium, 40 in Phalawang, 55 in Kabhra, 39 in Karagithi, 48 in Dharampani and 50 in Raspurkot). In the programme VDCs of Jumla and in Pyuthan, the full set of HFOMC strengthening activities were implemented by CEHP, where as the ADRA Nepal implemented initial activities in Salyan some years ago. HFOMC strengthening activities were supportive to make the members of the HFOMC and the HP in-charges more dutiful, they started review service delivery system and its management in a more regular basis, almost all HPs have started disseminating their services through citizen charter.the health post in Talium in Jumla which remained closed, has significantly improved the service delivery with the same staff members due to the actions of the HFOMC. The health posts and sub-health posts of Bardia were visited to explore the status of those institutions. HFOMC of those institutions were found active and felt that there is no need of promotional activities for HFOMC strengthening. Result 2.3: Access to safe drinking water and sanitation is secured Indicators: In Pyuthan 50%, Bardia and Salyan 40% and in Jumla 30% of the households have access to sanitary latrines In Bardia and Pyuthan 70%, Salyan 60%, Jumla 50% have access to any kind of toilet 1,863 HHs have new access to safe drinking water Result analysis: Extensive activities were carried out by the groups to improve access to safe drinking water and sanitation. The endline KAP survey 2010 showed that 36%, 54%, 48% and 39% HHs have access to sanitary latrines as well as 55%, 58%, 75% and 68% HHs have access to any kind of toilets in Bardia, Salyan, Pyuthan and Jumla respectively. Despite of satisfactory achievement on construction of sanitary latrines in the programme VDCs, the KAP indicated that it is lower than targeted in Bardia and Pyuthan district. This situation will be tackled during follow up period through ODF and post ODF activities, so that adequate toilets are in the community. 44 villages in the programme districts have declared ODF in this year. 895 HHs (2,092 HHs in 3 years), 1 Sub Health post and 1 school have new access to safe drinking water. Water Project Safe-drinking water is most important for the reduction of diseases. In the hills, water accessibility is very poor and also the quality is questionable. The CEHP supported needy communities within the WatSan & PHC component to avail water supply. Health and hygiene education was incorporated into the PHC to improve understanding on the use and handling of drinking water. Details of the completed water projects of year 2010 are listed below: Table- 1: Water schemes of 2010 S.N Name of Districts Name of Schemes Name of village, VDC No. of Beneficiaries HHs (people) Date of start Date of completion Gravity Flow (New) 1 Pyuthan Chiurikhola Upallo Banchare, Dharampani 30 (155) June 2009 Jan Salyan Chorkhola Karagithi-2, Chorkhola 11 (84) July 2009 Jan Salyan Lisekhola Kavra-4, Salibang 30 (155) July 2009 Jan Jumla Litakot Litakot, Tatopani 328 (1746) 1 School (250) Oct April Jumla Babira Tatopani 95 (514) Feb May, Jumla Tallo Rokayabada Talium 94 (516) Feb July Salyan Chhwarchware Nayagaon Basnewora, 29 (179) April, 2010 Dec CEHP Annual Report (Jan- Dec) 2010 (18) In collaboration with Swiss Red Cross

19 8 Salyan Pokharidanda Pimkhola, 14 (84) Phalawang 1 School(350) April, 2010 Nov Salyan Chyalkanda Chyalkanda, Phalawang 28 (156) April, 2010 Nov Gravity Flow (Maintenance) 10 Pyuthan Salthanti Salthanti, Raspurkot 18 (129) June 2009 Jan Pyuthan Jebundanda Jebundanda, Dharampani 13 (74) June 2009 Jan Spring Protection-New 12 Pyuthan Kudapani Mundanda, Dharampani 24 (126) March 2010 Dec Pyuthan Balibisauni Balibisauni, Raspurkot 25 (150) March 2010 Dec Pyuthan Syanilekha Syanilekh, Chunja 40 (240) March 2010 Dec Hand Pumps 15 Bardia Dhadhawar, Baniyabhar Bardia ground Magargadi, Padnah, water Mohammadpur, 247 (1,371) Nov June, 2010 Rain water harvesting 16 Pyuthan Rain water harvesting Chunja, Pyuthan 52 HHs(276) 1 School (649) 1 SHP(12/day) March 2010 Dec Photo: A Rainwater Harvesting Jar in Pyuthan. Altogether 54 rain water harvesting jars have been completed in Pyuthan including 1 jar in SHP and 2 jars in a school. 11 hand pumps were installed in 5 programme VDCs of Bardia district. 9 new and 2 maintenance of GFWS and 3 new spring protections have been completed in These schemes directly provided water to people of 895 HHs, students of 3 schools and about 12 persons each day visiting a sub health post. CEHP Annual Report (Jan- Dec) 2010 (19) In collaboration with Swiss Red Cross

20 The District Development Committee (DDC) in the district is the official authority to approve and coordinate the use of water sources in the community. 21 water user committees (WUCs) and water sources were registered at the DDC's water source management sub-committee by the community members after the completion of the construction, so that the water systems will benefit in the future from larger maintenance budget for the DDC office. 3 days construction and fund management training for WUCs has been conducted once in Jumla, Pyuthan and Salyan where 52 members participated. The DCs also conducted 7 days training to 33 caretakers on water scheme maintenance. A technical consultancy to evaluate the water projects was carried out in April 2010 with the help of a foreign water consultant 2. He visited Bardia, Jumla and Pyuthan to observe and study water services and sanitation activities. He appreciated the extensive work carried out by the Red Cross in the area of water and sanitation, the community participation and the excessive linking and networking with the local administrative bodies for funds. He recommended to improve water quality aspects through regular water quality testing and also to improve the construction of the water source catchment area to ensure improved water quality. Regarding the sanitation services, he recommended that the CEHP needs to revise its subsidy policy for latrine construction and move towards modified Total Sanitation Approach. He further suggested that the subsidy for the toilets need to be stopped and that the community should have possibility to have a wider choice of latrine options promoted by the project addressing different needs and financial abilities as per the social status of a family. CEHP has taken up all its recommendation for improvement in future programme. Following feedback from the water consultant, Mr. Ramesh Bajgai visited Uttiseni Tarakhase WSS project of Seri VDC, Dailekh to observe NEWAH constructed water scheme. The objective of the visit was to find out the differences between CEHP supported schemes and NEWAH so that we could further improvement of spring catchment area of our schemes. During the visit he observed all structures of water scheme such as spring, intake, collection chamber, RVT; RVT with attached tap, tap stands, etc. He also observed Institutional latrine, utensil stand, washing platform and sanitation information plate. He found that the NEWAH water projects are having provision to use plastic sheets to cover intake in order to prevent flood contamination, they also construct check dam around the source and they also provide better and wider fencing around the source. These provisions will also be introduced in the CEHP water projects in future. Sanitation The KAP survey also showed positive changes in the field of water and sanitation. Now nearly above 90% in all districts of the program area people wash hands after defecation and before taking meal. Latrine coverage has also increased. People in the program areas have developed a habit of covering food, disposing wastes in proper place and the above most importantly that they need to wash hands regularly and keep toilets clean. Red Cross Saved Our Dignity I am Dev Bahadur GC, the headmaster of Janjyoti Lower Secondary School, Chunja, Pyuthan. One day, we were celebrating our annual day; one of the guardians raised the issue of toilet. It was reality that there was not any toilet. All teachers and students used to go to the jungle for urination and defecation. We felt shy and became speechless for some while but I committed to attempt for a latrine construction. Then after, being a secretary member of the school management committee, I called a meeting of the school management committee and we discussed about the latrine construction. This issue was challenging for us as the financial status of our school was so poor but we made the decision to request some of the organizations to get support for latrine construction. Then we approached Red Cross too. The Red Cross supported 2 sets of non-local material for toilets. The school managed skilled labour and their cost and students and guardians also contributed labour collecting local materials and constructing the latrines. Now, we don't go to the jungle for urination and defecation. Really, Red Cross has supported us to save our dignity. Many thanks to Red Cross. Community group members have constructed 2,838 latrines. Out of this, 2,026 families have constructed a sanitary latrine subsidized by SRC funds. 143 families have constructed a sanitary latrine without subsidy and 669 families have constructed pit latrines both of sanitary and non sanitary type. Only materials were subsidized, 2 Technical evaluation of the water supply options and sanitary latrines built between in Bardia, Jumla and Pyuthan districts Nepal ; Didier Boissavi, Nommo Consulting, 2010 CEHP Annual Report (Jan- Dec) 2010 (20) In collaboration with Swiss Red Cross

21 labour and local materials like stones, sand, aggregates had to be managed by the households. Some of the families who had received free materials from other agencies for toilet construction in the past were motivated to finally install and use them. Graph 1: Toilet status in the programme VDCs/districts by end of Bardia Salyan Pyuthan Jumla 0 Baseline Endline Baseline Endline Sanitary Toilets Any Kind of Toilets Access to sanitary latrines from the beginning of the project up to December 2010 increased to 36%, 54%, 48% and 39% HHs in Bardia, Salyan, Pyuthan and Jumla and access to any kind of latrines to 55%, 58%, 75% and 68% HHs in Bardia, Salyan, Pyuthan and Jumla. The end-line KAP survey showed that that latrine is regularly used by 94%, 94%, 91%, 92% of household members over 5 years of age in Bardia, Salyan, Pyuthan and Jumla respectively. The regular use of latrines is continuously promoted by the community members. CGs have declared 44 communities, Bardia (19), Pyuthan (7), Jumla (14) and Salyan (4), as Open Defecation Free (ODF) villages through a formal programme in the community. The main criteria for declaring ODF are that all households (HH) in the village have access to latrine, all HH members use latrines, feces of children are disposed in the latrines or buried into pit,, all toilets are clean and all HH members wash hands after the use of the latrine. The DCs of Bardia, Pyuthan, Jumla and Salyan provided NRs. 3,000/- as a reward to each CG who declared their village as open defecation free village. We are proud to declare our village "Open Defecation Free" I am Rupa Bohora (30 F) and live in Phalawang VDC of Salyan. I am the Secretary of the Navjyoti Samaj Sudhar community group. One day, we were reviewing the progress in our community. Our Community Facilitator (CF) shared that in our district not a single community has been declared as open defecation free (ODF) even though many villages had been declared open defecation free in other districts. Then we felt shy and committed to declare our village as ODF village as well as and we prepared a plan. It was really a challenging task for us as no household of our community (total 35 households) had a latrine. We organized a sanitation campaign for latrine construction. It was special campaign for two months. Then we found that 14 households had already constructed latrines. It was big challenge to construct the latrines in the remaining families as they were so poor. Then our CF shared the possibility of support from Red Cross for latrine construction and we requested Red Cross to help us. With their support the remaining latrines were constructed and we have declared our village as ODF village. We are really proud of being the first community to declare ODF village in Salyan. We all thank Red Cross for this support. The 11 th National Sanitation Week under the slogan "Initiation of local institution for the promotion of open defecation free area" has been celebrated by programme districts by organizing different activities such as rallies with play-cards, cleaning schools, taps and foot trails, demonstrating hand washing, constructing utensil stands and waste pits, organizing folk song competitions, organizing declaration programmes of open defecation free villages, broadcasting PHC messages through FM and distributing IEC materials. CEHP Annual Report (Jan- Dec) 2010 (21) In collaboration with Swiss Red Cross

22 The CG members also initiated various other activities on their own initiative. 1,046 HHs constructed utensil stands made by bamboo to sun-dry their utensils. 280 HHs dug waste pits to manage household wastes. Other communities were cleaning their footpaths, did road works and forestation. The combination of the health promotion (soft component) together with the hardware provision (water systems and sanitary latrines) has immensely increased the communities interest and impact in the villages. Overall, the CGs started to realise that they can achieve much more if they work collectively. Villagers are becoming more and more interested to join the CG's activities as they could see the benefit for their community through information, education and collaboration for software and hardware provisions. The shift away from only software input brought about a positive development. Result 2.4: The capacity of the community groups is developed towards self-reliance. Indicators: 5% of groups reach stage A of self reliance, 50% of the community groups reach stage B of self reliance, and 45% of the community groups move towards stage B Result analysis: A tool was developed to assess the capacity of community groups. An internal and external assessment of CGs was also carried out. The 4th internal assessment categorised 24.79% of CGs to A and 65.97% to B level for their status. Self-reliance of community groups In order to provide systematic input to the CGs, the programme developed a Community groups' capacity assessment tool, to be used on quarterly basis. It consists of 7 parameters and 25 Indicators. All CGs had carried out self-capacity assessment in Graph 2: Development of CGs capacity from CGs Internal Capacity Assessment 2008, 2009 & >=81 (A) >=51 (B) <=50 (<B) Self-reliance Status District Bardia Pyuthan Salyan Jumla Total % Total Groups 104 (104) 50 (50) 40 (40) 44 (44) 238 (238) 100 (100) >=81 (A) 12 (5) 21(4) 17 (7) 9 (1) 59 (17) 25 (7) >=51 (B) 70 (75) 29 (42) 23 (31) 35 (35) 157 (183) 66 (77) <=50 (Towards B) 22 (24) 0 (4) 0 (2) 0 (8) 22 (38) 9 (16) Table - 2: DC wise CGs' internal capacity analysis result of 2010 in comparison to 2009 mentioned in brackets. In order to enhance sustainability, CGs are registered as a civil society organisation with the VDCs of their district. During this period, 112 CGs (38 in Bardia, 32 in Salyan, 27 in Pyuthan and 15 in Jumla) were registered in the VDCs office. In the whole phase, 145 CGs were registered, which comprises of 61 %. Efforts continue to register particularly the CGs of Bardia. CEHP Annual Report (Jan- Dec) 2010 (22) In collaboration with Swiss Red Cross

23 In order to promote the CGs towards self-reliance, they are encouraged to achieve a minimum set of indicators, so that they can be called a model village. The CG may declare their community as a model, once they are registered as Community Based Organisation; develop a safe motherhood revolving fund, have a functional transportation system to health service; and are ODF certified. 8 villages (Jumla-1, Salyan-1 and Pyuthan-6) have been declared as model village in 2010 organizing a formal programme with the local authorities. Cooperation with partners/stakeholders The Jumla DC integrated food for work activities in the construction of the water schemes in Babira village of Tatopani VDC and Tallo Rokayabada village of Talium VDC. The food was provided by the World Food Programme to the DC who paid community people who were involved in digging channel for the water pipe line with rice as their daily wages. Coordination with local institutions such as the D(P)HOs, DDC, Division of Water and Sanitation and Sewerage, Medias (FM), PHC, Health/Sub Health Posts took place to celebrate special days, receive health services and distribute IEC materials. CEHP coordinated with ENPHO, UNICEF, NFHP, Geruwa Rural Awareness Association, Helping Hands-Bardia and Family Planning Office for IEC materials to provide all FCs, CFs and community groups. As recognition of NRCS services on sanitation, Tatopani VDC office allocated NRs. 100,000 for sanitary latrine construction. 90 sanitary latrines have been constructed with the joint fund of the VDC office and CEHP. Kabhra and Karagithi VDC office of Salyan also allocated NRs. 5,000 and 7,800 to provide prizes to the CGs that declare the village as ODF. Likewise, as recognition of NRCS services on water scheme construction, Phalawang VDC of Salyan allocated NRs. 50,000 for water scheme and Pimkhola GF scheme has been constructed with the joint effort. DDC Pyuthan also supported NRs to construct rainwater harvesting jars and 54 jars have been constructed with the joint fund of DDC Pyuthan and CEHP. Jan Akata sanitation group of Lamra, Jumla coordinated with District Education Office and got the support NRs. 10,000 for safe motherhood activities. DC Salyan coordinated with DHO Salyan and a CF got the chance to participate in reproductive health training. DC Pyuthan also coordinated with Women Network Committee and Sub Health Post, Raspurkot and some of the CG members also got chance to participate in HIV and Safe Motherhood related training. District Sanitation Monitoring Committee of Pyuthan monitored all ODF declared communities of Pyuthan during the 11th national sanitation week and declared the best community and first prize to Upallo Banchare of Dharampani VDC where Sri Ganesh community group has been working. Problems, solutions and recommendations The level of ANC in Jumla is still low compared to other programme districts, however institutional delivery is satisfactory. This situation indicates that the ANC drop out are possibly high. Thus, there is a need to further activate Action Members to make home visits to encourage women to go for at least 4 ANC visits. The PHC team will disseminate this situation to the relevant in the program VDCs and promote appropriate actions. The HFOMC in Jumla will also be encouraged to mobilise their members and the FVCHW to give more attention in this aspects during outreach clinic. Despite of satisfactory achievement on construction of sanitary latrines in the programme VDCs, the KAP indicated that it is low in Bardia and Pyuthan district. This situation will be tackled during follow up period through ODF and post ODF activities, so that adequate toilets are in the community. Interestingly also the uptake of simple latrines was below target in Bardia and Salyan. In how far the subsidized and more sophisticated sanitary latrines hamper people from building any kind of latrine at all, needs to be explored. Due to various strike and blockages some district level activities such as orientation to HFOMC members and water care taker training were postponed. 3 CFs of Bardia, 3 CFs of Jumla and 1 CF of Pyuthan and Mrs. Rupa Pandey (FC Bardia) left the job for better opportunity in other organization. This high turnover of well trained staff from the rural areas hampered the community level activities for some weeks. The DC took over the role of CFs and Mr. Shankar Bhattarai from CEHP was deputed to NRCS Bardia to maintain the momentum of the services. CEHP Annual Report (Jan- Dec) 2010 (23) In collaboration with Swiss Red Cross

24 The demand of community people for sanitary latrine through subsidy approach is so high which can not be solely met by Red Cross funds. The DCs are encouraged to coordinate with other stakeholders to obtain possible support. 2 days review meeting and 1 day promotional activities related to HFOMC in Tatopani, Jumla has not been carried out yet as health post in-charge are not giving priority and not managing time for these activities but programme is coordinating with health post and D(P)HO regularly. CGs registration process in Bardia became delayed as the VDCs authorities did not know about their right to register CGs in the VDC office or not. The DDC sent a circular to VDC offices to affiliate the CGs and process will hopefully start in Outlook for 2011 of WASH-PHC Component By the end of 2011 the project will stop the work with the existing 238 community groups. Thus 2011 is a phase out year where community facilitators will focus on the capacity building of the community groups to make the group leaders able to manage the groups completely by themselves and achieve full self-reliant. In follow up VDCs, registration of CGs in the VDC office and WUCs in the DDC office will have high priority, as well as declaration of ODF villages and establishing more safe motherhood funds and transport systems, so that many more villages can be a model village. With the start of 2011, the project will expand into new VDCs and two more districts (Jajarkot and Dang). Sanitation related activities will be carried out as per the 'National Sanitation Master Plan' which has been developed in 2010 and is presently about to be endorsed by the Government. The fulfilment of the plan will be done in entire coordination with the District WASH Coordination Committee (D-WASH-CC) and VDC Wash Coordination Committee (V-WASH-CC). Communities will be highly encouraged to construct the latrine and declare ODF community through Community Led Total Sanitation (CLTS) approach. For this, staffs and members of programme DCs will be trained on Ignition-PRA. Some public institutions i.e. schools, VDC offices and birthing centres will be supported to construct public latrines. Many water schemes including rain water harvesting system will be constructed. Only after completing the registration process of the water sources the construction process of WS will be started. The water quality of program supported water projects will be tested three times starting at the time of detailed survey (while doing the feasibility study ), at the middle of the project and after completion of the project. HIV and AIDS prevention will become integral part of the PHC component starting from A detailed framework has been worked out by the project. HIV and AIDS related activities will focus on migrants and their families. One PLHA in each program district will be recruited as staff to implement the HIV and AIDS related activities. It will be carried out coordinating with the District Aids Coordination Committee (DACC) and the local health facilities. The staffs including FCHVS of S/HPs will be oriented on HIV and AIDS referral mechanism to VCT centres. Programme will assist to expose PLHIV to form self-help group or link them to existing networks. PLHIV will be provided support for ART and CD4 count. Orphans and vulnerable children will also get educational and nutrition support. Staff PLHA and other PLHAs will be encourages to share their experiences and HIV related information to the community group members. PLHAs will also be oriented on life sharing skill. They will visit migrant families and do individual counselling, as well as providing condoms and special gift items to them. Partnership between CGs and local institutions - such as DDC, VDC, Health post and NGOs will be further promoted. CEHP Annual Report (Jan- Dec) 2010 (24) In collaboration with Swiss Red Cross

25 3) HIV and AIDS Prevention This programme is implemented in 6 districts (Jajarkot, Rukum, Salyan, Pyuthan, Rolpa and Jumla) and also integrated with 238 community groups of Water-Sanitation and PHC programme in Bardia, Salyan, Pyuthan and Jumla districts in the Mid-West region. The programme covers 110 follow up schools from the said districts. Objective 3: To reduce the vulnerability to HIV and its impact in the Mid West Region Result 3.1: School based HIV peer education programme to prevent further infections is consolidated and institutionalised. Indicators: 13,860 students in 6 districts are reached by peer education. 60 % of the follow up schools (110 schools) follow up schools developing annual plan, carrying out HIV activities and submitting reports to DCs as per annual plan. 10,000 students directly reached by IEC activities. Result analysis: 14,617 students (105% of target) in 6 districts were reached in this year. 76 follow up schools (115% of target) that are institutionalised HIV programme have submitted their reports of HIV activities to the DCs as per their annual plan. 9,014 copies of IEC materials (90% of target) were provided to the students, this includes IEC materials received from various stakeholders. School based HIV Peer Education (PE) The programme has been implemented in 110 follow up schools in 6 districts. This year also a lot of focus was given on institutionalisation of the HIV prevention and awareness programme in schools was characterised as the phase out year for the school peer education programme with hand over of the management to the DCs. 76 Schools out of 110 has institutionalized HIV program in Institutionalisation means that the schools incorporate HIV Peer Education activities in the annual plan of the schools, incorporate HIV activities in the J/YRCs annual plan, a system for replacement of graduated peer educators is in place; regular monthly meetings of J/YRCs happen; discussions on queries on a monthly basis are done; J/YRCs have their own fund to carry out minimum activities on HIV prevention and regular reporting of the school to the sub-chapter and DC is done. 4 Resource mobilization trainings for Teacher Sponsor were conducted in the programme districts where 70 TS participated. The training was conducted to generate ideas to collect local fund to sustain the HIV and AIDS peer education activities in schools after the phase out of the programme. Five programme district chapters organised an orientation meeting for DC, sub-chapter and J/YRC leaders to understand the concept of institutionalization of the HIV peer programme and the role of the DC after the phase out of the programme. 120 members from 5 districts participated in the meetings. As a part of the institutionalization process, the District chapters also carried out meetings with the members of the School Management Committee (SMC). Trained volunteers of DC conducted 101 meetings with SMCs. All meetings focused to sensitize the participants on the current situation of the HIV and AIDS in the nation, the impact of HIV and AIDS on the national development, public health and others sectors, the importance of a functional prevention program in the school level, and the role of SMCs in preventing further infections. The main aim of the meeting was to ensure the continuation of the HIV and AIDS activities in the schools as per J/YRCs annual plan. All 6 programme DCs organised planning meetings with the participation of 99 teacher sponsors (TS) in the respective programme districts. In the meeting, the TSs developed further understanding of the institutionalization process and they prepared an action plan for CFs of Salyan, Pyuthan and Jumla also participated in the meeting and they shared the HIV and AIDS activities to be conducted in 2010 in the CGs. The J/YRCs district assembly is an annual forum for school youth from NRCS. The assembly was held in 3 programme districts. 192 students from Junior and Youth Red Cross Circles of 60 schools participated in the assemblies to develop annual plans of the district level J/YRC Committee. CEHP provided token support and the youth themselves raise funds to carry out this activity. In the assemblies, the J/YRC presented their annual report CEHP Annual Report (Jan- Dec) 2010 (25) In collaboration with Swiss Red Cross

26 of various activities including HIV prevention carried out by them in the school and in the community during the year. Each of the J/YRCs also presented their annual plan that was compiled in the assembly as annual plan of activities of J/YRCs District committee for next academic year. The main components of the plan are HIV and AIDS prevention, First Aid, Disaster Preparedness, Membership Promotion, Sanitation, etc. 98 J/YRCs implemented HIV activities as per their plan. 437 peers were replaced among 58 schools to carry out effective peer education with 20 peer educators per school. Action plan from the schools and follow up The TS facilitated the development of annual plans on HIV and AIDS which is part of the JRC annual work plan. Sub-chapter or DC makes visits In order to monitor the implementation of activities. During this period the volunteers visited 101 schools out of 110 programme school for 163 times. 104 schools submitted their activities report to the DC. J/YRCs conducted quiz competitions and essay competitions in some Friday sessions as extracurricular activities. Queries discussions are carried out on a monthly basis in the schools. J/YRCs utilize their funds generated by membership fees for conducting different extracurricular activities including HIV activities. Some schools provided additional logistic support. J/YRC of Jeevan Jyoti Higher Secondary Schools, Rim Salyan collected a fund of NRS. 1, for the activities of J/YRCs by showing films on HIV and AIDS. The films were shown to 300 students and from each student Rs. 5 was received for watching the films. Similarly, J/YRC of Sarada Jana Kalyan Higher Secondary School has collected a fund of NRS 1,500 for its activities by showing a film Tikeka Tin Mantra related to HIV and AIDS. The film was shown to 1,500 persons (including students and community people) and from each participant NRS. 1 was collected. Trainings carried out by DCs The DCs of Salyan, Pyuthan, Jajarkot, Jumla Rukum and Rolpa organised 6 Refresher TOTs with participation of 106 teacher sponsors. During these trainings a review of their ongoing activities was done and ART services and PMTCT were also discussed. One PLHA was invited to the reviews and shared how he was infected with HIV and the effects of HIV and AIDS in his life. The DCs themselves organised 13 competitions (essay, drawing, quiz) on HIV and AIDS to reduce stigma and discrimination where 794 students from 104 schools participated. Furthermore, the DCs of Pyuthan, Salyan, Jumla, Rukum, Rolpa and Jajarkot arranged HIV and AIDS sessions with PLHAs in 39 schools for 2,951 students. 286 Interaction sessions were conducted by peer educators with participation of 3,722 students. 269 session/ discussion on queries were performed in participation of 7,150 students. The queries were received from the queries boxes. Information and education Altogether 9,014 students received IEC materials in the programme districts. IEC materials provided by CEHP were mainly focused on life skills, HIV/AIDS and Reproductive Health issues. Some materials were related to peer educators i.e. peer diary, batch, life skill guidebooks etc. CEHP supplied 5,000 Yoba Chautari (Quarterly publication of NRCS HQS related with queries and issues of HIV & AIDS) to the programme districts. Result 3.2: Further infections in the community in 4 districts are prevented through greater awareness and promotion of safer sex behaviour. Indicators: 80% of sexually active male population are using condom for safer sex. 60% of community people know four modes of transmission of HIV. Result analysis: A KAP survey revealed that 63.4 sexually active men always use condom in the service VDCs. 70.7% of Community people know four modes of transmission of HIV in Jumla, 67.5% in Salyan whereas only 41.5 % in Pyuthan and 39.4% know in Bardia. In total 49.3% community people know four modes of transmission of HIV. The both targets are achieved low. CEHP Annual Report (Jan- Dec) 2010 (26) In collaboration with Swiss Red Cross

27 Promotion of Safer Sex Behaviour CFs are continually encouraging and training the action member/action group members of HIV and AIDS formed by the WatSan & PHC component in 4 programme districts to effectively disseminate their knowledge on HIV and promote behaviour change at the family level. The 238 Action Members/groups of HIV and AIDS conducted 266 sessions in the community groups where 5,125 members participated. This year additional 60 practical condom demonstration sessions were also carried out with participation of 1,333 community people. In Bardia, Jumla, Salyan and Pyuthan 66 HIV and AIDS sessions were conducted involving PLHA in the community groups, where 1,850 people participated. The sessions were facilitated by the PLHA facilitator from Helping Hand in Bardia, Pyuthan Plus in Pyuthan, Sharada Plus in Salyan. The Sessions at Jumla were conducted by PLHA from Regional office of NAPN Plus Nepalgunj. These interaction sessions were found very effective in the CGs, because the community people have not seen PLHA before and a lot of myths surround in the community about HIV and AIDS were clarified directly with the PLHA. The community people realized that AIDS is a real issue and possibly approaching to their door. The PLHAs openly shared their story, often getting to know their positive status only after their spouses' death from AIDS after they had spent a lot for treatment before being diagnosed as HIV positive. The session also informed about available treatment services. After these sessions an increasing trend was observed visiting the VCT service by the clients in the districts. Effectiveness of this service has convinced CEHP that in future some PLHA may be employed by the project for the HIV programme. Condom Boxes installed in the bathrooms of CEHP office were refilled whole the year aiming to increase the easy accessibility of condom to staffs and visitors. The supply of condom is regularly maintained in boxes coordinating with DPHO Banke. In an average of 60 condoms per month is consuming from the condom boxes. People visiting CEHP are appreciating this initiative. Result 3.3: Access to information and services for treatment, care and support is promoted. Indicators: 94 PLHA supported for accessing services. 504 people referred to VCT. At least 1 Support Group in all 8 districts exist and the identified PLHA are linked to them. Result analysis: 81 (86.2% target achieved) PLHAs were financially supported this period. 464 (92% target achieved) cases were referred for Voluntary Counselling and Testing (VCT) during this year. Out of 8 programme districts in 6 districts (75%) support groups exist. There is still no support group in Jumla and Jajarkot districts. 21 PLHAs were linked to existing support groups in the 6 programme districts. Support to PLHA The programme also focussed on identification of positive cases, de-stigmatisation and linking positive people to existing services and self-help groups. 464 persons were referred to VCT centres for testing their HIV status. 81 PLHA were financially supported to go to Dang or Nepalgunj for testing CD4 count and for fetching Anti-retroviral drugs. This support has been much welcomed by the PLHAs who find it very difficult to pay for the transport to get their life-saving drugs on a regular basis. 21 PLHA are linked to existing support groups in their districts. The programme also started the greater involvement of positive people in capacity building and during international days and public events. Life Sharing Skill training for reduction of stigma for PLHAs was conducted in Pyuthan district. 13 PLHAs participated in the trainings. For the first time the PLHAs got a platform to share their problems. They were found to have very poor knowledge of HIV and AIDS and ART which resulted in a deep rooted feeling of self discrimination. They had the thinking that disclosing their status with more people discrimination will increase. The training was able to provide the basic knowledge of HIV and AIDS including ART and lots of discussion was held to overcome self discrimination and discrimination from the community. They were also made aware about rights and responsibilities of PLHAs. Somewhat the feeling that being HIV positive is not the end of life; it is the start of courageous life has been developed in them. CEHP Annual Report (Jan- Dec) 2010 (27) In collaboration with Swiss Red Cross

28 Photo: A positive person shares the story to CG members. I am taking lots of hopes for life My husband is in India. He did not know that I am infected with HIV. If he knew that, he would not come home from India and if came he might kick me out from the house. I always think what to do if he kicked out me from the house. And always I come to a conclusion of committing suicide. Now, after participating in the "Life Skill Sharing Training for PLHA for Reduction of Stigma" organized by Pyuthan Red Cross, my thinking has completely changed. I knew something about HIV and AIDS during my HIV test from the counsellor in the VCT mobile camp organized in our community. Until the training, for HIV meant for me death and a misery of life suffering from various diseases. My son of one and half year is also infected. Lacking enough information regarding HIV and AIDS, I used to see darkness everywhere ahead. Till now, nobody in my house and neighbours knows that I am infected. They do not know that I attended this training. Every time whenever I had to go to Nepalgunj for CD4 count, I pretended to go for a different work to make them not to worry about my status. I did not share to anyone fearing the possible stigma and discrimination from them. In this training I got the chance to hear the experiences of different friends and knew that I am not alone with my problems and fears. I got the information about rights and responsibilities of PLHA and realised our own roles to minimize discrimination. More importantly, I knew that I can live longer following healthy behaviour and life style. I learnt much from the others experiences. I found much difference in my thinking towards HIV and AIDS. Looking ahead I am confident enough to counsel my husband and make him go for a HIV test when he returns to Nepal. I will also share with him about HIV & AIDS and about the friends I made in this training, how they are living positively. After telling my husband about my status I will disclose my status and actively involve in reduction of stigma and discrimination. This training completely eradicated my thinking of suicide and I am returning with optimism to live a better life. A 36 year old lady Pyuthan district CEHP Annual Report (Jan- Dec) 2010 (28) In collaboration with Swiss Red Cross

29 National Condom Day & World AIDS Day 16th National Condom day was celebrated with the theme of Access to Condom for dual protection with the various events in Nepalgunj on October 30, A rally with a folk band moved around the main areas of Nepalgunj city. Participations from more than 20 organizations working in HIV/AIDS and RH (including all CEHP staff) as well as local authorities participated in the rally. After the rally, condom blowing and an open quiz contest on HIV and AIDS were conducted. An information corner was also established at the Nepal-India Boarder and through the information corner 500 IEC materials and 300 condoms were distributed. The 23rd World AIDS Day was organized with the slogan of Universal Access and Human Rights in all programme districts and Banke with the initiation of DACC and the participation of various organizations. All programme DCs organized various activities i.e. rally with health message, demonstration of condom use, poem competition, distributing IEC materials etc. HIV and AIDs related radio messages have also been broadcasted through the local FM radio. Various events were organized in Nepalgunj city and other places at Banke districts. Rallies were organised in Nepalgunj and Kohalpur. Participants in rally carried play cards and banners, distributed IEC materials (brochures and condoms to the pedestrians). Attention was drawn by a folk band, a decorated car with posters and blowing condoms, street dramas and condom blowing competition and open quiz at the centre of Nepalgunj where the rally was ended. An information corner was established at Jamunaha, Cross Boarder between India and Nepal for 5 days from December 1 to 5. Through the corner IEC and condoms were distributed. Street dramas were conducted in other four different places (Jamunaha Borders, Kohalpur, Khajura and Rimjhim Chowk. There was participation of more than 20 GOs/I/NGOs. Blood donation program was also carried out in the premises of Bheri Zonal hospital on the day. Throughout the whole year 15 street dramas on the theme of stigma and discrimination towards HIV and AIDS were shown during local events in the programme district and through the drama 3,626 people were reached. HIV Mainstreaming in other project components Information desks were established during 6 surgical eye camps (Jajarkot 1, Surkhet 1, Bardia 2, Dolpa 1 and Dailekh 1) to disseminate the HIV/AIDS and primary health care related message. A Flash board about HIV was placed in each eye camp; 3,190 IEC materials (including 2,120 leaflets, 120 posters, 200 pocket diaries and 750 Yuba Chautari) and 1,500 condoms were handed out to eye care patients and their relatives. During the Surkhet eye camp HIV/AIDS related video was shone daily in the evening for three days where 1,108 people participated. HIV prevention has also become an important part in the PHC programme through the CGs and PLHAs are extensively integrated sharing their life in the CGs and schools. An in house orientation on the HIV and AIDS programme and work place policies was conducted. The objective was to familiarize the CEHP team with workplace policies of various organizations and the draft workplace policy of the NRCS. The policy will come into effect once the NRCS Central Executive Committee endorses. Cooperation with partners/stakeholders The programme collaborates closely with other organization working in HIV and AIDS e.g. DPHO, Banke, Nagarjun Development center, Banke, Western Stars, Nepal, Institute of Community Health (ICH), Navakiran Plus and UNDP. 5 programme DCs organized a coordination meeting with 109 participants to seek cooperation and collaboration from the line agencies and also to brief them on the HIV/AIDS prevention project. The CEHP also regularly participates in the DACC meetings in Banke and maintains close links with NGOs managed by PLHIV. UNDP supported HIV and AIDS programme for migrants and their families is going to terminate in Rukum from February 2011 onwards. Save the Children/Global Fund supports a HIV prevention programme among migrants in Pyuthan Red Cross is stopped from September Problems, solutions and recommendations The KAP revealed that the practise for safe sex using condoms is still low in programme districts. Awareness about 4 modes of transmission was found comparatively low in Bardia and Pyuthan. The project will continuously encourage DCs to integrate collaborative efforts to increase access to condoms and also mobilise the existing volunteers to disseminate HIV prevention messages. Based on the still low use of condoms among men and the fact that the prevalence of HIV has continuously CEHP Annual Report (Jan- Dec) 2010 (29) In collaboration with Swiss Red Cross

30 increased among housewives and migrants, the DCs requested to scale up the HIV programme targeting community youth, housewives, migrants and potential migrants at risk. These matters were discussed and interventions were included during the planning meeting in August 2010 for the next phase The timely replacement of trained PEs and teacher sponsors, who leave the school, is a challenge which affects the institutionalization of the programme in the schools. Follow up from DCs and the SMCs is essential so that the knowledge transfer from PEs in higher grades to new PEs in lower grades is done each year. The annual plan of the schools needs to foresee time and a budget for this PE training. Supplementary training needs on life skills and Adolescent Health was expressed by the TSs to give them more innovative ideas for the monthly sessions/events. Not all schools do have sufficient resources to organise the HIV activities. The programme focussed on providing local fund generating ideas providing resource mobilization training to teacher sponsors in the year. PLHAs of the programme district do not have even the basic knowledge of HIV and AIDS resulting in a feeling of self discrimination and self-humiliation. Regular meetings with the PLHA group was are necessary to develop self efficacy or overcoming self discrimination. The programme plans to train more PLHA in the next phase from the districts where support groups exits. There are no support groups in Jumla and Jajarkot as there is no openly exposed. Since the HIV programme component does not operate with a big budget in this phase, the DCs are less interested to work in this area. They feel overburdened to follow up the sustainability without getting much financial benefit. Continuous result orientated motivation is done by the CEHP team. The facts that annual assemblies were held only with own funds has boosted the motivation of the DCs. Such examples need to be continuously highlighted, also in the Chetana bulletin. As a part of Sub-chapter strengthening plan, SCs are continuously motivated to participate in the SMC meetings, encouraged to organise day s celebration and competitions. Gradually, the J/YRCs are also affiliating them with the SC. CEHP will keep monitoring the DCs annual plan to ensure that they devote sufficient priority to the HIV programme. The continuation of the JRC assembly will certainly help the DCs to promote institutionalisation of HIV program at school level. Outlook for 2011 of HIV component HIV programme will focus on community level activities integrated into the WASH-PHC component of the project from the next phase. Please refer outlook of the WASH-PHC. 4) Organizational Development (OD) The DCs are the main partners to implement the services to the beneficiaries. Thus, their capacity building is key part for the CEHP. CEHP helps assessing the organisational capacity of the DCs through a tool called Institutional Capacity Analysis Process (ICAP). Based on the outcome of the 10 parameters through 116 indicators, each DC develops an action plan on how to minimize their weakness and convert their opportunities into strengths. The DCs were encouraged to this process form 2010 onwards on their own. As per need, CEHP also offers capacity building for resource generation, programme management skill development, proposal writing support, etc. Initially OD was working almost in isolation, over the past two years OD is integrated as a cross cutting and need based issue in all other programme components and for DC to achieve better performance. Earlier OD plans were also reviewed in January 2010 to develop OD as a need based support to program components and the DC. Objective 4: To strengthen the NRCS organizational and management capacity towards becoming a well functioning NRCS Chapter Result 4.1: ICAP is institutionalised and Plan of Action of the Chapter based on ICAP elements is developed and implemented. Indicators: DCs ICAP overall status improved by 25% by 2010 DCs planning and implementation status improved by 40% DCs good governance status increased by 30% CEHP Annual Report (Jan- Dec) 2010 (30) In collaboration with Swiss Red Cross

31 DCs office management status increased by 45% Result analysis: Initially OD was working almost in isolation, over the past two years OD is integrated as a cross cutting and need based issue in all other programme components and for DC to achieve better performance. The above Indicator was for During the annual performance review of 2009 the OD plan was revised. The revised plan of OD may not meet with the result and indicator mentioned above and can not be analyzed and compared with the indicators mentioned above. No District Chapter reviewed their ICAP plan and even 3 chapters (Banke, Dolpa and Mugu)did so far never conduct an ICAP assessment at all. These chapters could not allocate time to organise the ICAP workshop. However, in 2010, 6 subchapters carried out an ICAP. Early 2010, OD introduced input mapping and identified areas for OD input need for each unit. Based on the mapping OD supported all units in an integrated approach which has been apparent as very positive and enhancing the quality of all programme components. As an integrated or cross cutting matter, OD has facilitated the following major activities for 2010: Capacity building DC and CEHP Development of ICAP plan in remaining districts chapter and review of 3 year ICAP existing plan by DCs Training on Resource Mobilization (RM) at DCs Publication of Quarterly Bulletin Need based Support/facilitation for capacity building The CEHP provided support for capacity building activities of the district chapters and each unit of the CEHP as per their need. The OD unit had prepared and facilitated simple steps for CGs vision setting following appreciative inquiry approach, provided regular follow up to register WUC, CGs registration process and SCs mobilization and revised end line KAP forms in consultation with the PHC team and relevant authorities. OD helped to verify the capacity of the community groups; monitored the open defecation declaration events conducted by CGs; provided feedback to the different units for quality improvement. Based on the action plan developed in 2009, inputs were given to the sub chapters to strengthen their capacity to make them more responsible towards implementation of Watsan and PHC activities. For this purpose, OD carried out an orientation to the SCs on how they can be further responsible to implement development (WatSan-PHC) and other activities effectively. The OD unit also facilitated Institutional Capacity Analysis Process (ICAP) targeting for 6 Sub-chapters in Bardia and Jumla districts and developed a capacity building plan with the SCs. OD coordinated with NRCS HQs and district chapter Banke to integrate VCA in existing annual action plan of community groups. OD staff also supported the institutionalization process of the HIV programme, supported to design IEC materials and monitored DCs performance during district visits. The OD supported eye care unit to prepare structure of volunteers mobilization during cataract surgical camp to strengthen the collective effort, to revise Cataract and Trachoma related brochures, to finalize eye care related radio message, support to prepared a simple format of proposal to seek resource form local VDCs. Following the request of NRCS Bardia, Mr. Hari Subedi supported DC to develop 3 days schedule on Gender Sensitization Workshop. He also oriented the DC's facilitators on content of each session to prepare them for facilitation. There were 22 members (8 female) participated from sub-chapters, Red Cross Action Team and district chapter. The DC received financial support from Women Development Unit of NRCS HQ for the workshop. OD also helped to DCs to generate local resource for better achievement and ensure meaningful participation from local stakeholders. During this period NPR 2.35 million was raised by the DCs for eye care and Water and Sanitation related services. This year OD also contributed to organize planning workshop and annual review meeting; and to finalize project document for phase It also carries out Capacity and Performance assessment of CFs; analysed and shared the results of the study to the concerns. OD developed new district selection criteria to start up Total Sanitation and Hygiene related activities. 8 NRCS district chapters have submitted information based on the CEHP Annual Report (Jan- Dec) 2010 (31) In collaboration with Swiss Red Cross

32 questionnaire which were analyzed and Dang and Jajarkot was selected to implement the project. OD also supported to select new VDCs selection process in existing WatSan Program districts. Following a request from Bardia, Surkhet and Dailekh, CEHP facilitated Sanitation sensitization sessions during JRCS assembly in Bardia and Surkhet; CEHP supported Dailekh DC to develop a concept paper on eye care programme to be submitted to DDC for fund raising. It was my first successful proposal! Mr. Prakash Shahi - Incharge of the community Eye Care Center (CECC) in Dialekh committed to do additional fundraising for the CECC to meet the expenditure. Mr. Praksah Shahi and his team discussed with VDC secretaries and requested to help the CECC which has been providing eye care services in the district since its establishment and also informed them that the donor is phasing out their support. The meeting concluded to submit a concept paper to be presented in the upcoming DDC council meeting. The NRCS Chapter, CECC and CEHP jointly prepared a concept paper submitted in the meeting by Mr. Praksah. As an output, each VDC secretary committed to support Rs. 1,000 in this fiscal year. There are 51 VDCs in the district. NRCS chapter again requested all through written letter and was able to raise NPR. 17,000 in the year. 'It is not a big amount but in the context of the district, there was no practice to raise funds from the VDCs for such types of service' Mr. Prakash explained. It was my first success. It encourages me to take further steps to regularize fund raising and start up a new fund raising plan to sustain the CECC. I would like to thank to NRCS CEHP for valuable support to make it possible. Training on Resource Mobilization at DCs The resource mobilization training was integrated with the institunalization process of HIV & AIDS activities in the annual plan of schools. 4 workshops (out of 6) were facilitated in districts to achieve institutionalization. As a result schools have been generating fund applying various methods. Uma Maheshwori School Pyuthan has collected amount of Rs. 20,000 through a Deusi Vailo local concert during a festival. Similary Bhubhaneshwori Secondary school Pyuthan has collected Rs 80,000 for J/YRCs Assembly from VDC, local NGOs and local market. Bal Bikash Secondary School in Jajarkot has collected about Rs 40,000, Sarada higher secondary school, Salyan also collected about 60,000. Most of the schools are collecting seasonal grains from the students and has started to charge minimum amount Rs 5 to 10 from each students during admission and carry out its annual activities. Publications and information dissemination CEHP continued to publish the quarterly publication of Chetana (Consciousness) Bulletin since 2004, for disseminating information about the project, district chapters and the Red Cross movement. The bulletin mainly covers experience sharing, success stories, changes and lessons learnt from the communities and chapters and beneficiaries. All programme units provide support and materials to publish this bulletin. Website management The CEHP s website was regularly updated. Human Resource Development A new position of Deputy Programme Director was filled up with the recruitment of Mr. Deependra Chaudhari in the beginning of year of Mr. Chaudhari is having public health background and has worked for the government health services in the past. In order to upgrade skills and knowledge of the staff members of the CEHP they have participated in various trainings programmes as following: Mr. Dependra Chaudhari and Mr. Badri Shrestha participated in 1 day workshop of Strategic Planning for eye care service of Nepal organized by NNJS; Mr. Pradeep Gautam and Mr. Resham Khadka (Wat-San) participated on 7 days course on Community Driven Sustainable Development organized by Bala Vikasa, India; Mr. Pradeep Gautam participated on 8 days training on Comprehensive and Accelerated Sanitation and Hygiene Promotion organized by UNICEF; Mrs. Asha Shahi and Mr. K.L. Bajpai participated on Front Desk Handling Skill (2 days) training organized by CEHP Annual Report (Jan- Dec) 2010 (32) In collaboration with Swiss Red Cross

33 Standard Icon Kathmandu; Mr. Amulya Vaish participated on Strategic Financial Management for NGOs, managing for financial sustainability (3 days) organized by Mango training centre in Dhaka Bangladesh Mr. Bharat Rijal participated HIV & AIDS workplace policy organized by NRCS HQs. The participation of the staff members and volunteers in the various training and workshops has enhanced their motivation level and professional performances such as facilitation, presentation, leadership skills, etc. Regular in-house presentations are done. Knowledge exchange with other projects To bring effectiveness in running programme, capacity building of related programme staffs and volunteers, SRC organize exchange visit of Nepal Red Cross programme relevant staffs and volunteers in Tibet Red Cross to make exchange of leanings between two implementing partners. A team of 6 personnel from CEHP (Mr. Lalit Jung Shahi- Convener of CEHP, Ms. Narbada Sharma-Vice Convener, Mr. Kamal Baral-Programme Director, Mr. Badri Shrestha -Sn. Programme Officer-Eye Care, Mr. Raj Kumar Kshetri-Programme Officer-Wat/San & PHC, and Mr. Bharat Rijal- Programme Officer-HIV Prevention) visited Tibet for a week. In the Part of water and sanitation the team observed open water systems, gravity fed systems, Hand dug-wells at Gyatso, Putoe, Lhaste and Sakya as well as a school bathhouse in a primary school. For Gravity Fed system, stone machinery tanks have been constructed and green houses have been built to protect the taps from freezing water as well as to grow the vegetables. Springs were covered with the strong plastic sheet to protect form the flood water as well as other contamination. It's also interesting that no fund has been allocated to VHC by the government. During this visit, meetings were held with Tibet Red Cross in Lhasa, Shigatse Red Cross, Shigatse Prefecture Health Bureau and Women federation in Shigaste. The representatives of NRCS CEHP shared the activities of Nepal Red Cross Society and CEHP in those meetings. Under health promotion project, Village Health Committees (VHCs) have been formed to carry out village level activities and they were trained on hygiene, mother health, child health and first aid in township level with the help of Swiss Red Cross staffs. It's interesting that these are one/one day trainings. Mr. Kamal Baral visited Switzerland to join SRC International Workshop organised by SRC HQs. The aim of the workshop was to discuss on the International Cooperation Strategy and its implementation; revise health policy and to appraise partnership cooperation with international cooperation. Mr. Baral also visited the IC department and has meetings with various authorities on project issues and future programmes. A separate meeting was also attended of eye care projects team of the 5 countries from Asia and Africa and has presentation and exchanges on various sections of the services. Internal capacity building of CEHP staff/knowledge management During this year, the project made an extensive effort to interlink all project components. Annual Review of 2009 and Planning Meeting of 2010 as well as program orientations of all components was conducted jointly with Wat- San & PHC, Eye Care, HIV prevention and OD in Nepalgunj and all programme districts. The inter-unit sharing within the CEHP was continued and regular staff meetings held where experience is exchange and specific capacity building took place (NRCS Gender policy by Hari Subedi, HIV & AIDS work Policy by Bharat Rijal and Total Sanitation by Pradeep Gautam). At the DC level, the project management sub-committee members are sharing responsibilities and exchange ideas. The CEHP supported staff members are also involved occasionally in other services of the DCs and thus increase their skills and know-how. Capacity building of other organisations (given by CEHP staff) Mr. Hari Subedi of OD facilitated 3 days course on Conflict Management as requested by Sagarmatha Chaudhari Eye Hospital Lahan, Siraha and conducted an orientation on NRCS. Mr. Ramesh Bajgai (sub-engineer) provided technical input to NRCS Banke to design the rainwater harvesting tank and monitored its technical part during construction. Mr. Deependra Chaudhari and Mr. Resham Khadka co-facilitated in two days review meeting of HFOMC, in Pipladi Health Post of Kanchanpur and Kamdi health post of Banke and Mr. Pradeep Gautam participated as an observer in the training of Sitapur SHP, Banke organised by NFHP II Nepalgunj. On the request of NFHP, Mr. Deependra Chaudhari and Mr. Resham Khadka facilitated the HFMSP training at Sitapur SHP and Nepalgunj HP of Banke. Mr. Resham Khadka provided the assistance on District ToT on HFMSP programme of Jumla. Likewise, Mr. Pradeep Gautam and Mr. Resham Bahadur Khadka supported NFHP to carry CEHP Annual Report (Jan- Dec) 2010 (33) In collaboration with Swiss Red Cross

34 out 3 days orientation to HFMOC members of Srigaun PHC, Dang. Mr. Deependra Chaudhari and Mr. Raj Kumar Kshetri were involved in the planning, designing and proposal writing process to SRC for Urban Health and Waste Management Project in Nepalgunj together with the Banke DC. Photo: HFOMC orientation in Jumla. Cooperation with partners/stakeholders Since the last year a lot of efforts were made to create new partnerships. Successful partnerships have been created with, Wat-san Division office Pyuthan, VDCs of Jumla and Pyuthan, DHO of project districts, Community Forest User Committee of Bardia, GRAA of Bardia, Himalaya Eye Care Foundation, UNDP, FPN Nepal, Contraceptive Retail Sale, Pyuthan Plus, National Trachoma Programme, NFHP, ADRA, NNJS and various eye hospitals and ophthalmologists in the Mid and Far West. A lot of support has been received from the different partners in cash, kind, IEC materials and technical expertise, which is much appreciated by the CEHP. Problems, solutions and recommendations Further effort is needed to promote OD as a core part of the DCs development, so that the DCs focus on their organizational development. HQ also has focused in its Five Years Development Plan ( ) to establish a system to enhance the capacity of the district chapters. Some of the DCs are repeatedly changing the OD related activity schedule. This has made it difficult to conduct planned activities in time. Banke, Mugu and Dolpa DCs still lack the baseline data of ICAP, and further attempts will be made to do it in all DCs in the region. It still remains a challenge for the OD unit to make the DCs realize that capacity building is one of the most important aspects of their institutional development. Since most volunteers from the chapter are nonprofessionals they consider input to infrastructure as main criteria for OD. The development of the professional capacity among volunteers is a basic requirement in order to be compatible to other development agencies and competitive when applying for tenders. CEHP will continue to change the thinking of the volunteers CEHP Annual Report (Jan- Dec) 2010 (34) In collaboration with Swiss Red Cross

35 and to develop their professional as well as networking skills as well as ensure that they implement the learnt into practice. Competition among Partner National Societies or other donors who work with the same DC is a major problem to be overcome. Richer National Societies with big projects get more attention than smaller ones (like SRC). Effective coordination and communication is necessary to avoid overlapping/duplication of resources from various projects for capacity building and project implementation. Outlook for 2011 of OD component OD component will remain active to strengthen the capacity of the DC and its volunteers with various approaches in line with the 6 th Development Plan of NRCS. The unit will provide input to strengthen management and fund raising capacity of the DC with various inputs; support writing proposals to obtain projects, provide technical facilitation for capacity building activities, etc. In 2011, a series of HFOMC strengthening activities will be facilitated targeting the program VDCs and enhance linkages with the community groups. Public Health in Emergency will be introduced in WASH & PHC program implementing district chapters to ensure immediate action during epidemic outbreaks and other health emergencies. CEHP will provide technical backstopping to develop contingency plan and its implementation in coordination with NRCS HQs. In 2011 OD will continue its support for all units of CEHP to do mini study, surveys, IEC development, guideline development, curriculum revision, etc, as per need. Transversal themes Gender CEHP continuously maintains a gender concern in all areas. During the development of all policies and manuals gender sensitivity is maintained at highest level. In the field more focus has been given to women s empowerment providing equal opportunity on leadership in community groups, ensuring their access to services on safermotherhood and reducing the burden on females in relation to water and sanitation. CEHP has trained one of its staff to national level master trainer on Gender. He provides gender related support to the DC and other direct partners. The Gender status were found low in most of DCs while facilitating ICAP in the past and now the Gender status is those DCs were found better. He has carried out sensitization workshops to the staff members at the CEHP. The vice-coordinator at CEHP itself is the female among 7 male members and plays important role on decision making. In overall within CEHP, it is still a very low number of female staff at all levels of management positions. Only at grass root level among CFs is an equal rate of male and female facilitators. All other areas are clearly male dominated. Even though the CEHP gives recruitment preference to females, it is hard to recruit female staff members because of the highly mobile nature of the work. Still many women are not allowed to travel extensively and stay away overnight, which is a major bottleneck to female recruitment. At the grassroots level, each of the programme VDCs for Wat-San and PHC has got a male and a female facilitators, and each of the group consist of at least 50% female members. Most of the group leader and action members are female in the community groups. However, there is very poor ratio on gender balance as regard to the teacher trainers on HIV and AIDS programme. This is basically because of the stigma and low population of female teachers in the programme area. While developing peer educators at the schools, gender balance is always maintained. Do no harm CEHP maintains the do no harm approach by being transparent and using participatory processes. A transparent well being ranking was done in the CGs and the results are publicly announced in order to not discriminate against. During the selection of water sites and selection of the beneficiary HHs, the CG members determine who should be prime beneficiary (e.g. in Pyuthan only 30 HHs have received a rainwater tank out of 84 HHs. The community members have determined who will get the tank.) Decisions are noted down by the CG members in the CG minute book. However, despite their direct involvement in beneficiary selection, some HHs and groups within the community keep complaining why they did not get a share. Thus, further attempts were made raise fund also at the local level to meet the need of the community. This made possible to obtain NPR 1 million (50% cost) from CEHP Annual Report (Jan- Dec) 2010 (35) In collaboration with Swiss Red Cross

36 DDC to support almost all HHs with the tanks. The poor and most vulnerable are attended as priority by the services of the project and special support is provided through poor patients' fund. Support for the PLHA is provided from all programme districts without any discrimination to any persons approaching to DC or CEHP if unable to afford transportation to access ART or CD4 count. Uncoordinated fund flow in the program area through many NGOs has posed a challenge to the self-help promotion principle. People are more interested to receive hardware facilities. In this context, it is still challenging to interest DCs in the software approach for self help. After the peace process in Nepal the NGOs are mushrooming. Many donors support local NGOs who can be established very easily. The project steers the intervention very carefully to keep to the mandate and to not double efforts.. HIV mainstreaming Please relate to page 27. Linking relief, rehabilitation and development (LRRD) CEHP team members received LLRD sensitization orientation from the Programme Director and also from the PC from Swiss Red Cross during her visit to project. Mainstreaming of LLRD is already a part of the project as the WASH PHC and Eye Care team is already in action during emergencies to provide immediate health relief. A team from CEHP provided active support during epidemic outbreak of diarrhea in Jajarkot. As a regular member of the district health sector service the eye care team also provides emergency eye care services as team members during flood and other disaster in Banke and Bardia districts. CEHP also provided support to Bardia, Salyan, Pyuthan and Jumla DCs to develop capacity to carry out Vulnerability and Capacity Assessments (VCAs) of the CGs. The VCAs will help to identify risks and to develop a risk reduction plan in the communities. CEHP in coordination with NHQs and NRCS Banke Chapter supported DCs to carry out VCA for 10 CGs. The CGs integrated VCA actions into their annual activities. Good governance The project transparently disclosed all funds and labour contributions invested by the various stakeholders and beneficiaries on public hoarding boards in each village. This approach fosters good governance as well as prevents conflicts. However, it is still challenging for the DCs to exercise a professional and participatory approach in the programme/project management. Most of the time classical management approach and internal politics create a significant interference to achieve results. Conflict sensitive Programme management The security situation of the country is still fragile, agitating activities such as road blockage; Bandh, etc. are directly affecting the CEHP and DC level services. Compared to the years before, the effects are less, but still prevailing. CEHP is constantly disseminating skills on conflict management for peace and harmony, and has been successful to promote techniques of conflict management which are used by CEHP team members and the NRCS volunteers. Consultants and Visitors Mr. Krischan Makowka, a student researcher from Germany stayed with CEHP for around 3 months since March to do a masters study on Water Quality of the projects carried out by CEHP. Mr. Didier Boissavi, a consultant from SRC paid visit in April to CEHP projects to carry out a technical evaluation of the water projects. Results are mentioned in section Water and Primary Health care, page??? In the presence of Mrs. Monika Christofori-Khadaka, Programme Coordinator of SRC, Mr Gunaraj Shreshtha, a consultant from Development Network (D-net) facilitated a three day planning workshop in August in Nepalgunj to review the previous performance and plan for next three years ( ) followed by preparation of a project document. The Executive Director and Director of Health Service Department from NRCS HQ, representative from Regional Health Directorate Surkhet, representatives from FBEH, members of CEHP steering committee, representatives from all the NRCSs Chapters of mid western region, Coordinators and In charges from CEHP Annual Report (Jan- Dec) 2010 (36) In collaboration with Swiss Red Cross

37 CECCs, Field Coordinators of the programme districts and all the staff members of CEHP were participated in the workshop. In the leadership of Mrs. Beatrix Spring, a film team from SRC HQs visited Dolpa in August to make a fund raising film. They had to face serious difficulty to reach Dolpa because of bad weather. The SRC President Prof. Dr. Rene Rhinow, with his wife and the Head of International Department of Swiss Red Cross, Mr. Martin Fuhrer visited SRC supported projects in the vicinity of Nepalgunj in November. They visited Bardia and Banke to observe eye care, PHC, HIV Prevention and the DRR project. Finance The total expenditures of CEHP in the field during January December 2010 were 32,187, NPR (equivalent to CHF). Project audit of 2009 was carried out by External auditor AJJ and Associate Chartered Accountants, Kathmandu. The internal and physical audit for the year was carried out by the Internal audit team of NRCS HQs. Mr. Amulya Vaish, Senior Finance/Admin officer visited Pyuthan, Rolpa and Surkhet in order to give further inputs to improve store management and account keeping to district chapters and CECCs staffs. He also visited Janakpur to support in preparation of financial reporting formats, account codes setting in software etc in the CECCs which are supported and extended by SRC. Mr. K. L. Bajpai, Finance/Admin Assistant also visited to Jajarkot and Surkhet to retrain the CECC In-charge on account and store keeping management. Conclusion The year of 2010 was a very successful period for CEHP. Political and security situation affected the services of CEHP less than in previous years. Staff members and volunteers worked effectively in the favourable environment. The services from the CEHP are directly reaching the people in need in difficult to reach and remote areas. In the communities, CEHP works with and for the most vulnerable, dalits and women. The RABB survey showed that the eye care services have made a significant impact in the Bheri zone, reducing prevalence of avoidable blindness by 50%. Expansion of cataract surgery from the Surkhet Surgical Centre was additional breakthrough to bring the surgical services to the needy. There are still unserved areas in the region and regular availability of eye surgeon for the project in future will provide further opportunity to expand community services to these areas. Water-Sanitation and PHC component is becoming more and more community transformation approach. These services are getting recognition and resources from the local bodies like DDC, VDCS, DHO, and various other district and local level agencies as sustainable development organisations. The evaluation carried out by the external consultant shows that the water schemes and improved sanitation has been most beneficial to the community to improve their health and social status. A great impact has been also realised in the networking. Because of the successful water and sanitation schemes, the Red Cross has gained much recognition and funds and is also becoming more and more open to include other collaborators gauzing strengths of collaborative effort for change. Involvement to strengthen HFOMC was also a sensible action of the project for the community. All DCs supported to raise fund for the community groups for various development activities. Promotion of Community Led Total Sanitation has brought a strong move to declare communities and villages as ODF. The government agencies and local NGOs have also contributed in this move. Red Cross DC has also got further recognition as one of the main contributor to the community for sanitation and drinking water in all 4 programme districts. Construction of Rainwater harvesting jars in Pyuthan has already established a very positive image of Red Cross among the local development bodies that it reaches the real needy. In the programme VDCs of the CEHP, there were no situations noted as health emergencies, indicates that the PHC component has very effective intervention services to improve the sanitation in the communities.. The sustainability of project components (e.g. the management of the CECCs and the institutionalisation of HIV in the DCs and schools) still remains a challenge and requires further motivation and input, but it has started to come a good way. CEHP s firmness in proceeding with the handing-over made DCs realise their potentials and CEHP Annual Report (Jan- Dec) 2010 (37) In collaboration with Swiss Red Cross

38 skills. The handing over also requires flexibility from the CEHPs side to accept the modes of continuation as set by the DCs. In how far this involves a compromise in quality service provision still needs to be seen. DCs ability to manage projects on their own was boosted through the award of other donor projects such as from Global Fund, UNDP, etc. There has been strong demand from the DCs that additional to working with schools, there is a need to work with the community people as the HIV is becoming more and more prevalent in housewives of the rural communities because of various risk factors. The program over all was successful to provide extensive services in need and was a help to initiate improvement on institutional capacity of DCs of programme districts. The overall services of the CEHP and its projects have further promoted positive image of the Red Cross in the region area is the last year of the remaining project phase. Sustainability concern has become a core part of the CEHP team, which will be further enhanced and promoted in the next years. Many thanks to Swiss Red Cross, the back donors and everyone who trusted us and contributed extensively to make this year very successful to serve people in need. Annexes Annex 1: List of abbreviations Annex 2: Volunteers and staffs at CEHP (at the last quarter of the year 2010) Annex 3: Cumulative HIV and AID situation of Nepal Annex 4: Type of training and workshops conducted by OD in Jan - Dec 2010 Annex 5: Fund raised in 2010 Contact information: Nepal Red Cross Society Community Eye Care and Health Promotion Program (CEHP) P.O. Box: 7, Near District Post Office Sadarline Road, Nepalgunj NEPAL Telephone: , Fax: cehp@nrcscehp.org Webpage: CEHP Annual Report (Jan- Dec) 2010 (38) In collaboration with Swiss Red Cross

39 Annex 1: Abbreviations used in the report ADRA Adventist Development & Relief Agency MoH Ministry of Health AG Action Group MoU Memorandum of Understanding AIDS Acquired Immune Deficiency Syndrome NAPN National Association Of PLHA Nepal AM Action Member NEWAH Nepal Water for Health ANC Antenatal Care NFHP Nepal Family Health Programme ART Anti-Retroviral Therapy NGMC Nepalgunj Medical College BCC Behaviour Change Communication NNJS Nepal Netra Jyoti Sangh CECC Community Eye Care Centre NRCS/RC Nepal Red Cross Society/ Red Cross CEHP Community Eye Care & Health Promotion NRs Nepalese Rupees Programme CF Community Facilitator NTP National Trachoma Programme CG Community Group OD Organizational Development CHF Swiss Franc ODF Open Defecation Free CLTS Community Led Total Sanitation ORS Oral Rehydration Solution CSR Cataract Surgical Rate PC Programme Coordinator DACC District AIDS Coordination Committee PE Peer Educator DC District Chapter PHC Primary Health Care DDC District Development Committee PHiE Public Health in Emergency DHO District Health Office PLHA People Living With HIV and AIDS D-Net Development Network PMTCT Prevention of Mother To Child Transmission DPHO District Public Health Office PRA Participatory Rural Appraisal DRR Disaster Risk Reduction RAAB Rapid Assessment of Avoidable Blindness D-WASH- District Water and Sanitation Hygiene RH Reproductive Health CC Coordination Committee ENPHO Environment and Public Health Organisation SC Sub-Chapter FBEH Fateh-Bal Eye Hospital SHP Sub Health Post FC Field Coordinator SMC School Management Committee FCHV Female Community Health Volunteers SRC Swiss Red Cross GFWS Gravity Flow Water System STI Sexually Transmitted Infection GIPA Greater Involvement of Persons living with HIV TIO Tilganga Institute of Ophthalmology GO Governmental Organization ToT Training of Trainers' GoN Government of Nepal TS Teacher Sponsor HF Health Facility TT Trachoma Trichiasis or Tetanus Toxoid HFMSP Health Facility Management Strengthening UNDP United Nations Development Programme Program HFOMC Health Facility Operation & Management UNICEF United Nations International Children Emergency Committee Fund HHs Households VA Visual Acuity HIV Human Immunodeficiency Virus VC Vision Cell HP Health Post VCA Vulnerability and Capacity Assessment HQs/NHQs Headquarters/National Headquarters VCT Volunteer Counselling and Testing I/NGOs International/Non Governmental Organizations VDC Village Development Committee ICAP Institutional Capacity Analysis Process VHC Village Health Committee ICC Information Communication Centre VHW Village Health Worker ICH Institute of community Health V-WASH-CC VDC-Water Sanitation & Hygiene Coordination Committee IEC Information, Education and Communication WASH Water Sanitation and Hygiene J/YRC Junior/Youth Red Cross Circle WASH-PHC Water Sanitation and Hygiene Primary Health Care KAP Knowledge, Attitude and Practice WatSan Water and Sanitation LRRD Linking Relief, Rehabilitation and Development WHO World Health Organisation M & E Monitoring and Evaluation WUC Water User Committee MCHW Mother and Child Health Worker MDG Millennium Development Goal CEHP Annual Report (Jan- Dec) 2010 (39) In collaboration with Swiss Red Cross

40 Annex 2: Volunteers and staffs at CEHP (at the last quarter of the year 2010) Steering Committee of CEHP Name Position Name Position Mr. Lalit Jung Shahi Convener Ms. Narbada Sharma Vice-Convener Mr. Ajeet Kumar Sharma Member Mr. Sanat Karki Member Medical Director, FBEH Member Director, Health Dept, NRCSHQ Member Mr. Kamal Baral Member Secretary Staff members, Nepalgunj & DC Base Over all programme management Mr. Kamal Baral Program Director Mr. Deependra Chaudhari Deputy Programme Director Community Eye Care (CEHP Base) Organisation Development Name Position Name Position Mr. Badri Prasad Shrestha Sn. Program Officer Mr. Hari Prasad Subedi Sn. Program Officer Mr. Ram Bahadur KC Ophthalmic Officer Mr. Prem Kumar Dixit OA Supervisor Mr. Sher Bahadur Chand Ophthalmic Assistant Water-Sanitation & PHC Mr. Purnimaya Gurung Ophthalmic Assistant Mr. Rajkumar Kshetri Programme Officer Mr. Nim Bahadur Dangi Ophthalmic Assistant Mr. Pradeep Gautam PHC & Office coordinator Mrs. Buddhimati Tharu Motivator Mr. Resham Bahadur Khadka Field Coordinator Mr. Kali Bahadur Dangi Motivator Mr. Ramesh Prasad Bajgai Technical Coordinator/Overseer Community Eye Care Centers DC Staffs for Water-Sanitation & PHC CECC, Bardia (full management of Red Cross DC) Mr. Shankar Bhattarai (Bardia) Mr. Hari KC OA Supervisor (Clinic Incharge) Mr. Binod Sharma (Salyan) Mr.Kamal Kishor Joshi Ophthalmic Assistant Mr. Dharm Raj Shahi (Pyuthan) Mr. Kushal Gautam Optical/pharmacy Mr. Hari Gopal Chaulagai Assistant (Jumla) Mr. Ran. B.Chaudhary Office Assistant HIV/AIDS Prevention Field Coordinator Field Coordinator Field Coordinator Field Coordinator CECC, Surkhet (full management of Red Cross DC) Mr. Bharat Rijal Program officer Mr. Ghan Bahadur Thapa Ophthalmic Officer Mr. Bijay Shrestha Ophthalmic Assistant Finance/Administration Mr. Ramesh Gautam Optical/pharmacy Mr. Amulya Vaish Sn. Finance/Admin Assistant Officer Mr. Ram Prasad Acharya Office Assistant Mrs. Asha Shahi Store In-charge CECC, Dailekh Mr. Kanhaiya Lal Bajpai Finance/Admin Assist. Mr. Prakash Chandra Shahi Ophthalmic Office Mr. Mani Ram Tharu Driver/Logistic support Mr. Yam Prasad Pandey Office Assistant Mr. Prem Bahadur Bohara Office Assistant CECC, Jajarkot Mr. Bijay Thapa Magar Office Assistant Mr. Pradeep Jung Shah Ophthalmic Office Mr. Prakasah Chaudhary Guard Mr. Sushil Pun Office Assistant, CMA Total staff members: 38 (CEHP, CECC and district chapters) CEHP Annual Report (Jan- Dec) 2010 (40) In collaboration with Swiss Red Cross

41 Annex 3: Cumulative HIV and AID situation of Nepal Ministry of Health and Population National Centre for AIDS and STD Control Cumulative HIV and AIDS Situation of Nepal As of Mansir 2067 (15 December, 2010) Total HIV infections reported Male Female Total Cases Reported in This Month 11,061 5,997 17, Cumulative HIV infection by sub-group and sex Cases Reported in This Sub-groups Male Female Total Month Sex Workers (SW) Injecting Drug Users 2, ,677 * 8 Men having Sex with Men (MSM) Blood or Organ Recipients Clients of Sex Worker 7, , Housewives 4,467 4, Male Partners ** 0 Children ,094 7 Sub-group NOT identified Total 11,061 5,997 17, * Mode of Transmission IDUs or Sexual ** Male Partners of FSW/Female IDU/Female Migrant Cumulative HIV infection by age group and sex Cases Reported in This Age group (Years) Male Female Total Month , , ,371 1,399 3, ,537 2,100 6, , , above Total 11,061 5,997 17, Source: NCASC, 2010[as of 15 December 2010] For more information contact at : SI Unit, NCASC, Teku, Kathmandu Tel : Fax : ncasc@mos.com.np, data@ncasc.gov.np Web : CEHP Annual Report (Jan- Dec) 2010 (41) In collaboration with Swiss Red Cross