ETSC (Education, Training and Services for the Community), we will increase the health and well-being of pregnant women and infants and thereby reduce deaths across 75 wards of Makwanpur district of Nepal.
Community Health First will deliver support to the most disadvantaged women and children by;
1) Increasing knowledge of maternal and child health. We will establish 25 Women’s Health Committees (WHC) per year for three years, who, supported by a Men’s Support Group (MSG), will each develop and oversee a health and literacy education programme for women and adolescent girls in their ward.
2) Enabling women to generate income and joint savings schemes to pay for safer health practices. We will develop a business skills and savings skills toolkit to help local women transform their subsistence activities into small scale income generating ones. We will also provide technical support such as growing specialist crops.
3) Lobbying for improvements in mother and child health services. Nine Maternal Health Committees, made up of men and women, will lobby for improvements in mother and child health services through government medical centres, health posts and Sub Health Posts. Collectively they will lobby national government for improvement sin long term sustainable mother and child health. The project will directly reach over 5,100 women and girls over three years, including 2,012 from the most marginalised groups. An additional 27,450 people will indirectly benefit.
Gaps in existing services
Although Nepal has made significant steps in improving maternal and infant health, there are gaps in services and differences between policy and practice. Nepal advocates free maternal and infant healthcare for all with a policy of providing over 30 medicines and services free of charge throughout the health facilities, including tetanus vaccinations, iron supplements, oral rehydration salts and antibiotics. This policy appears to be in operationat Sub Health Post, health post and District Hospital levels, although supplies are frequently limited or poorly managed and our research showsit is poorly publicised among the target communities. Consequently there remains an expectation among communities of a requirement to pay which acts as a deterrent, particularly to the most marginalised women.
In addition, serious doubts were expressed by qualified doctors at Hetauda Hospital during the project development phase about the efficacy of the medicines available free of charge from the Sub Health Posts. For example, antibiotics supplied through the Sub Health Posts appear to be of inferior potency, resulting in ineffective treatments and patients subsequently have to travel to the hospital, their health having deteriorated further.
There is a network of 56Sub Health Posts across Makwanpur which are advertised as open seven days a week from 10.00 to 17.00. However, visits to Sub Health Posts during the project development phase (November – June 2013) indicated that they are seldom open after 14.00. Sub Health Post managers interviewed indicated that their staff are often withdrawn to support other services, leaving the Sub Health Post unable to open.
Three Government programmes for prioritising maternal and infant health are particularly relevant to this project:
- There is a programme to build a birthing centre in every Village Development Centre (VDC) which will offer 24 hour delivery services. However, the birthing centre in Basamadi was closed when visited during the project development period. Many of the communities within 3 – 5 km were unaware of its existence and none of the women interviewed had given birth there.
- The Government is also in the process of implementing a policy of training the nurses at Sub Health Posts in delivery through a four month training programme. Only 1 of the 5 Sub Health Posts visited have been part of this programme. This Sub Health Post was held in higher regard by the local community and a higher proportion of local women appeared to be using its services.
- The government has adopted a ‘12 point access’ approach to childbirth, delivery and post-natal check-ups, with an expectation that all pregnant women will attend anti-natal clinics on at least 4 occasions. Whilst significant progress has been made in urban areas, these targets are far from being met in rural areas.
Clearly, there is a significant gap in terms of community awareness about improvements to existing services, resulting in a poor uptake and which feeds back into poor resourcing. This project has been designed to bridge this knowledge-awareness-uptake gap.
Description of the project
Over three years, we will establish 75 Women’s Health Committees in 75 wards (25 per year) across nine Village Development Committees (VDCs) in Makwanpur District, Nepal. The Committees will each consist of a team of 7 local women, drawn from different sections of the community (traders, farmers, labourers, different religious groups, different levels of education) and each including at least three women from the most marginalised groups (widows, disabled, non-literate women).
Women’s Health Committees
The recruitment of the Women’s Health Committees will be led by four full time Field Officers employed by our in-country partner, ETSC, in close collaboration with male and female community leaders.The Women’s Health Committees will initially be trained in (over 12 sessions):
- the scope of the project
- committee roles and responsibilities
- the role of literacy in health education awareness
- project management and reporting skills
- advocacy and lobbying skills
- the role of livelihoods and savings in the project
- how to reach the most marginalised people within their community.
Over three years, the Women’s Health Committees will:
- Receive on-going training and support from our in-country partner ETSC coordinated by their local Field Officer
- Recruit a Health Literacy Facilitator from their local community (75 in total) and co-ordinate health literacy classes
- Run community workshops and awarenessraising events using printed materials, theatre and song for women and adolescent girls
- Support the formation of health savings groups through which pregnant women will save for transport and other costs to access health facilities
- Liaise with Men’s Support Groups to disseminate the role of men and boys in improving the survival and welfare of pregnant women and infants
- Coordinate the visit of adolescent girls to the Sub Health Post
- Lead a poster competition for adolescent girls in their community
- Working in partnership with Radio Hetauda, co-produce a radio programme production
- Lobby through the Village Health Committee and the Mother’s Health Groups (which are government-established groups) for additional maternal and infant health services for their village (one member will join the Maternal Health Committee to lobby for improvements in services)
Health Literacy Facilitators
Fewer than 20% of women in the target area have sufficient literacy skills to understand written programme. The Women’s Health Committees will each be responsible for recruiting a Health Literacy Facilitator, with support from ETSC and in line with agreed criteria. Health Literacy Facilitators will be respected members of the community with reasonably sound literacy skills and a commitment to improving the health of their village, thereby providing an on-going community resource.
Health Literacy Facilitators will each run classes for 30 women (seven committee members plus 23 additional women), teaching basic literacy and focusing on health knowledge and skills. In total, these classes will reach 2,250 women (30 x 75 wards), with at least half coming from marginalised families.
Classes will meet for 7.5 hours per week for six months, organised around the women’s existing daily commitments. The timing and duration of classes has been decided through consultation and will be flexible to meet the needs of each ward. Health topics will be guided by the District Health Department and likely topics will include: preventable diseases; clean water, sanitation and good nutrition; the benefits of family planning, vaccination and medication; care during and following pregnancy; infant and child health; and the dangers of anaemia, septicaemia, malaria and dehydration. As a result of participating in the classes, women will be able to identify common health problems, make changes and take appropriate action, which will ultimately lead to increased survival rates and improved well-being of pregnant women and their infants. Participants will also be aware of how they can access health services and read and write essential personal information about themselves and their families when accessing health services.
The literacy element will be specifically tailored to support improvements in health; learning vocabulary relating to commonly encountered medical conditions, medicines, vaccination, personal information and health services. Education materials will use images and simplified text. Facilitators will encourage discussion about the topic, sharing knowledge and asking questions, rather than presenting information in a lecture format. This approach has previously been used by us and ETSC in other projects including those outlined in section 2.5.
Health Literacy Facilitators will be supported through 20 of days training (15 days initially with five days follow up) and provided with health education materials to use in their classes.
We will provide women with two kinds of livelihoods support. Firstly, a practical business skills and saving skills toolkit will be developed in consultation with successful local women traders, consultants in livelihoods and the Business and Savings senior Field Officer. This toolkit will be used by the Field Officers in weekly sessions with each of the women’s health literacy groups over three months. Through these sessions, women will learn how to develop their existing farming and handicraft activities, into small scale income generating activities. For many women this will involve working collaboratively, purchasing seed or stock in bulk, keeping records of their expenditure and forming savings groups to manage their income.
Secondly, the women will have access to livelihoods technical training in their selected livelihood activity. This will include ginger growing where the soil is suitable, iron-rich vegetables, goat rearing and mushroom farming. This technical training will build on their existing knowledge and focus on improving crop/production and maximizing the sale price. For example, storing ginger to sell throughout the year for a higher price, rather than selling at point of harvest to an intermediary for a lower price. This additional income will allow for women to increase spend on health of the family and pay the costs of attending health facilities, this was a clear limiting factor that came out through community consultation during project development.
Engaging adolescent girls is crucial to the success and sustainability of the project as they will be some of the most ‘at risk’ women during pregnancy and child birth in the next five years. Early marriage, leading to adolescent pregnancy, increases the risk of long labour and life-threatening complications during delivery. Adolescent girls are also key carers for new born infants, especially when the mother suffers from complications during delivery. As such it is important to educate adolescent girls on the danger signs in the first 28 days of life.
2,775 adolescent girls (11-17 years) (37 per ward) will be supported over six months. The Health Literacy Facilitator will facilitate 13 sessions (two hours each) using selected units from the Health Literacy Materials as well as more age related materials, e.g. on menstruation, a key rights issue for young women in rural Nepal. The adolescent groups will visit the Sub Health Post, coordinated by the Women’s Health Committee, for a session on the support available by the Sub Health Post for antenatal, delivery and post-natal care. They will also participate in a poster competition on the care of infants in the first 28 days of life. Adolescent girls will also contribute to an ETSC Adolescent Girls Newspaper on infant care. Selected girls will co-produce a radio programme, in partnership with Radio Hetauda, a popular station for girls of this age, discuss using the tailor made worksheets. Through these activities adolescent girls will begin to play a pro-active role in the care of their own bodies during menstruation, be more able to make informed decisions about sex, marriage and pregnancy and also be able to support mothers in the prevention of life-threatening conditions during the first 28th days of life.
Men’s Support Groups
We know from running similar projects that, for the project to be a success, we must have the support of men within the local communities. Our consultation with men has shown that once they understand the purpose of the project, they are highly supportive. We will therefore also establish a Men’s Support Group in each village, consisting of 20 members, who will: i) receive 12 training sessions on maternal and child health over the course of a year ; (ii) visit the Sub Health Posts accompanied by the Field Officer to find out about the services available for mothers and children from qualified staff; (iii) lobby local health facilities to improve their maternal and infant services; (iv) facilitate six dissemination advocacy sessions reaching an additional 20 men and boys in their community; (v) contribute to, listen to and discuss the radio slots for men and boys.
Maternal Health Committees
We will establish nine Maternal Health Committeesacross the region, reflecting the boundaries of the Village Development Committees (VDC) (the local council structure).
Each Maternal Health Committee will consist of 13 members, nine women representatives from each of nine Women’s Health Committees and four men. Their role will be to lobby their local Village Development Committee to increase their focus on maternal and infant health.Collectively, they will lobby national government for improvements in long term sustainable mother and child health.
Radio is a well-respected public service vehicle in Nepal, especially in remote areas. Even the most mountainous areas now have good reception with the advent of mobile phones. A series of radio programmes (9, 3 per year) will be developed in collaboration with the local radio station Radio Hetauda, with whom ETSC has strong links. ETSC has previous experience in the production and hosting of a radio series on marginalized communities in remote areas of Nepal. Separate programmes will be made for men and adolescent girls. The themes will be taken from the health literacy toolkits, although the content will rely heavily on drama. Local adolescent girls and men will co-produce the programmes.
Community awareness training events
The Women’s Health Committees, Men’s Support Groups and adolescent girls will reach out to new community members disseminating the knowledge and skills gained and changing attitudes and behaviours of men and women in the community.
Men’s Support Groups will facilitate community meetings and events, each reaching 20 new men per year (3,000 men in total) over the life of the project. They will raise awareness through printed information and education materials and short radio programmes created specifically for men. These events will also be supported by the Field Officers and members of the Women Health Committees and adolescent girls, where appropriate. The emphasis will be on low cost, culturally appropriate changes which will increase access to health facilities for pregnant women in particular for early identification and treatment of high risk conditions.
Women’s Health Committees will facilitate outreach dissemination workshops using information, education and communications (IEC) materials and selected activities from the Health Literacy materials.
Adolescent girls will use drama, posters and newsletters which they will produce in their sessions to disseminate via schools and community events to other adolescent girls. Specific materials will be produced for the adolescent girls on key relevant topics, including (i) managing menstruation without isolation and exclusion, (ii) early marriage and pregnancy related risks, (iii) care of new born infants and danger signs in the first 28 days of life. (Managing menstruation and early marriage are girls’ rights issues, directly relevant to mother and child health and which will also be included in the material for both women and men’s health education.)
Knowledge sharing workshops
The Women’s Health Committees will participate in bi-annual knowledge sharing workshops to disseminate best practise, successful techniques and learning from the project with other local and national community, NGOs, the District Health Department and umbrella organisations. These meetings will enable us, ETSC and other organisations to develop ways to improve our maternal and children health services. This will be complemented by the Committee members using newly learnt advocacy skills to proactively engage with local leaders through strategic networking and meetings, supported by ETSC.