Farming, Health and Environment, Nepal 2017-2020

1. Relevance of the intervention

The overall objective of the intervention is to improve the health of farmers and consumers by promoting a healthy and sustainable food production in Nepal with a focus on Integrated Pest Management.

The project design focuses on 1) Promoting effective Integrated Pest Management (IPM) and ecological alternatives among farmers and pesticide dealers. 2) Improving health personnel’s ability to prevent and treat pesticide poisonings cases. 3) Raising awareness and strengthening advocacy in the civil society for a healthy and sustainable food production.

Geographical context: Nepal is situated between India and China populated by 28.9 million persons of whom the majority lives in rural areas. The annual population growth is 1.35%. The subtropical climate in the southern lowlands, temperate climate in the middle mountainous zone and alpine climate up north covers elevation ranges from 66 to 8.848 meters above sea level. Although Nepali is the official language of the country, 123 different languages are spoken. 125 caste/ethnic groups were reported in the 2011 national census. The main religions are Hinduism and Buddhism.

The proposed project area is in Chitwan District (one of 75 administrative regions in the country) in the lowlands in the southern part of the country. It covers 10 out of 38 Village Development Committees (VDCs) in the district. Chitwan is one of the inner Terai districts in the Central Development Region of Nepal. Chitwan has pocket areas for commercial vegetable cultivation, coupled with easy availability of pesticides. Chitwan was largely an uncultivated dense forest before Nepal government started spraying DDT for Malaria Eradication Project in 1950s. Immediately after control of malaria, the Chitwan Valley became a major farming region, and services and infrastructure expanded across the area. Agriculture has been the primary source of income for 75 percent of the population of the district. It is one of the highest vegetable growing districts of Nepal and there are 4000-5000 active commercial vegetable farmers. Out of total 46,894 ha. of arable land, 44,291 ha. of land is used for agricultural purposes. There are 630 registered Farmers’ Cooperatives in Chitwan. Though there is a strong network of Farmers’ Cooperatives in this district, they hardly receive training on pesticide and other production issues. There have been projects in Nepal focusing on Integrated Pest Management, with the purpose of reducing pesticide use. However, the present project is the first one to combine a focus on reducing pesticides with awareness raising and advocacy amongst consumers, farmers, pesticide dealers, and district as well as national stakeholders, for a more sustainable farming production.

Five of the proposed villages are the intervention villages from the first project: Bhandara, Chainpur, Jagalpur, Mangalpur, and Sukranagar. The control villages from the first project (Gitanagar, Jutpani, Kumroj, Padampur, and Shivanagar) shall be the new five intervention villages. Indigenous people constitute at least 40% of the population in Nepal. For centuries, they have experienced systematic discrimination and marginalisation. With the 1990 Constitution, Nepal saw an upsurge of ethnic organizations and new political demands such as linguistic rights, and

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equitable representation in State institutions. But as a census from 2001 on education shows they are still socially excluded: 73% of those who had a Bachelor’s degree in 2001 were High-caste Hindus, as compared to only 22% belonging to Janajaatis groups. Not surprisingly, this inequality is reflected in the state-bureaucracy (IWGIA 2012). Altogether, there are approximately 30,000 households in the ten villages in the project area, with about 130,000 people residing in them. Ethnically, the native Janajaatis, including Tharus, form more than one-third (37%) of the population. The caste hierarchy introduced by the Hindu Elites, is not followed among the Janajaatis, and the evaluation of the first project did not show any problems related to the caste hierarchy, between staff from Katmandu and staff from Chitwan or farmers.

Socio-economic context: In 2011, 25.5 percent of the total population was below the national poverty line (ADB, 2011). Nepal has an adult literacy rate of 57 percent (males 72 percent, females 45 percent) (CBS, 2011). The total fertility rate per woman was 2.3 in 2013 (WHO, 2015) and life expectancy at birth is 64.6 year for males, 67.1 years for females and 65.8 years overall (CBS, 2011).

Political context: Democracy was introduced in 1990, but the Nepali state has suffered from political instability. In the past ten years, signing of a peace agreement between the former Maoists and the state, a new Interim Constitution, the election of a Constituent Assembly, the abolition of monarchy, five governments, and the rise of strong ethnic identity movements took place. The country finally got its new constitution in September 2015.The new constitution intends to lead to major restructuring of the state.

Earthquake 2015: An earthquake of magnitude 7.8 hit Nepal in April 2015 causing colossal loss of life and property. The earthquake has also adversely affected the mountainous part of Chitwan District, whereas the plain areas of the district where the former project took place were not severely affected. The country is presently recovering from the colossal damages that the earthquake and its numerous aftershocks have caused to the nation.

The health sector: Nepal has had a fair amount of health policies, strategies and plans since 1991. The most recent policy was launched in 2014 with the goal to provide health services through equitable and accountable health systems while increasing access of every citizen to quality health services to ensure health as a fundamental human right to every citizen. The third Nepal Health Sector Implementation Policy with the Plan 2015-2020 was recently approved. This plan focuses on four main areas: Equity, quality, sustained reform, and multi-sector collaboration. Besides the major issues of infectious diseases, reproductive health and nutritional health issues, NHSP-III also incorporates upcoming health issues such as non-communicable diseases and - of relevance for this project - occupational health. Thus, the project will take place in a political environment where there is a will to work with the poor, and occupational health has been put on the political agenda. This will form an important background for advocacy activities in the project.

The farming sector: The farming sector is the backbone of Nepalese economy and the main source of food and income. Most Nepalese farmers are subsistence/small-scale farmers and therefore dependent on farming related activities for their livelihood. Pesticides form an important part in increasing farming production for controlling pests in plants and diseases in animals. The use is particularly high in the lowlands including the project area with intensive commercial farming of cotton, tea and vegetables. The import of pesticides to Nepal has increased considerably over

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the last years and was 2-3 times higher in the late 2000s than in 1999. Most of the pesticides are imported from India. The quantification of pesticides could be seriously under-reported. As an example, only 25 % of the chemical NPK fertilizer used in Nepal 2011/12 was imported officially (Journal of the Plant Protection Society Nepal; MoAD). Among the imported pesticides are the very toxic organophosphates.

Nepal is a signatory of international conventions related to pesticides such as the Stockholm Convention, Basel Convention, Rotterdam Convention and Montreal Protocol. The Pesticides Act 2048 was established in 1991, and rules in the act were framed by means of Pesticide Rules 2050 in 1993. The act and rules have been effective since 1994 aiming at the implementation of national and international rules and regulations on pesticides. Nevertheless, making the conventions and control mechanisms functional in the farming districts is lacking from the authorities, and little interest is given to these issues by the farmers and consumers due to lack of knowledge and awareness.

The Ministry of Agricultural Development has the overall responsibility of executing the UN promoted Integrated Pest Management (IPM) strategy introduced in 1997. IPM is considered an effective, economically sound and environmentally sensitive approach to pest management that relies on a combination of common-sense practices that enhances, rather than destroys, natural controls. IPM is the concept on which the project builds, and thus the project supports official policy about pesticides.

Lack of knowledge about integrated pest management: Pesticide use in Nepal is on an increase (tripled within the last decade), and there is an urgent need to intervene now to prevent even more poisonings in the future, as an increased use is shown to carry more poisonings with it in several studies. This project is targeting the health of farmers and consumers by promoting a healthy and sustainable food production through integrated pest management. Globally, three million cases of pesticide poisoning are estimated to occur annually.

Farmers confront a particularly high risk of pesticide poisoning due to the added risk from their occupational exposure. Research in the project area has shown that a majority of the farmers spraying pesticides complained of acute health problems like headache, muscle twitching/pain, respiratory depression among others and had affected blood parameters attributed to pesticides (Neupane D. et al, 2014).

Food consumers are confronted with a risk of pesticide poisoning due to the presumably high level of pesticide residues, especially in vegetables and drinking water.

At the structural level, there are several causes to poor management of pesticides in Nepal. There is no controlling mechanism for proper application of expired pesticides, no quality control of pesticides and no monitoring of consumer safety. Illegal trading due to open borders, especially with India, is also an important matter as is the low import and limited availability of alternative pesticides. Systematic disposal mechanisms are non-existing and therefore storage of obsolete pesticides is not always well managed, obviously posing serious health threats. Due to a poor monitoring system, adequate enforcement of pesticide regulations is not taking place and several misuses of pesticides could be happening (Plant Protection Society). So far, little public awareness has existed about the risk of pesticide poisonings, and therefore authorities have also not been held accountable by the public.

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At the health care system level, prevention and treatment of pesticide poisoning cases, whether intentional or unintentional, is poor in Nepal due to lack of relevant skills among health personnel. A study from ‘Nepal Drug and Poison Information Center’ found that suicidal poisoning is a major public health problem in Nepal and that pesticides accounted for more than half of the cases. Apart from acute poisonings, chronic diseases like cancer, fertility issues and injuries on the fetus are other serious negative health consequences of pesticide use.

The majority of pesticide poisoning cases are handled at peripheral levels of health care units such as health posts and district hospitals, where the treatment of poisoning cases is based on individual level skills, knowledge and experience. There are no standard protocols for handling such cases immediately after arriving in the emergency ward. Also, the existing health care education is not effectively managing the poisoning cases, thus making it difficult for health personnel to recognize and manage pesticide poisonings as well as to provide an actual picture of the prevalence of pesticide poisonings and their characteristics.

At the practical level, inappropriate pesticide behavior among farmers and pesticide dealers are unfavorable for the management of pesticides. The majority of farmers in Nepal still apply highly toxic pesticides because they think that more is better in the sense that more toxic pesticides are more effective in killing pests. 50 % of the pesticides used in the first project area were classified as moderately hazardous and 15 % as highly hazardous. Other issues are overdoses, frequent use, not following pre-harvest waiting periods, combining a broad spectrum of insecticides, considering them casually like human medicines, and inappropriate storage. Forty-four percent of farmers interviewed in a study had stored pesticides within the reach of children, 7 % stored pesticides in the kitchen and 7 % stored pesticides in the sleeping room. Moreover, the farmers usually do not have or apply personal protective equipment, either due to lack of awareness or discomfort. In addition, the farmers are exposed to the aggressive marketing strategies of pesticide dealers and retailers (Plant Protection Society).

The Nepalese society including the project area has a strong tradition of civil society organisations. Farmers are organized in Farmers’ Cooperatives that promote the rights of farmers, and in addition, women are organized in Mothers’ Groups. Farmers’ cooperatives look after welfare of the member farmers mainly from financial, marketing, technical and vocational perspectives. Mothers’ Groups are active mainly in health aspects, and the member mothers learn about various health issues through the community health volunteers in their meetings. Through these civil society organizations, the intervention shall advocate rights to safe working conditions (safe occupation), access to information and finally right to health by promoting availability and accessibility of personal protective equipment (PPE), and creating awareness among stakeholders of multiple sectors like farmers, mothers’ group, health workers, female community health workers and pesticide retailers.

The intervention on one hand brings down the family’s expenditure on pesticide by promoting its rational use. Also, by preventing its exposure to those who are using them, it protects their health, which reduces the out-of-pocket payment on treatment for possible pesticide poisoning. The impact and importance of preserving health and cost-cutting are even more relevant in case of the poor and marginalised groups because ill health and high expenditure can lead them further down in the vicious cycle of poverty.

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2. Partnership

Danish Society for Occupational and Environmental Health (DASAM) was founded in 1980 and hosts a membership of 170 specialists in occupational and environmental health. In 2004, a subcommittee for international collaboration called International Centre for Occupational, Environmental and Public Health (ICOEPH) was created through which DASAM coordinates its international collaboration.

The mission of the committee is to facilitate low-income countries in ensuring occupational and environmental health by means of advice and promotion of focus on occupational and environmental health issues.

DASAM has conducted development activities with CISU grants in Ghana and Tanzania and has been supporting the Danish NGO Diálogos and its projects on prevention of pesticide poisonings since 2004 in Bolivia, Nepal and Uganda and in the Philippines on the reduction of mercury- pollution from small-scale mining. In the projects, DASAM has assisted with the elaboration of adequate teaching materials, informative materials and programs, the revision of curricula in relevant training courses, educational programs, scientific studies documenting the magnitude of the challenge and the effect of interventions etc.

These experiences have been used for public awareness raising, advocacy and information activities in Denmark and abroad in national and international conferences, through teaching, different media and publications.

The field of occupational and environmental health is part of DASAM members’ profession and daily work in Denmark where the members are working to promote healthy working conditions in Danish workplaces. DASAM sees a need and an obligation to help improve workers’ health at a global level, because the Danish experiences with establishing a decent working environment, workers’ rights and sustainable production are unique. We believe that by sharing such experiences we can facilitate a process of improving workers’ health in low-income countries in close collaboration with local colleagues.

Through Diálogos DASAM has a very solid local knowledge and network in Nepal and apart from this DASAM members are supervising Nepali students and Danish students on thesis work at university level with data from Nepal.

The members of the working group in Denmark are specialists in occupational and environmental health, agronomy, anthropology, journalism, and public health science. They have extensive experience with project activities from their normal jobs in Denmark and from assisting Diálogos in the occupational health and environment projects.

Diálogos is the primary other Danish partner. Since 1994, Diálogos has been committed to a) assisting populations in low-income countries on their self-chosen way out of poverty, b) working for democracy and just resource distribution, c) involving and activating large resources in the

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close network of associations, institutions and companies in Denmark. Diálogos has been carrying out projects in Nepal, Bolivia and Uganda on the prevention of pesticide poisonings. The organization has proven its ability to work together with local and international NGOs, local agencies and authorities (universities and ministries) as well as international organizations. Diálogos is used to organizing and coordinating activities for their members and activate Danish and international professional networks to help conduct activities in projects. The individual members of Diálogos have a strong network of relevance to the projects carried out by Diálogos.

A working agreement will be signed between DASAM and Diálogos specifying the responsibilities of each organization.

Diálogos has experience from Nepal since 2007. DASAM and Diálogos have been in a fruitful collaboration for many years where Diálogos’ experience working with the civil society and administrative set up to handle day to day administration and accountability is matching the professional expertise on pesticides from DASAM. Diálogos as a CSO has vast experience in advocacy and sustainable development in low-income countries.

Other collaborators in Denmark are Danish Universities, Clinics of Occupational and Environmental Medicine, National Research Centre of Occupational Health among others. By way of example, from the Faculty of Science, University of Copenhagen, agronomists will be consulted on specific matters and students from various Danish Universities are enrolled in research studies and thesis writing.

Nepal Public Health Foundation (NPHF) was established in 2010. It is a democratic, non-profit organization with the mission to have concerted public health action, research, and policy dialogue for health development, particularly of the socio-economically marginalized population and with a goal to ensure civil society's pro-active intervention in public health. NPHF is a credible organization managed by highly skilled professionals as board members, advisors and technical staff. The members and employees of NPHF have worked as senior government officers, employees of national and international organizations, professors of universities, leaders of consumer groups, environmentalists and human right activists which increases NPHF’s lobbying capacity with governmental institutions in Nepal. NPHF has a strong professional relationship with stakeholders and multiple government line agencies. Furthermore, NPHF works together with community based organizations, people's health movements, other NGOs, and private sectors.

The current partners with NPHF include Ministry of Health & Population, World Health Organization, Nepal Health Research Council, project HOPE, Centre for Disease Dynamics Economics and Policy, UNICEF, Save the Children, Nepal and Epidemiology and Disease Control Division. NPHF has solid knowledge on health issues in local conditions and good experience in working with other civil society actors such as Female Community Health Workers, foreign donors and WHO. Over 50 health professionals are members. The executive board members are elected every five years in the Annual General Meeting. Day-to-day activities of NPHF are carried out by the NPHF office headed by the Executive Chair.

NPHF has a satellite office in Chitwan District from where day-to-day activities are carried out. DASAM and Diálogos have passed on an updated Scandinavian model for Occupational Health and Safety (OHS) organization to NPHF, to be further developed in this project. This knowledge

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transfer has the potential to make NPHF one of the leading players in building Occupational Health and Safety services and knowledge networks on Occupational Health and Safety in Nepal together with national authorities.

Through 3 years of collaboration, the partners have already achieved important results. An external evaluation was carried out in September 2015. The evaluator found that the project was well into achieving its objectives and that a solid foundation had been made. The recommendations have been taken into account in this project proposal: - No major changes to modalities - Advanced level training for existing groups - Increased geographical coverage - Collaboration with District Advisory Committee, municipalities, and VDCs - Advocacy activities at national level - Clearer reflection in the project proposal of the functional roles of NPHF and other stakeholders - Capacity building on participatory development.

The end-line study from 2016 has revealed reduction in the proportion of farmers using chemical pesticides by over 10 %. Use in excessive dosage is also reduced. Further, reports of accidents with pesticides have decreased, storage has improved, and a drastic reduction in sale of unregistered pesticide has been noted due to a significant decrease in demand for banned pesticides. The knowledge on safe use of pesticides for a healthy living has been increased and is appreciated by the entire target group, and other villages have demanded to extend the project area into a wider area. Improvement has also been noted in storage of pesticides in shops and disposal. Health facilities have started registering and diagnosing pesticide poisoning cases for further clinical management. Production and display of information materials have been carried out in an effective way. Overall, the knowledge and practice have improved. The Agriculture and Forestry University in Chitwan has conducted joint research on wrong agricultural practices and injudicious use of antibiotics in farm animals and poultry. Four Nepali Master’s level students have received help with their research on pesticides. The evaluation report confirms the impressions that the project is highly relevant and has been embraced by all the key stakeholders. Besides, local level advocacy at district level done through engagement of concerned authorities (district agricultural office, district public health office and district development committee) along with relevant civil societies has been crucial in bringing together all the stakeholders, and pushing forward the pesticide agenda.

By now, we have 3 years of experience of cooperation between the partners and of working on farming, health and environment in Nepal, and with good results. Both DASAM and NPHF Nepal are well matched partners in terms of their similar concerns, commitments, and credibility in the area of public health. There has been a mutual learning between Diálogos/DASAM and NPHF regarding the way of conducting this kind of project (civil society-based), mutual involvement, involving the best from both cultures, and experiencing the strength of the existing everyday networks in the field of farmer cooperatives, women’s groups, village-community-groups, etc. We have also learned a lot about how we can support each other (between the different partners and stakeholders), and how we can get even better in ensuring local ownership, both with our partner and between our partner and the local networks.

Due to the different learnings in the previous project period, NPHF has demonstrated a great interest in capacity building in occupational health and the special working methods for this field, and for capacity building in knowledge about local spreading of the knowledge and local ownership

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to the project. The previous project period has also shown a need for developing communication – both between partners and also between central and local levels. There is also a need for clarifying some of the roles and expectations at the different levels.

In the first 6 months of the implementation of the first project, Diálogos and DASAM members were working as researchers and as a part-time project coordinator, accountable to Diálogos Denmark. At the same time, there was a big local staff turnover. That created a lack of role clarity between Diálogos and NPHF. During a project visit from Diálogos, the partners had fruitful discussions on responsibilities, the roles of the partner organizations in the project, and the division of work tasks between Diálogos, NPHF headquarters and NPHF Chitwan. The learning process has shown the importance to assure the local ownership to the project and clarify roles and responsibilities in theory and practice. NPHF has turned out to be just as strong and reliable a partner as expected, and with strong capacity-building skills in the area of civil society-based projects. During the past 3 years, they have performed the planned project activities and kept the budget lines. They have made the requested quarterly reports and budget estimations and have shown great interest in participating in the future project period. They have participated actively in the preparation of this application. The change of DASAM becoming main responsible towards the donor instead of Diálogos will not influence the collaboration with the local partner or the conduct of the project. If anything changes, it should be in a positive sense including more members to become active from DASAM, where young members are interested in this type of work having the globalization of the Danish production and companies in mind.

In Denmark, students from Danish Universities’ Faculties of Medicine and Public Health will be taught on Occupational Health and Safety at a global level where one of the themes is including experiences from this project. At least four students will be involved in research and thesis writing together with fellow students from Nepal. Materials developed and experiences from the project are shared through WHO and ICOH networks and in conferences and scientific papers so they can be downloaded for use and inspiration at a global level for training of farmers and health care workers.

In Nepal, many actors have already been involved in the project, and the project will continue liaising with strategic actors. Key actors participate in the project’s two steering committees:

The Central Steering Committee in Kathmandu has participation of stakeholders at national level: Nepal Agriculture Research Council, Plant Protection Directorate, Ministry of Health and Population, Department of Labour, Nepal Health Research Council, DILYAK Monasteries, Kathmandu Medical College and NPHF. The Central Steering Committee meets quarterly to supervise project activities, make suggestions for implementation and plan advocacy at central level.

The District Advisory Committee in Chitwan has as its members representatives from farmers organizations, the Institute of Agriculture and Animal Science Rampur, District Public Health Office, District Administration Office, District Agricultural Development Office, Fresh Vegetable and Fruits Production Cooperative, representatives from Agro-vet and NPHF. The District Advisory Committee meets quarterly to supervise project activities, make suggestions for implementation and plan advocacy at district level.

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The logic behind this is to have a local advisory board taking care of project management, whereas the Central Steering Committee - that has several members from relevant ministries - is in a position to try to get project activities streamlined into national planning activities etc.

Internationally, the partners will continue mobilising and raising awareness about the pesticide problem in relevant fora including scientific conferences, working groups etc.

In the project, DASAM contributes with its experiences from Denmark and abroad with international networks on Occupational Health and Safety, teaching, and science, from which DASAM has gained a profound theoretical knowledge and practical experience when it comes to the unique Scandinavian Occupational Health and Safety model and its relevance to low-income countries.

Diálogos has a broad Danish civil society network, many years of experience from similar pesticide projects in Uganda and Bolivia aside from a long presence in in Nepal with project work in the health field.

NPHF has a well-functioning organization that targets public health issues and how they can be resolved with development projects and science. NPHF has experiences from coordinating activities in the Nepali society including farmers and experience in handling donations from United Nations, the Government of Nepal and others.

The concrete division of roles and responsibilities in the project is as follows:

DASAM is responsible towards CISU as the donor. DASAM will deliver specialist input and technical support and will monitor overall project management and day-to-day matters. In Denmark, a project group exists to ensure continuity. The group consists of volunteers with relevant professional knowledge and experience. The group meets at least quarterly to revise project plans, quarterly narrative and financial reports and to provide technical input and supervision to the project when needed. A person from this group has the direct day-to-day communication with the project personnel. Members of the project group will participate in some of the activities in Nepal as technical experts, and the group will pay regular visits to Nepal to monitor project progress.

Diálogos will support DASAM with its administrative skills and expertise in project management as well as skills on gender issues. Moreover, Diálogos’ accountant and secretary will continue to be part of the collaboration with NPHF.

NPHF is responsible towards DASAM for project activities and funds transferred to Nepal. The Executive Chair of NPHF will head the project and act as counterpart to the Danish project group. He will be the approving authority in financial and administrative matters as per the approved proposal and will provide periodic updates to the Board and consult for board members’ involvement as needed. The project personnel in Chitwan will be directly responsible for the day- to-day activities of the project.

To support the core staff of NPHF, consultants may be hired for special tasks like the elaboration of teaching and information materials, documentation studies, revision of budgets etc. Now there are no staff in the project, as the project officially closed down by the end of July 2016. The part time project coordinator and the finance manager work in the office of NPHF in Katmandu, ready to get involved with the new project. The rest of the staff in Chitwan will be re-employed to the extent

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possible. Although wages are not high, people are eager to work with NPHF because of its reputation.

3. Target groups

Different target groups have been chosen for the intervention, all with a strategic view to their contribution to the problem of pesticide use and poisonings, and a view to their potential contribution to the solution of the problem. A detailed description of the strategic choices and the rationale behind the different target groups can be found in chapter 4.

At district level During the baseline study of the first project an epidemiological research of pesticide poisoning cases in Chitwan District was made. NPHF chose 10 Village Development Committees (VDC), 5 VDC included for the intervention and 5 included as control group. The intervention VDCs got the whole project intervention whereas no interventions were undertaken in the control VDCs.The project will now expand its operation to 10 villages in Chitwan District including the five villages where the first project took place (Bhandara, Chainpur, Jagalpur, Mangalpur, and Sukranagar) and now also the control villages (Gitanagar, Jutpani, Kumroj, Padampur, and Shivanagar). The latter have been chosen, because they themselves have expressed interested in the project after seeing the interventions in neighbouring areas. They are therefore considered highly motivated for change. Geographical placement of the ten villages can be seen in the following map:

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Their respective organisations and authorities will select the individuals that are going to receive training. This will help to ensure that the individuals chosen are respected by their peers and thus will be in a position to transfer their knowledge to others after the training. In VDCs that were involved in the first project, those already trained will receive refresher trainings and some of them may be involved in trainings in neighbouring newly involved VDCs together with project staff. Overall, the direct beneficiaries are as follows:

 160 members of the primary target groups (youth, farmers, and women) in old and new VDCs selected by Farmers’ Cooperatives and Mothers’ Groups. Expected sex ratio 60% males and 40 % females.  15 pesticide dealers selected in local agro chemical shops in coordination with the District Agricultural Development Office. Expected sex ratio 60% males and 40% females.  20 professional pesticide sprayers selected in coordination with Farmers’ Cooperatives. They do not belong to any organization but work informally on a daily wage basis paid by the commercial farmers. Expected sex ratio 90% males and 10% females.  45 health care workers from the health clinics in the old and new VDCs. Expected sex ratio 40% males female and 60% females.  90 Female Community Health Volunteers in old and new VDCs. These women are nominated by the village unit and work voluntarily doing home visits to support families with health and nutrition issues, especially for infants. Expected sex ratio 100 % female.  40 teachers from public schools, 2 teachers from 2 different schools in each VDC, will be offered a guide and teaching materials. Expected sex ratio 50% males and 50% females  1500 grade 6 to 10 schoolchildren will be reached by an effort to include ‘pesticide, health and environment’ as a theme in teaching environmental issues in the schools. Expected sex ratio 50% males and 50% females.

Secondary and indirect target groups are the population in Chitwan reaching an approximated 500.000 persons in the district. Advocacy will be directed towards particular groups who hold decision making power or are in a position to otherwise influence others, e.g. local leaders of Farmers’ Cooperatives.

At national level Primary target groups will be:  Stakeholders from ministries, organisations of farmers and agro-dealers. They will be included in the project steering and advisory committees, and they will be encouraged to get involved in advocacy efforts, and in producing, sharing and disseminating IEC materials. Expected sex ratio 70 % males and 30% females  10-20 students and teachers from universities of Nepal. They will be targeted through operational research on the project and revision of teaching modules to include relevant project themes at the university. Expected sex ratio 50% males and 50% females.

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 NPHF as an organisation will be strengthened to advice and advocate for specific matters on Pesticides, Health and Environment, but also more broadly on Occupational and Environmental Health and Safety matters. Expected sex ratio 50% males and 50% females.

During the closing ceremony of the first project in Chitwan, all the stakeholders reiterated the importance of the continuation of the project and strongly urged NPHF to do their best to continue the project. This is the strongest possible indication that the target groups see the project and the project partners as legitimate.

The project has had an active collaboration with the stakeholders and beneficiaries during the planning phase. The kick-off for the project proposal writing was made during a workshop held between partners of the first project (Diálogos, NPHF project staff, NPHF board members and steering committee members) in September 2015 in relation to the evaluation of the first project. After this meeting, NPHF has had several rounds of interactions with the stakeholders in Chitwan to be able to develop the project according to their needs and wishes:

 A roundtable discussion with 34 stakeholders (farmers, farmer’s cooperatives, Female Health Workers, Health Post, Agro-Vet dealers, pesticide dealers)  Meeting with Kerunga Taja Fresh Vegetable and Fruit Cooperative, Jagatpur  Meeting with Sukranagar Women’s Group and Chhaha Women’s Group  Meeting with Bhandara Health post

As for the target group’s influence during project implementation, a District Advisory Committee already exists that meets quarterly to supervise project activities, make suggestions for implementation and plan advocacy at district level. Committee members are the representatives of farmers’ organizations, the Institute of Agriculture and Animal Science Rampur, the District Public Health Office, the District Administration Office, the District Agricultural Development Office, the Fresh Vegetable and Fruits Production Cooperative, representatives from Agro-vet, and NPHF. The composition of the District Advisory Committee has been reassessed recently, and a need was identified to include consumers in order to maximize the work of the committee. The committee will be reorganized accordingly.

4. Strategy and expected results of the intervention

The project has the following objectives linked to the overall objective of improving the health of farmers and consumers by promoting a healthy and sustainable food production in Nepal with a focus on Integrated Pest Management.

Objective 1: To prevent occupational pesticide poisonings among farmers, professional sprayermen and pesticide retailers by strengthening their knowledge, attitude and practice on IPM and organic alternatives to pesticides.

Objective 2: To prevent pesticide poisonings including those due to self-harm and accidents by increasing awareness in the villages among the health care workers about treatment and prevention.

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Objective 3: To facilitate advocacy to reduce pesticide poisonings and pollution by dissemination of knowledge, strategies and materials developed in the project at district and national levels.

Immediate Objective 1

To prevent occupational pesticide poisonings among farmers, men and women, sprayers and pesticide retailers by strengthening their knowledge, attitude and practice on IPM and organic alternatives to pesticides.

Indicators 1. 160 representatives from the primary target groups have increased their knowledge of safe pesticide handling at home and alternatives to pesticide use in agriculture. (Youth, farmers and womens groups) 2. 120 of the trained farmers are sharing knowledge each one with a minimum of five fellow farmers from their Farming Cooperative. 3. 15 trained pesticide dealers give counseling to farmers on protective measures to undertake when spraying pesticides and sell personal protective equipment in their shops. 4. 20 trained sprayermen in vector programs perform safe spraying techniques and use personal protective devices. 5. Empty pesticide containers are not seen left in the environment but disposed and handled in a safe manner within the project area.

Means of verification

 Base- and end-line survey interviews  Focus-group discussions  Inspection of sprayers during spraying Results Activities 1.1 Trained farmers use IPM and safe 1.1.1 Training of 5 new farmers’ groups of 20 farmers pesticide handling methods. each 1.2 Crops are not being sprayed too close to 1.1.2 Training of 60 farmers from old project area harvest or after harvest to avoid pesticide during two courses. Supervision of farmers in 4 residues on food. villages every month. 1.3 Farmers advocate for IPM and safe 1.1.3 Training of 15 pesticide retailers during 5 courses. pesticide handling in the Farmers 1.1.4 Supervision through visits to each pesticide Cooperatives. retailer shop once a year. 1.4 Trained farmers (new and old) are aware 1.1.5 Trainings of 20 professional spray men during 5 of healthier virtues of IPM products and courses. Supervision of professional spray men market their products as such. three times during project. 1.5 Pesticide retailers advocate for and advice their customers on safe pesticide handling and do market personal protective devices. 1.6 Sprayers comply with rules for safety when applying pesticides in vector control programs. 1.7 Farmers, retailers and sprayers dispose pesticide containers in a safe manner.

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Immediate Objective 2

To prevent pesticide poisonings including those due to self-harm and accidents by increasing the awareness in the villages and among the health care workers about treatment and prevention.

Indicators

1. 45 trained health care workers are able to diagnose and treat pesticide poisonings and teach villagers to prevent pesticide poisonings (occupational, by self-harm or accidental) and pollution. 2. 90 trained female community health volunteers are teaching villagers reasons for pesticide poisonings (occupational, by self-harm or accidental) and possible preventive actions. 3. A picture of pesticide poisonings (numbers and reasons) is made available through registration of poisonings in the villages and at the health facilities. 4. 40 trained school teachers have included pesticide poisonings (occupational, by self-harm or accidental), pollution and prevention in their teaching of children in public schools. Means of verification

 Base- and end-line survey interviews among health workers  Revision of hospital registers  Focus Group Discussions with school teachers

Results Activities 2.1.1 Training of 25 new health care workers with 2.1 Health care workers are able to register, three courses in one group. diagnose and treat pesticide poisonings. 2.1.2 Refresher training to 20 health care workers 2.2 Health care workers are teaching in the villages who have received training in first project about prevention of pesticide poisonings. divided into two groups with three courses in 2.3 Female community health volunteers are each group. teaching in their villages about prevention of 2.1.3 Training of 45 new female community health pesticide poisonings. volunteers divided into two groups with three 2.4 School teachers are teaching pesticide courses in each group. dangers, reasons for poisonings and 2.1.4 Refresher training to those female prevention. community health volunteers who have received basic level training in first project divided into two groups with three courses in each group. 2.1.5 Trimestral visits to villages and health posts to supervise health care workers and female community health volunteers 2.1.6 Training sessions for 40 school teachers divided into two groups with three courses in each group. 2.1.7 Supervise each teacher two times while giving classes in schools. Immediate Objective 3

To facilitate advocacy to reduce pesticide poisonings and pollution by a dissemination of knowledge, strategies and materials developed in the project at District and National level.

Indicators

3.1 NPHF staffs, the District Advisory Committee and Central Project Steering Committee members have increased their knowledge and advocate for safer pesticide handling and organic farming among relevant local and national stakeholders.

3.2 Preventive activities such as banning of the toxic class I pesticides, strengthened extension services for farmers on IPM, improved control with illegal pesticides retailers has been initiated and/or implemented

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in Chitwan and/or at national level.

3.3 New knowledge has been created and distributed in articles and at conferences by the project staff in collaboration with local and international universities.

Means of verification

 Key-person interviews  Revision of articles and conference abstracts

Results Activities

3.1 NPHF staffs, District Advisory Committee and 3.1.1 Conduct a one-day seminar for NPHF staffs Central Steering Committee have increased District Advisory Committee and Central Steering knowledge on pesticides and the reasons Committee. behind pesticide poisonings (occupational, 3.1.2 Information (posters (10), radio-spots (6), accidental, self-harm). and IEC materials are revised and/or developed 3.2 NPHF staffs, District Advisory Committee and and distributed in district and at national level. Central Steering Committee elaborate an 3.1.3 Conduct quarterly community meetings in advocacy-plan so preventive measures are on the project villages. the agenda among the population and relevant 3.1.4 Conduct researches in collaboration with local and national stakeholders. Nepalese and Danish university/institutions. 3.3 New knowledge has been created through the 3.1.5 Produce, print and publish articles about IPM baseline and end-line studies and minimum and pesticide, health and environment in another 3 studies during the project lifetime. newspapers and in scientific paper and/or on 3.4 Articles have been published in newspapers conferences. and in scientific paper and/or on conferences. 3.1.6 Organize one conference on pesticides, 3.5 A national conference on sustainable health and environment, where experiences can agriculture and health has been held. be shared with other partners and entities to advocate for healthy and sustainable solutions.

The pesticide use and associated problems is complex: On the one hand, pesticides increase yields, but on the other hand, they also lead to intoxications and environmental pollution. For the time being, we do not believe that pesticide use can be avoided completely in the bulk of agricultural production or in vector control in public health programmes. However, their use can and must be minimized, and this can be done by following the FAO promoted Integrated Pest Management strategies and the exploration of new and alternative pesticides such as bio- pesticides and botanical pesticides. With the aim of minimizing negative health effects in IPM, pesticides are used sparingly and selectively; it is sought to always use the less toxic options; and the use of appropriate personal protection is promoted. Moreover, the focus is on safer handling and storage of pesticides, and on prevention of exposure to pesticides of farm workers and dealers. IPM is at the core of the strategy of the project.

The point of departure of the project is a multi-stakeholder strategy. The project will involve those who handle pesticides directly in their daily work like male and female farmers, agro dealers, and spraymen. All these groups are vulnerable to the dangers of pesticides. The involvement of women in pesticide handling, harvesting, spraying and disposal of outdated pesticides puts them in a particularly vulnerable position, and if they are pregnant, pesticides may also be hazardous to the fetus. The female farmers in the project area are members of a variety of strong volunteer women’s organizations and groups with a focus on women’s issues, improving social welfare and prosperity for all. The project will focus on women´s empowerment at the grassroots level by encouraging

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local mothers’ groups and women´s leaders to be involved in the training workshops for farmers. It will also involve womens’ groups as a formal setting in which knowledge on IPM and pesticides can be disseminated.

The intervention will involve health staff who deal with pesticide poisonings, and who may also play an important role in local teaching and advocacy activities. Finally yet importantly, it will involve school teachers, and school children. These groups have been chosen for strategic reasons because school children and youth are the future farmers, and because they may be important advocates for the IPM message in the farmers’ homes.

Finally, stakeholders who are in a position to not only influence and lead the project but who can also serve as advocates and catalysts for the changes sought by the project have been chosen to participate in the two steering committees of the project.

The intervention will cover mainly two basic principles: Training and awareness rising.

Training will be carried out based on participatory training methods. The main methodology is the ‘training of trainers’ principle or peer-education principle. It has been applied with success in many health programs in Nepal, and in fact, remains a cornerstone of Nepal’s success in health - particularly in maternal and child health issues. Indeed, there are various barriers and enabling factors that affect the success of this principle, but the former project witnessed a satisfactory level of transmission of knowledge and skills from the trained farmers to the fellow farmers. This approach has also proven effective in the similar Diálogos-DASAM projects in Uganda and Bolivia as documented in various scientific publications and recently in a Ph.D. thesis from the University of Southern Denmark (Jørs E 2016). An exceptional success is the case of one illiterate woman from Sukra Nagar with profound leadership skills, who not only dramatically improved her own pesticide-related behavior, but also that of 28 other households in her vicinity. She made them adapt better pesticide-related behavior, as she taught all other women in her womens’ groups about the dangers of the pesticides and how to be safe from them.

The methodology can be described as a pyramid, where the project staff trains the farmers and the farmers train their fellow farmers in both theory and practices. The knowledge in the primary target groups and among key stakeholders is shared by working together, through seminars and courses.

Training sessions are adapted to the peasant’s schedule, usually taking place on Saturdays for a period of 22 weeks, which gives the possibility to follow up on safer handling of a particular crop. It is an integral part of the training that supervision takes place in the villages, so that questions can be addressed as promptly as possible, and the supervisor has a chance to see with this own eyes how things are proceeding and interact directly with each of the farmers.

The strategy with the Health Care workers and Female Community Health Volunteers is to provide trainings and strengthen their capacity to promote prevention, registration, diagnosis and treatment of pesticide poisonings.

Awareness raising/advocacy

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Advocacy will take place at different levels. Locally in the villages, the project will interact with civil society groups (farmers’ communities, womens’ groups etc) to promote the idea of IPM, and those trained in the project will be encouraged to advocate towards their peers.

NPHF has formed advocacy group in each VDC of the project districts. The advocacy group consists of 5 members: VDC secretary/Ex-Chair of VDC, Health Post Incharge, Teacher, Social worker and FCHV. The main objective of the advocacy group is to make the mothers’ group and health Facility Operation Management Committee active. The advocacy group is also formed in order to make VDC allocate budget for refreshment cost for conducting the mothers’ groups and health facility operation management committee. The Social Mobilizers of NPHF make the advocacy groups formed in the different VDCs conduct a meeting twice a month that discuss strengthening the mothers’ group and health facility operation management committee meetings.

NPHF has also formed the advocacy group at the district level. The aim of the advocacy group is to strengthen the mothers’ group and health facility operation management committee.

At the district level, the district advisory committee comprises of local actors who are in a position to promote IPM further. The same goes for the central level, where the members of the central steering committee, who are representatives of the relevant stakeholders including ministries, shall be encouraged to take up the pesticide issue as an important development agenda, and transform the knowledge into policy and programs. During the first project, emphasis was primarily put on advocacy at district level, and the time has now come to raise advocacy to a national level as well.

Awareness campaigns will be directed towards the public through village meetings, radio spots, conferences and newspaper articles and also through teaching in schools. Posters, pamphlets etc. will be part of the advocacy strategy directed towards the general public.

Research experience has been gathered during the first project, and with regard to dissemination, a huge potential has now been created: Experience has been gathered, and posters, pamphlets etc. have been produced that can easily be disseminated to other parts of the country as we have seen it happening in similar projects in Uganda and Bolivia.

Last but not the least, the project aims to present its results in scientific papers and conferences, thereby reaching out to a global audience.

The project focuses on capacity development and on advocacy with a strong interlinkage between the two: Capacity development and practical experience - including the fact that the IPM method has been shown to be feasible in the area - will form the basis for advocacy and dissemination at both local and national level. The project doesn’t plan for service delivery.

As can be seen, the basis for advocacy has already been built into the project. Furthermore, NPHF is a member of other networks that may potentially be relevant for advocacy activities: NPHF is in the process of being part of NCD (Non-communicable Disease) alliance of the Ministry of Health, Nepal. This will help in addressing the risk of non-communicable diseases that comes due to compromise in occupational safety. NPHF is also part of Nepal Public Health Education Institute’s Network (Nepal PHEIN) which will help in addressing farming health safety related information gap through involvement of the academic sector. Further, NPHF is also member of Civil Society

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Alliance for Nutrition, Nepal (CSANN) which aims to ensure qualitative, extensive and inclusive participation of CSO’s in the nutrition movement of Nepal. The major role of CSANN is to inspire, advice, and work as a watch-dog and lobby the government to improve the situation of malnutrition in Nepal. This is also related to agriculture and consumer’s health rights.

The district advisory committee and the central steering committee of the project will each develop a concrete advocacy plan together with NPHF staff. The plans will include but not necessarily be limited to the activities stipulated in project objective 3, to which funding has been allocated in the project. This includes community meetings, IEC materials, information posters and radio spots, research, newspaper articles, scientific papers, and a national conference on sustainable agriculture. A concrete strategy on how to approach key stakeholders at national level will be an integral part of the advocacy plan.

Given the fact that the recently promulgated Constitution of Nepal and Nepal Health Policy 2015 entitles every Nepalese citizen to health as their fundamental right- coupled with growing evidence of non-communicable diseases in the country, including cancers, occupational diseases and self- harm - the proposed project is well placed, well timed and deals with a well prioritized issue.

Nepal has adapted the Multi-sectoral Action Plan 2014-2020 for Prevention and Control of non- communicable diseases, and the proposed project is an excellent example of multi-sectoralism, both at the central level, and even more so, at the field level. Indeed, the project brings together health, agriculture, education and cooperative sector in a single forum. Further, it perfectly brings in the principles of primary health care on which Nepal‘s health care system is founded – including community participation and appropriate technology.

The primary assumption on which this project is based is that the primary beneficiaries are motivated, willing and able to participate in the project activities. This has certainly been the case in the first project, which was also shown in the evaluation, and we have no reasons to believe that it would be any different now. The project staff has proven to be able to motivate primary beneficiaries to implement what they learn, and they have proven to be able to plan and implement teaching activities etc. in ways that take into consideration socio-cultural and other issues. One important way of overcoming scepticism has proven to be “learning by doing” and working together with the farmers on assigned fields where the IPM principles have been used, and the farmers have been able to get first-hand experience with the results.

The project will be working with pesticide dealers and professional sprayers. This requires particular attention, since they may feel that the project is threatening their livelihood. However, experience from other projects has shown that it is possible to work with these groups when the key messages are about minimizing the use of the most toxic pesticides and handling the pesticides safely. Actually, the dealers have already expressed their interest in learning about protective measures.

The steering committees both locally in Chitwan and in Kathmandu have had some challenges during the first project, but measures have now been taken to diminish the problems. This includes appointing new members and making a clearer definition of roles. It also includes advocacy training for the central steering committee in Kathmandu, whose members will play an important

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role in future dissemination of knowledge and results. It is therefore safe to assume now that the members of the steering committees will play an active role in the project.

Nepal has a new constitution, and the country seems politically relatively stable at the moment. Though there is some dissatisfaction regarding the constitution in a fraction of the population, there is a strong possibility that solutions will be found through political dialogue. It is expected that the federal structuring of the country and election of local bodies shall take place in the near future, and it is unlikely that there shall be any major political upheavals that would affect the implementation of the project.

Nepal was hit by severe earthquakes in 2015, and the risk obviously still exists that more earthquakes or other natural disasters occur. Again, the project will try to be as flexible as possible when making their plans. Notably, the earthquakes in 2015 only gave rise to a minor delay in activities, and staff was quick to resume work.

Last but not the least, there is always a risk of corruption in projects of this kind. The risk of this will be mitigated by strict internal procedures, thorough analysis of financial reports and immediate response in case suspicions of corruption arise.

Results and experiences of the project will be compiled and presented in scientific papers and at national as well as international conferences as was the case during the first project.

On a more day to day basis, the activities of the project will be regularly monitored by the field staff to collect feedback from the farmers and the other stakeholders and to help to improve the ongoing activities. The local monitor team also includes the IPM farmers facilitators, and cooperative members. Central NPHF staff regularly monitors and is involved in major events, and monthly staff meetings will be held within NPHF.

Quarterly reports will be sent to the Danish project group summarizing achievements and challenges, and the group will provide technical inputs to the project when needed. One person from the group has the direct day-to-day communication with the project personnel. The regular meetings held by the project personnel and steering committees in Nepal and Denmark will ensure that relevant actions are taken if the conditions that the project is conducted under fail in one way or the other.

A baseline survey including health and agricultural matters of relevance to the project will be elaborated in the new villages. An end-line survey will be conducted to document expected positive changes in knowledge and behavior as seen from indicators. Furthermore, in general, information on the indicators will be gathered by means of questionnaires and interviews to be analyzed with sound quantitative and qualitative analytical methods. Monitoring visits from the Danish project group are planned to take place at least once a year. An external evaluation is planned and budgeted for that will analyze the degree to which the project has been able to reach the expected outcomes and provide recommendations as to whether project activities should be continued and in which form.

5. Phase-out and sustainability of the intervention

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It is our overall aim that when the project activities phase out, they will continue as mainstream activities among target groups and stakeholders. The project and its activities respond to the needs of target groups. In the midterm evaluation, its high relevancy shows from the responses, e.g.one farmer expressed: “Oh my god, I am still alive despite careless handling of poison”. As this project concept and approach are innovative in the project area, the target groups wished to learn more.

NPHF’s extensive governmental expertise has created good possibilities for continuous lobbying, negotiation and information sharing with policy makers on the topic of farming, health and environment, and this will help to bring the pesticide issue on the agenda and make this project sustainable and scalable. Farmers in the project will have improved their production by implementing healthier and more sustainable IPM production methods. This will not only affect their own health but also the health of consumers in Nepal. Eventually, a strong voice from the consumers may help forcing the farmers to use pesticides in a proper way and to seek ecological alternatives.

Health personnel will have improved skills in the prevention and treatment of pesticide poisonings through this project. Recent discussions at the Ministry of Health and Population promised an interest and thereby possible sustainability “as the project is offering training of staff, improvement of registration, documentation of health problems and improvement in food safety all in the interest of the health system”, as expressed by a senior public health officer during the evaluation.

Hoping that there shall be government-run programs on IPM and pesticides as an outcome of advocacy, the knowledge gained by the project, including the training manuals developed, shall be a useful contribution to the future endeavors as well.

NPHF shall make efforts for the local stakeholders such as the farmers’ cooperatives and local government bodies to take up responsibilities to ensure that the work shall be carried further. The project is expected to become socially sustainable if a) farmers see an economic and health advantage in IPM or organic farming, b) pesticide dealers embrace the economic and human aspect in selling and guiding appropriately and c) health personnel experience an increasing number of pesticide poisoning cases forcing them to take action. Experience in similar projects has already shown that social sustainability is a reachable goal for a project of this kind. It is important to stress that the project builds on existing structures in the project area (farmers’ cooperatives etc.).

The project is expected to become politically sustainable if the decision makers after advocacy and documentation of the magnitude of the problem consider the problem big and serious enough to take action on. In similar projects in Uganda and Bolivia, the strategies and materials of high quality have given rise to interest from other organizations, e.g. farmers ‘cooperatives, operative branches of ministries, teaching institutions and other NGOs who have adopted the theme. They themselves have asked and paid for courses, which is a reflection of the necessity of the intervention. If the same level of interest is reached in Nepal, the project has a fair chance of becoming politically sustainable.

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According to our previous experience, IPM farming has shown to be economically beneficial and some farmers have actually changed their farming to organic farming because of the economic benefits. Thus, for the primary beneficiaries the project should be financially sustainable.

The project partner, NPHF, has existed for many years and has many different activities. There is therefore no risk of the project creating financial dependency on the funding provided in the project for the organization to continue.

6. Planned intervention-related information work in Denmark

DASAM aims at informing about project activities and experiences with the purpose of raising awareness about the problems and possible solutions linked with pesticide use in the global South. This will be a continuation of the information work that has been done so far by the project group members and others. Notable examples of the information work done until now are mentioned below. As can be seen, the information work is not limited to Denmark but also reaches out internationally, and particular emphasis is put on reaching out to professionals and future professionals.

Information work is done through taking part in networks discussing and advocating for solutions to global issues on occupational and environmental health. Professional networks are used, e.g. ICOH (the International Commission on Occupational Health), WHO networks, and international agricultural and mining networks on occupational health and safety. Results from Nepal and other Dialogos/DASAM projects have been published in scientific papers and have been presented at several international conferences in both low- and high-income countries. Some information on the activities can be found on DASAM and ICOEPH websites (www.dasam.dk, www.icoeph.com).

Teaching in Danish universities has been mainstreamed during the past years, and every year hundreds of students are being taught on OSH in low-income countries, poisonings with pesticides and mercury – something that would not have been possible without the experience from the Diálogos/DASAM projects.

Another media strategy has been to carry out professional journalistic work through articles in the press, as well as to produce radio programs about the development work. A journalist visited the project in 2015, and the outcome was two articles for DialogosNyt that is distributed to all members of Diálogos, and one 7 minutes broadcast on P1 about pesticides and about the project.

Apart from the above, unforeseen information activities happen, e.g. agronomists from projects in Nepal, Uganda, and Bolivia were interviewed on Danish television when visiting Denmark a couple of years back.

Contributions from DASAM, Diálogos, Danish universities and others in the information work have so far amounted to considerable sums and have supplemented the funds granted through the project.

Examples of documentation/research studies from the Nepal project:

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-Neupane D, Jørs E, Brandt L. Pesticide use, erythrocyte acetylcholinesterase level and self- reported acute intoxication symptoms among vegetable farmers in Nepal: a cross-sectional study. Environ Health 2014; 13: 98th

- Varma A, Neupane D, Bonde JP, Jørs E: Is prevention of acute pesticide poisoning effective and efficient, with Locally Adapted Personal Protective Equipment? A randomized crossover study among farmers in Chitwan, Nepal. Med Lav 2016; 107(4): 271-283.

- Kofoed D Jørs E, Varma A, Thomsen JF. Symptoms of pesticide poisoning and blood cholinesterase depression after spraying with an organophosphate compared to a non-toxic pesticide is there any difference? Submitted to Journal of Environmental Health.

-Pesticide Poisoning in Chitwan, Nepal: A Descriptive Epidemiological Study. By Deepak Gyenwali, Abhinav Vaidya, Prakash Khatiwada, Daya Ram Lamsal, Shrikrishana Giri. Farming, Health and Environment Nepal Project, Nepal Public Health Foundation, Kathmandu, Nepal.

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