दोलखा स्वास्थ्य प्रवर्धन परियोजना Promotion of Child, Adolescent and Maternal Health Promotion Project- Dolakha (DHP) PROJECT BRIEF 1. Background Green Tara Nepal (GTN) is a non-governmental, non-political and non-profit organization established in 2007. GTN is registered with the Kathmandu District Administration (Registration Number: 632- 2064/65) and the Social Welfare Council in Nepal (Affiliation number: 24077/2064). GTN has been established with the aims to improve health, education and well-being in rural Nepal through behavior change and community-based approaches by promoting health and strengthening public health services. At the national level, GTN works to improve the impact of public health services. Besides, GTN has extensive work experience throughout Nepal. GTN is currently active in 13 districts of Nepal and provides indirect technical assistance in another 24 districts in the areas of health promotion, health system strengthening, women empowerment, service demand mobilization, evidence-based health policy, advocacy, training and social mobilization. ChildAid Network (CAN) –a Germany based non-government organization has been supporting rural communities in Nepal for improving health, education, livelihood and community development. Since 2019 CAN has been working partnering with GTN to address the need of integrated health promotion activities for improving health and wellbeing of the mothers and children in the rural communities of Ramechhap and Dolakha districts. Recently recognizing the need of health promotion activities both at the schools and communities, as well as the activities enhancing the public heath structure and system for increasing access of health care and sustainability, CAN has provided financial and technical support to GTN to implement ‘Promotion of Child, Adolescent and Maternal Health Project’ in Dolakha district of Nepal. Health issues of women and children are mostly neglected in Nepal. Their right to access proper information and services are mostly dominated. Women including adolescents face disparities in health and social care all over the country, especially in rural communities of Nepal. Child care is also poor due to illiteracy, improper knowledge, skills and access of health care services. Education system in public owned schools are not only poor but they lack safe drinking water, healthy and hygienic environment; toilets with proper cleanliness and supply of water, provision of sanitary pads for girls to use during menstruation and their management. Similarly, public health systems lack skills to provide available services like promotional, preventive and curative, with proper respect to the service seekers esp. women and adolescent girls; and these facilities also lack equipment, medicines, IEC materials and adequate number of staffs; besides lacking proper coordination and communication with authorities at local, provincial and federal levels. Green Tara Nepal (GTN) has been working for health promotion since its establishment, Dolakha Health Promotion (DHP) Project is expected to address these problems in collaboration with schools, FCHVs, local health facilities, rural communities and municipalities. 2. Context and significance of the project Maternal mortality is still high in Nepal (239/100000 live birth in 2016). Though the government is increasingly committed to eliminating inequalities in health care and has recently focused on improving access to services for the needy population, especially in rural areas, the country still faces many health challenges. The latest 'Nepal Health Facility Survey'; clearly shows how difficult it is to provide quality health services, retain qualified professionals and ensure regular availability of primary health care commodities, especially in rural areas. The lack of coordination between the different levels of government as well as the lack of organizational and planning capacities at the local authorities, which leads to the fact that, for example, required consumables and the medicines provided free of charge by the government are usually not available in the health stations. The Health Facility Operation and Management Committee (HFOMC), which is responsible for the management of the health facilities, but, they usually meet irregularly, often without an agenda, and hardly any binding decisions are taken. Basically, it can be said that these problems are based on causes in two areas. On the one hand, the population lacks awareness of key health issues and knowledge about the services that the government is supposed to offer free of charge. Secondly, the local health system is weak. Lack of awareness about basic hygiene practices, the presence of preventable diseases and illnesses, lack of access to health care and poor hygienic infrastructure in schools, increase the health risks for school children. In the target area, knowledge about hygiene, proper waste disposal and health as well as access to adequate WASH facilities among school children including availability of sanitary pads and knowledge of MHM among adolescent girls are still insufficient and are not addressed by schools. Adequate menstrual hygiene management requires access to appropriate sanitation and hygiene services, as well as access to information on understanding the menstrual cycle and how to manage menstruation hygienically. However, adequate menstrual education is not offered to girls in schools or mothers in the communities. Similarly, in a sample survey, 144 students were asked about their dental hygiene and brushing habits. About 53% of the students said that they brush their teeth after breakfast and only 45% of the students brush their teeth before going to bed. The result is tooth decay and toothache, reported by 19% of the students. Safe drinking water is another major issue in the area. The Multiple Indicator Cluster Survey conducted by UNICEF in 2019 showed that about 80% of the drinking water in rural households in the project area was contaminated with E. coli. The mothers in these rural communities face many challenges regarding family planning, safe motherhood and child nutrition. Specialized care by obstetricians and gynecologists' is not available to local women, and basic laboratory and radiology facilities are also far away. The mothers only find support from the Auxiliary Nurse Midwives (ANMs) in the local health facilities, who are often inadequately trained. The sample survey showed that only 28% of mothers received three or more antenatal care (ANC) check-ups as recommended by the Nepalese government, and only about 8% of them received postnatal care (PNC) check-ups. Thus, less than 10% of mothers avail the continuum of care (4 ANC, institutional delivery and 3 PNC). This is partly due to the fact that disrespect and abuse during institutional delivery as well as examinations is a widespread phenomenon with different manifestations. These include physical abuse, non-consensual care, poor relationship between women and health workers, stigmatization and discrimination. Basic care for new-borns is equally inadequate in the region. The sample survey shows that 20% of new-borns were bathed in the first 24 hours after birth, contrary to general recommendation, and although breastfeeding is generally accepted in the region, only 24% of mothers exclusively breastfed their new-born for six months. Supplementary feeding, often with contaminated food, leads to diarrhoea and thus little nutrient intake, which has a lasting impact on new-born development. After infancy, child nutrition is not balanced, especially in poor, marginalised families, or children are given money for junk food (chips, crackers, etc.) especially as a substitute for the midday meal they have to bring to school. According to the Female Community Health Volunteers (FCHVs), pelvic organ prolapses (POP) as one of the most common health problems among women in their community. Women in the region generally have very few choices in family planning methods. Commonly available and used methods are contraceptive hormone injections, oral pills and condoms. Sexual and reproductive health is not a priority in rural Nepal. Issues are not discussed and adolescents continue to be exposed to many myths and misconceptions due to low awareness. Adolescents' and young people's concerns about sexuality and the physical and mental changes associated with it are not openly discussed within the family. Village communities try to hide cases of sexual violence. For many school-age girls, the main reasons for dropping out of school, besides economic hardship, are early marriage and unexpected pregnancy. GTN’s unique Health Promotion (HP) approach addresses these issues. Health promotion plays a vital role in transforming the health to individuals, society and the healthcare system by promoting mobilizing change, including preventative health care. The following key issues justifies the need of this project. Basically, this project aims to address the following issues. • Increased individual awareness and agency leading to healthy and hygienic environment, improved WASH facilities in schools and communities • Engage schoolchildren/child club members for promoting oral and menstrual hygiene • Train and mobilize local resources • Women group and FCHV mobilization for RH and gender roles • Empower women leadership in local government/municipalities • Capacitate multiple stakeholders coordinate for smooth functioning health facilities • Changes in social norms and behaviors 3. Strategies: Health promotion approach will be a key strategy targeting both at the schools and in communities of the project implementation areas. We will follow Individual, Family and Community (IFC) model while implementing the intervention. We also will coordinate with the governmental health facilities, schools and local political leaders including local governments. Considering local needs and priorities, we have come in conclusion to focus on health promotion activities, in which GTN has a long experience. Despite multiple needs of the local communities, this project will target on selective and high impact interventions. The project aims to improve i) personal hygiene of the children including oral hygiene, ii) sexual and reproductive health of the adolescent girls including menstrual hygiene and iii) reproductive health of the married women including pregnancy (Antenatal, delivery, post-natal) and family planning. • Scalable at GON resources and system • Identical to existing health and education system of Nepal. • Covering the issues and needs of the targeted populations (mothers, children, adolescents and/or left behind population) • Promoting evidence-based healthy behaviors • Fostering coordination, collaboration and partnership 4. Project Area and Target population Dolakha Health Promotion (DHP) Project covers two rural municipalities viz. Tamakoshi and Baiteshwar, and one urban municipality –Jiri of Dolakha district. This project covers all twenty-four wards of three municipalities with 48000 populations, 103 schools, 26 health facilities 393 FCHVs and Health Mother groups besides elected representatives and staffs of municipalities; members of SMCs, PTAs & HFOMCs; and other community based stakeholders. However, the prime beneficiaries of this project are school children, adolescents and young women. 5. Objectives of the Project The goal of the project is: Dolakha district residents lead healthy lives into old age thanks to a strong public health system, increased health awareness and good health practices. The main objective of the project is: The health situation of the inhabitants of the communities of Tamakoshi, Baiteshwor and Jiri in Dolakha district, especially that of children, adolescents and mothers, is sustainably strengthened due to healthy behavior, a safe and health-promoting school environment and a functioning public health system. This project aims to achieve the following four results Result one: 103 schools have created a health and awareness-enhancing learning environment in the areas of physical, dental and menstrual hygiene and nutrition, and access to health services has improved for 14,191 students. Major activities: 1.1 Improving WASH facilities in schools, providing support with health and hygiene equipment, equipping model schools. 1.2 Mobilizing children's clubs to promote basic health services and health awareness. 1.3 Training of primary school teachers for primary health care and care of pupils 1.4 Promoting the health screening system for school children 1.5 SMC training on developing mechanisms to monitor school health activities 1.6 Parents-Teachers Association (PTA) meeting to mobilize support for health promotion activities in schools 1.7 Celebration of special days in schools to raise awareness and sensitization on personal, dental and menstrual hygiene. Result two: 8,000 mothers are capacitated regarding safe motherhood, family planning and child nutrition, as well as sexual and reproductive health. Major activities: 2.1 FCHV training and regular meetings 2.2 Meetings of mother groups 2.3 Celebrations of special occasions in 24 communities Result three: The community-based health system in Jiri, Baiteshwor and Tamakoshi is functional and well-equipped, and staffs are skilled and motivated. Major activities: 3.1 Maintenance and equipment of health facilities 3.2 Training of health facility staff (ANM) 3.3 Train health facility staff in respectful maternity care and client-friendly services 3.4 HFOMC orientation and training Result four: The local authorities are strengthened and the level of coordination between the different actors to improve the quality of services is enhanced so that adequate services are provided. Major activities: 4.1 Joint meetings of head teachers, health station staff and representatives of the authorities 4.2 Coordination meetings at RM level 4.3 Joint monitoring with representatives of rural communities 4.4 Joint annual meeting with authorities of the rural municipalities and the district 4.5 Publication of project results and best practices Prevention from COVID: While conducting activities, trainings, meetings etc. in the mass/groups, we strictly follow the measures to protect participants from COVID-19 infection by distributing face masks, hand-washing/sanitizing provision, and keeping safe physical distance. 6. Project Duration: Officially, the tenure of the project is of 38 months since the project is effective from November 1, 2022 and valid until December 31, 2025. However, field level implementation starts from Jan 2023 to December 2025. 7. Organizational detail: Green Tara Nepal is an apolitical, non-profit making and non-governmental organization, established in 2007. It works in research, publications, advocacy, training, program implementation and social mobilization in a holistic community development approach. Contact: Mr. Ram Chandra Silwal, Country Director Green Tara Nepal (GTN) Kathmandu Metropolish-4, Lamtangin Marg, Baluwatar, Kathmandu 977-1-4432698, email: info@greentara.org.np Web: www.greentara.org.np