fundament voor opschaling from pilot towards impact Jaarverslag 2013 FIRST PHASE IN NEPAL (2007-2013)

Karuna Founda on : First Phase in Nepal 1 1 ©Karuna Founda on, 2014

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Photos on front page: (Henk Braam)

Above: Newborn baby at Bhokraha Sub-Health Post Sunsari

Below: A mother with her daughter who has mul ple disabili es.

Text and produc on coordina on: Monitoring & Evalua on Sec on 2 Contents

A Dream I

A Life Awakening Journey III Introduc on 1 Karuna Founda on in Nepal (2007-2013) 4

Project I: Share&Care (SC) 6

Project II: Training of Professionals 23 Training and Capacity Building 25

Project III: Inspire2Care Project 29 Community Based Rehabilita on (CBR) 32

Project IV: PAAN 41 Partnership 43 Financial Summary 46 The Organiza on 51 Our Donors 52 Plan to scale up Inspire2Care (2014-2017) 54 The Blue Guideline 57

Language Edit By: Prawin Adhikari Printed By: Jagadamba Press, 01-5250017-19 Design and Layout By: Gopal Babu Ghimire [email protected]

Karuna Founda on : First Phase in Nepal 3 by strengthening exis ng health system and empowering communi es

4 A Dream In March 2007 Karuna Founda on did not exist. In April, we (the founder René aan de Stegge, me and child rights ac vist/researcher from Nepal, Deep- ak Raj Sapkota), got to know each other. In May 2007 we formulated our vision and our mission: reduce the number of children with a disability and improve the lives of children with a disability in developing countries. But we also had a dream: to develop a model which could be replicated so that many more children and their families could benefi t. Now, at the beginning of 2014, this dream has be- come reality. Karuna Founda on was able to in- Be eke de Gaay Fortman spire communi es to work on preven on of avoid- able childhood disabili es and on improvement of General Director health care for the en re popula on with special a en on for children with a disability. By improv- ing access to adequate maternal health care, risks of having a newborn child with a disability were reduced. According to calcula ons, in the past 7 years we have prevented 750 children from being born with a birth defect. The lives of more than 500 children with a disability have been improved, and communi es have become more recep ve and more inclusive towards children and adults with a disability and towards their families. Around 60% of the villages, in which we introduced the projects, will con nue the ac vi es with their own resources, knowledge and commitment a er the project period. So it is clear that the system has started to change. René aan de Stegge Besides the important results directly related to our goal there were many other results. The abil- Founder ity of poor communi es to claim ownership and to

Karuna Founda on : First Phase in Nepal I 5 take their lives into their own hands has in- pletely new phase. In the fi rst 7 years Karuna creased. Local, district and central authori es Founda on developed a promising and inno- serve their people in a more accountable way va ve approach towards improving the lives by implemen ng disability and health poli- of the poorest of the poor for this genera on cies and laws more eff ec vely and effi ciently and genera ons to come and towards creat- than before. Finally, other development or- ing an inclusive society, including persons ganisa ons, both small and established larg- with disabili es and other vulnerable groups. er ones, were inspired by the results of a de- The two developed models, named Inspire- centralized and cost eff ec ve approach and 2Care and Share&Care,have been locally em- adopted some of the strategies to increase braced in several villages of Nepal. We are community ownership and sustainability in very close to establishing a joint-venture with their own programmes. Liliane Founda on and Netherlands Leprosy Relief to jointly scale-up our Inspire2Care Reaching the children with a disability, ful- program from the community level to the fi lling their needs, and crea ng an enabling Ilam and Rasuwa districts. environment so that they can fully develop themselves, has become a reality because The Share&Care model is also ready to be fur- of the dedica on, professionalism and learn- ther developed and fi ne-tuned on a district ing a tude of the team of Karuna Nepal, level in the two districts men oned above, the leadership and inspira on of the Board, preferably in partnership with established or- and the support of the advisors and donors ganisa ons. If these two models can be suc- of Karuna Founda on. Without our founder, cessfully implemented in these two districts, René aan de Stegge, who inspired us with his we hope that both models can be replicated dream, led us and mo vated us to make our in the whole country and even beyond the common dream come true, we wouldn’t have borders of Nepal. This is our next dream. come this far. We feel proud of having planted a small seed In the past seven years we have made many that is now growing bigger and bigger. We mistakes, learnt from them and improved our feel challenged to meet the level of expecta- approach, performance and strategies. We ons of the people who have the right to lead are very grateful and indebted to the commu- a dignifi ed life, as well as of our partners and ni es of the fi rst phase that worked so hard, donors. We are commi ed to saving children and invested resources, me and people. It is from disability, one by one, to improving the due to their success that the me has come lives of children with a disability, one by one, to scale up some of the programs. Therefore, and to reaching the poorest of the poor, one we are grateful to the people from the com- by one. This is only possible with the con n- muni es who taught us so many things. ued trust, support and joint eff orts of the peo- ple who we try to serve, and of our team mem- At the moment of the publica on of this re- bers, partners, donors and Board members. port, we are at the verge of entering a com-

6II A Life Awakening Journey

It’s been amazingly great to be able to express my- self in this report. While wri ng this page, I trav- elled back in me and I was reliving again those six great years with the Karuna Founda on, trav- elling from one village to the next in Nepal, in In- dia and in Holland together with the thousands of people who have contributed to our work. During my journey, I worked with extremely poor people, people having a good life, professionals running a er career and money, and the passionate peo- ple aiming for eff ec veness and impact. Inequal- ity is one of the deepest concerns I encountered. I have heard some profound refl ec ons and retro- Deepak Raj Sapkota spec ves! I can undoubtedly say that this period was the most blissful and life awakening journey Country Director for me. I am no more the same person as I was when I joined and started Karuna Founda on with my great friends and inspirers: René, the Founder and Be eke, the Director. My strong commitment in the years to come is to inspire and change the lives of people who still don’t have a dignified life in this modern era.

My Nepalese colleagues have supported every move and decision uncondi onally; they have en- couraged Karuna to set higher goals; and gave their best performance. Thank you everybody for this generosity and humility ! In terms of organiza on, the voyage started with three people from Holland and Nepal and now we are a team of 21. A team of strong and dedicated professionals commi ed for eff ec veness and crea ng impacts. To have a team of commi ed people is half a race won!

Karuna Founda on : First Phase in Nepal III7 In terms of result and impact of our work, we In terms of preven on of childhood disabili- are quite op mis c and inspired by what we es and rehabilita on of children and adults have achieved. The endorsement and apprecia- with disabili es following Community Based on from many organiza ons and individuals is Rehabilita on Matrix, we have made our suc- rewarding. But the most sa sfying part for us cessful reach to more than 750 Children and is to see the changes in the quality of lives of adults with disabili es with the empower- children with disability and their families, and ment of their families. Early detec on cam- the changes in the community perspec ve. In paigns were conducted in various schools fo- terms of health Insurance, the program is cur- cusing on eye, ear and malnutri on for early rently opera onal in 7 villages with about 8000 detec on of disability. Likewise, by strength- households covering a popula on of approxi- ening maternal child health programs includ- mately 40,000. On an average more than 30 ing but not limited to programs like preg- percent of the total households have been en- nancy registra on, antenatal care visits, child rolled as member households and 80% of popu- birth planning, and immuniza on, and nutri- la on (both members and non-members) have on promo on, we are sure that many chil- u lized improved health services. We have es- dren were prevented from disabili es. tablished func oning birthing centers, organized people, iden fi ed concerns, and proposed pos- With all these concrete founda ons, we have sible solu ons. These are some of our signifi cant decided to move further covering a specifi c achievements that give us mo va on as well as geography i.e. Ilam district to demonstrate ex- add challenges. The confi dent feeling of ‘we can pansion and replica on of a proven model at a make it!’ which emerges within the community is larger scale. This new challenge we have set for the most rewarding proof of development. us is highly mo va ng to aim higher.

Progressive changes in the policies, higher At last, my humble thanks to all people in- and visible commitments at policy mak- volved in the process, from an isolated re- ing levels, and increased resource alloca- mote community to na onal policy bodies, tion are the examples of successful lobby- my colleagues from Nepal offi ce to Holland ing and networking. Serving as an INGOs Offi ce, all the donors and well-wishers, our steering committee, being nominated for partners and most importantly the children the national level policy drafting body for with disabili es and their families and the Health Insurance, and creating accessibility children born without disabili es. Thank you guidelines are the examples of recognition everybody for either crossing or travelling the and acceptance of Karuna’s approach. journey with us!!

8IV Introduc on Vision Approach Karuna Founda on believes in a world in Karuna Founda on’s approach is entre- which each individual, with or without dis- preneurial and ac on-oriented, working abili es, has equal access to good quality towards se ng up and strengthening ex- health care, can lead a dignifi ed life, and can is ng local health care systems, s mu- par cipate as much as possible in community la ng community par cipa on and re- life. Karuna Founda on was founded in the sponsibility - including health promo on, year 2007 by a Dutch entrepreneur, René aan preven on and rehabilita on - through de Stegge, with the aim of reducing the inci- empowerment of communi es, with the dence of preventable disability and improv- aim of: ing the quality of life of children with disabili- es in developing countries. • Reducing children born with birth defects by 5-10% by ensuring safer pregnancy and Mission safer delivery; and reducing the number Karuna Founda on strives to decrease the of children with malnutri on, diseases number of birth defects and disabili es and disabili es by 30-40% by ensuring among children in developing countries safe infancy and a healthy childhood. by improving exis ng health systems and • Improving the quality of life of Children empowering communi es and vulnerable with Disabili es, through be er health groups within these communi es, such as care, educa on, par cipa on, empower- children with a disability, mothers and new- ment and livelihood. borns, to develop their capacity to claim their right to healthcare. Besides, Karuna works to • Developing a sustainable and replicable improve the quality of life of children with a dis- health care model. ability and their families.

Core Values

Living a dignifi ed Power to People and Con nuous life, not as favor, but Self-reliance improvement and as a basic transparency human right

Karuna Founda on : First Phase in Nepal 1 The Cause Karuna Founda on Heralds

Prevalence of childhood disability and its of childhood disability and crucial interven- defi ni on is s ll a conten ous issue. How- ons ,together with awareness crea on, can ever, it is well established that disability is prevent disability acquired at a later stage in largely preventable. Strengthening maternal life. Karuna Founda on has also devoted its and child health care, especially ensuring eff orts towards rehabilita on of children with safe pregnancy, safe delivery and safe infancy disabili es in their communi es, following with a healthy childhood, are considered crit- Community Based Rehabilita on (CBR) guide- ical health system approaches towards pre- lines developed by the World Health Organi- ven ng disability. In addi on, early detec on za on (WHO).

A physiotherapist counseling parents of children with a disability

2 Principles Development Commi ees (DDC), and com- Karuna Founda on’s eff orts are based on muni es are mobilized to an op mal degree a set of principles. One of the principles of so that ac vi es are oriented towards own- Karuna Founda on is to work in coordina on ership-building and sustainability. In carrying with stakeholders to bring about a mul plier out coordinated eff orts in the community eff ect. This coordinated eff ort is carried out development process, Karuna Founda on by empowering the community and nurtur- Nepal follows a Blue Guideline for involving ing leadership within the community (Power stakeholders (see page 57). to the People). Local resources from Village (http://www.karunafoundation.nl/aanpak/ Development Commi ees (VDC), District blauwe_draad_uk.html.)

Principles of Karuna Founda on

Local Resource Blue Guideline for Mobiliza on and involving Cost Effi ciency at all stakeholders layers

Mul plier Eff ect by Power to the working with gov- People ernment system and coordina on with other stakeholders

Karuna Founda on : First Phase in Nepal 3 Karuna Founda on in Nepal (2007-2013)

Country Director KFN (le ) and SWC Member Scretary (right) signing a KFN project Agreement

A er registering with the Social Welfare years period star ng in 2007, Karuna Foun- Council (SWC) of Nepal as an Interna onal da on aimed to set up be er health services Non-Governmental Organiza on (INGO) in from exis ng local health ins tu ons; s mu- August 2007, Karuna Founda on Nepal (KFN) late community par cipa on and responsi- started its opera ons in Rasuwa, Kavre and bility through its Share&Care project (SC); Sunsari districts, with the country offi ce in train health workers to prevent avoidable dis- Kathmandu, and fi eld offi ces in Sunsari, Kavre abili es by developing their own preven on and Rasuwa. To support the programs, organ- projects through Training of Professionals iza on and fundraising, there is a small offi ce project (ToP); facilitate comprehensive pack- in Arnhem, the Netherlands. Over the six age for improvement of quality of life of chil-

4 dren with disabili es through Inspire2Care synergy between KFN’s projects and na onal (Community Based Rehabilita on and Disa- policies through Policy Advocacy and Net- bility Preven on project) and, lobby to bring working (PAAN).

Inspire2Care Training of Pro- (I2C) fessionals (ToP)

KFN’S Projects 2007-2013

Policy Advocacy Share&Care and Networking (SC) (PAAN)

Karuna Founda on : First Phase in Nepal 5 Project I: Share&Care (SC)

As an entrepreneurial organiza on, KFN has ingful par cipa on from the very fi rst day. always sought to ini ate programs in a com- This way members of the community become munity that understands the value of self-re- a part of the process, carry out the designed liance, takes ownership and aspires to bring ac vi es from the very beginning and realize about substan al changes in their lives by the principle of cost-sharing. The SC program recognizing self-esteem. Respec ng the role has been designed in such a way that families and power of the community as a force of par cipate in every stage of the program evo- change, KFN has ac vely welcomed its mean- lu on, which includes a fi nancial contribu-

Health worker of Bhokraha talking about health insurance

6 on, and they also play the role of catalyst by ma on about the pre-requisites to launch the convincing the local authori es/bodies of the program and benefi ts of the program. Once the value of the program and by taking advantage community is ready to implement the program of exis ng opportuni es. a er an ini al assessment, a baseline survey is conducted, insurance package is defi ned; and Process training and capacity-building of HFOMCs and The incep on of Share&Care program (SC) oc- health workers is carried-out. HFOMC is both curs when a community feels the need for bet- the owner of and leader for this program. KFN ter health care and improved quality of life for par cularly facilitates the membership cam- disadvantaged groups. Once Karuna Founda- paign and overall technical issues during the on, together with the community, agrees to implementa on phase. The basic opera onal explore the possibili es of star ng the SC pro- framework of SC is shown in the following fi g- gram, a mee ng is organized with community ure. As shown here, the fi nancial resource for leaders, including representa ves of the poli - the program comes from the community, lo- cal par es, Health Facility Opera on and Man- cal health ins tu ons, and local government agement Commi ee (HFOMC) to share infor- where KFN also contributes during the fi rst 3 years. Process of Implementa on of Share&Care

Supervision/ Meeting with Local Monitoring and Leaders/In-charge Evaluation of (S)HP

Recruit HR/Upgrade Health Facility/ Community Ready to Implement/ Initial Program Implementation Agreement

Annual Planning and Training Capacity- Final Agreement Building / Defining Package

Membership Campaign

Karuna Founda on : First Phase in Nepal 7 Financial Resources for Share&Care

Resources Resources + +

District Health Office - Local Health Share & Care Community Institution • •Improved health care •Prevention •Rehabilitation Livelihood

Training on Training on leadership & leadership & accountability building independence Financial support 23 years

Karuna Foundation

Saving children from disability, one by one

Our Share&Care program is guided by fi ve major objec ves.

• Health Promo on and Childhood Disabil- out the social, medical and educa onal ity Preven on is focused on ac vi es re- goals of the child and includes a plan to lated to the improvement of maternal and achieve them. The individual projects are child health like promo ng registra on of carried out by a Community Based Reha- pregnancy at health ins tu ons; pregnan- bilita on Facilitator (CBRF) together with cy care, including nutri on, immuniza on the parents of the child. and regular antenatal checkup; promo on • The Community Based Health Insur- of ins tu onal delivery, awareness ac vi- ance (CBHI) scheme pools the costs and es, etc. fi nancial risks of health care. It includes • Community Based Rehabilita on (CBR) awareness raising ac vi es; membership is focused on iden fying Children with campaigns where community people pay disabili es, assessing their situa on and to become members of the scheme; man- developing rehabilita on plans togeth- agement of addi onal drugs beside those er with families based on the individual available through the free health care child’s assessment and diagnosis. This sets program; and, lab services and referrals

8 Five Major Objec ves of Share&Care

Health Promo on and Disability Pre- ven on

Community Based Reha- Community Good Governance bilita on of Based Health & Local Capacity Children with Insurance Building Disability

Community Based Enterpreneurship

Livelihood program in Bhokraha

Karuna Founda on : First Phase in Nepal 9 for secondary and ter ary treatment and ance are the basis for the implementa on life insurance. This cashless scheme that of all components. The project leads to ad- aims to cover the whole popula on of di onal aff ordable and accessible services village is managed by the Health Facility at local health ins tu ons. The program Management and Opera on Commi ee. is managed by the HFOMC, which is a lo- cal structure with members represen ng • Community Based Entrepreneurship in- the community, teachers, Female Com- cludes livelihood schemes for marginal- munity Health Volunteers (FCHV), Health ized families and families of children with In-charge, and the VDC Chairperson. Fur- disabili es. It enhances local entrepre- ther, training on leadership development neurship, promotes local skills, and helps and program management, and engaging to explore new opportuni es in the local them in fi nancial and overall management level. Loans are provided to the poorest has simultaneously resulted in local lead- of the poor so they can increase their in- ership-building and ownership of the pro- come and thus improve their living stand- gram. ards, make regular savings and become members of the insurance scheme, which ul mately ensures be er health and nutri- on of children. • Good Governance and Local Capacity Building: The Health Facility Management and Opera on Commi ee manages the fund in a transparent manner and publish- es status updates periodically. Along with the fi nancial contribu on, the households also oversee the management and de- mand access to the status updates, which has been now established as an en tle- ment. Community members par cipate in planning and designing workshops, and a end review mee ngs. All these mecha- nisms contribute to the prac ce of good governance. Good leadership and ac- countability towards the local popula on ul mately contribu ng to good govern-

10 Year-by-year SC Program implementa on Status

S.N. VDCs 2008 2009 2010 2011 2012 2013 Ra onale for phase-out 1 Syafru 2 Dhaibung Inadequate community support 3 Naryansthan Inadequate community support 4 Chapakhori Management problems, depen- dency on KFN too high 5 Mechchhe Management problem, lack of ownership of local commi ee. Program is s ll running at very small scale but not including CBR. 6 Hansposa Dependency on Karuna too high and not suffi cient local account- ability 7 Bhokraha 8 Madhesa 9 Bhaluwa 10 Aurabani Total VDCs 2 6 8 7 7 7 New VDCs 2 4 2 2 0 0 Phase out VDCs 0 0 3 0 0 0

Legend Pilot VDC Phased outVDC Ongoing VDCs Func onal with limited service Year-by-year evolu on of SC Program in diff erent Village Development Com- mi ees (VDCs) of Rasuwa, Kavre and Sunsari districts The SC program was ini ated in Mechcche we learnt about the community dynamics and VDC of Kavre and Hansposha VDC of Sunsari local ideas while the program was evolving. In at the end of 2007, and was consolidated in 2009, the program was further expanded in 2008. As it was a new program for us as well, Chapakhori VDC of Kavre, an adjoining VDC

Karuna Founda on : First Phase in Nepal 11 of Mechchhe, because some community VDC of Sunsari district. All basic condi ons leaders were inspired by the fi rst VDC. By were present for successful implementa on the end of the year, Narayansthan, an ad- of SC and people were developing an ap tude joining VDC of Chapakhori of Kavre, also for the program even though it was very dif- wanted to adopt the program, and there- fi cult to get meaningful poli cal commitment fore it was introduced in Narayansthan from the poli cal leaders. Even though they too. In case of Sunsari, the leaders from were always suppor ve in discussions, their Bhokraha VDC were enthusias c to have support could not be translated into reality. the program brought to their community. The ambiguous role played by Health Profes- Interes ngly, the Syafru VDC of the Rasuwa sionals also was against the principles of the district where KFN was implemen ng only program. As an entrepreneurial organiza on, the Community Based Rehabilita on pro- following the Blue Guideline(con nue with gram, along with four other VDCs of Ras- the project:Yes/No), we therefore decided to uwa came to know about the SC program end the program in August 2010, not going and approached us to introduce the pro- along with the general trend of development gram in their VDC. At the end of 2009, the actors to con nue for years and years with- program had a presence in 6 VDCs (with out concrete results. 1799 Families), Unfortunately, in 2010 the program could not go ahead as planned in The year 2010 became a year of retrospec- one of the fi rst villages of KFN – Hansposa on. There were more requests from Sun-

Membership Campaign in Kavre

12 sari and Rasuwa districts. Karuna introduced faced and the achievements made in past 4 Share&Care in Dhaibung VDC of Rasuwa, years. The conclusion was simple and solid: where the poli cal commitment was higher. the achievement was phenomenal and we A baseline survey was conducted in Mad- should con nue on a larger scale, with some hesha, Ghuski and Narsingh, three VDCS in governing principles, i.e.: change agent are Sunsari, where the local and district-level po- the people themselves, not us; people should li cal leadership showed an interest. But, by realize the need for change; any new ini a- the end of the year, Narsing and Ghuski could ves must go together with exis ng programs not show the commitment required to start and structures; there has to be wider poli cal SC, which resulted in the decision to refrain support and coopera on; and the district and from star ng Share&Care there. KFN also central level authori es must be involved, reached the conclusion that in Dhaibung of etc. Furthermore, it became clear that it is Rasuwa district, and Narayansthan of Kavre produc ve to implement such programs in district, SC could not achieve the desired goal clusters rather than in a sca ered way. Un- due to lack of coordina on between key surprisingly, all 7 villages were able to run the players within the VDCs. Fortunately, Madhe- program successfully, making some signifi - sha VDC was all set to go, and the program cant progresses in 2012. was launched successfully. The year 2013 was a year of prepara on for In 2011, Mechhe, Chapakhori, Syafru, Bhokraha scaling up the SC program. Madhesa and Bh- and Madhesha achieved new heights by being aluwa were able to maintain the momentum able to enroll almost 40 percent households by enrolling almost 50% households, where- into the program, locally raising almost a mil- as Bhokraha and Aurabani VDCs maintained lion Nepalese Rupees for the program. Concur- the momentum gained in previous years rently, two new VDCs from Sunsari – Bha- luwa and Aurabani – came with proposals to commence the program. A er assessing the minimum criteria to start the program in light of our learning over the past years, we decided to collaborate with these two VDCs as well. By the end of the year 2011, there were altogether 7 VDCs implement- ing SC.

The year 2012 became quite important for us as this was the fi h year of our op- era on in Nepal. We assembled quietly and refl ected seriously on the challenges Signing of 3rd year agreement of Share&Care, Bhaluwa, Sunsari

Karuna Founda on : First Phase in Nepal 13 with nearly a quarter of households enroll- desired, but the program s ll exists there in ing into the program. Syafru also completed some forms. three successful years of running the SC pro- gram, but took a longer pause to prepare for In 2013, based on what we had learned, we the renewal and membership campaign for were all set to implement the SC on a larger the fourth year. We are asser vely backing scale, covering en re districts. Following the up the process. We had a plan to phase out na onal ini a on of pilo ng health insur- from Kavre in 2013 a er the fi h year of pro- ance in fi ve districts of Nepal, we submi ed gram implementa on. However, due to lack our formal request to the Ministry of Health of ownership by the Health Management and Popula on for partnership in Ilam dis- Commi ee, and management problems in trict, with the knowledge base we had gained Chapakhori, the program could not con nue by implemen ng SC for half a decade in vari- into the fi h year. In Mechche, however, the ous villages of Nepal. Due to the prolonged popula on had high regards for the program, na onal insurance policy formula on pro- but there was no leadership from the Health cess, the Karuna team spent considerable Management Commi ee. The Health In- me in further developing the other commu- charge was a stable factor, and was s ll mo- nity model – Inspire2Care, based on Preven- vated to con nue. The insurance scheme on & Rehabilita on and incorpora ng les- was shrinking and could not con nue as we sons from Share&Care.

Opening of membership Campaign in Bhaluwa

14 HF within reach ofreach of those bers outbers % mem- holds house- of total of total bers outbers % mem- ment period ment % of total total holds house- al re- new- Total % Total al % Re- new- % of total total holds house- ber holds Mem- house- total total % of holds house- newal Total % Re- % Total total total holds house- bers of bers New % mem- New % of HF holds reach reach within House- ons Total Total Popu- la Total Total holds House- year year plete plete 34 485 2,5353 3,200 315 19,368 2,0802 1,290 188 165 7,023 392 1,567 839 5 9,200 164 551 9,75 1,018 451 36 43 394 3,604 55 34 634 25 421 14 415 118 58 423 43 564 24 55 33 18 419 27 43 477 35 68 236 37 595 43 15 90 38 441 19 517 40 45 71 19 40 76 24 29 40 38 62 15 23 45 70 Com- Syafru Syafru (2009) Bhokraha (2010) Madhesa (2010) Aurabani (2011) Bhaluwa (2011) Total 7,517 41,730 4,886 1,713 23 1,878 57 25 1,836 24 58 1,112 54 25 25 39 1 Year 2 Year 3 Year 4 Year Agree- Recent Year-by-year status of membership in current VDCs of Share&Care Program VDCs of Share&Care in current of membership status Year-by-year

Karuna Founda on : First Phase in Nepal 15 Program Coverage and Key outputs of SC program 2008-2013

S. No. Indicators/VDCs 2008 2009 2010 2011 2012 2013 1 Community Based Health Insurance Cover- age 1.1 VDCs covered 2 6 7 7 7 5 1.2 Total number of households in coverage 5,483 10,364 10,089 9,301 9,312 7,515 VDCs 1.3 Total popula on of VDCs 31,000 61,147 59,525 54,969 54,955 41,730 1.4 Total Member Households 1,046 1,799 1,927 2,114 2,294 1,907 1.5 member popula on 4,006 10,794 11,370 12,472 13,010 11,250 1.6 % member households of total households 19% 17% 19% 23% 25% 25% Service U liza on CBHI 1.7 Number of persons Referred 35 NA 285 445 523 530 1.8 % referral out of member popula on 0.9% 0.0% 2.5% 3.6% 4.0% 4.7% 1.9 Total OPD Visits 21,000 50,000 50,844 69,399 60,425 42,030 1.10 % OPD visitors of total popula on 68% 82% 85% 126%* 110%* 101%* 2 Upgrade Health Facili es 2.1 Renova on of Health Facili es 0 6 5 0 0 0 2.2 Support to /establishment of birthing 114551 centre 2.3 Laboratory establishment 0 2 1 0 0 0 2.4 Addi onal HR by commi ee 7 30 18 0 0 0 3 Livelihood 3.1 Total families Supported (Number) 43 88 66 214 30 56 3.2 Total Saving (NRs ) N/A 42,688 18,540 75,363 81,414 86,369 3.3 Skill Development Training 0 0 1 1 0 3 4 Health Promo on and Disability Preven on 4.1 Ward-level and School Health Educa on 0 0 21 33 32 3 4.2 Health Camp 2 9 6 8 9 6 4.3 Strengthening PHC/ORC 0 17 0 4 0 0

NA-Not Available, N/A-Not Applicable *Exceeds 100% because of repeated visits and people from adjacent villages visi ng facili es due to improved health care.

16 Member Households from 2008 to 2013

transla ng it into day to day work was very challeng- ing. Huge amounts of energy and me were spent on coor- dina on.The reality is that it is s ll “an INGO project” for some health work- ers un l the system accepts it as a gov- ernment program. The challenge may remain the same even though the im- pact created is huge.

KFN learned tremen- dously from all these N= Number of total households in project villages experiences and events throughout CBHI = Community Based Health Insurance the years. Our only commitment was – and remains – to make people aware that the de- Refl ec ons and Achievements velopment required for the popula on is possible of the Share&Care Journey only if the service users themselves realize the need, and, more importantly, take collec ve decisions and While running our projects for more than 5 years, assume responsibility to bring about changes in the we have been through various ups and downs. As quality of their lives. Realiza on by community and an external development organiza on we were coopera ng systems is the basis for any develop- commi ed to strengthening exis ng health pro- mental endeavour. Thus, wherever and whenever grams and systems rather than crea ng new ones. we realized that the popula on was not moving As every VDC has a public health facility, we estab- with breaking the “mental dependency,” i.e., always lished a func onal rela onship with them. At the expec ng help form outsiders for their develop- beginning it was diffi cult for us to convince people ment; and that the system was not coopera ng up and authori es that an INGO could develop a pro- to the expected level, we withdrew the program, gram using fi nancial support from the locals them- although it was always a very painful choice. The selves. In terms of local resource mobiliza on, we decision to not con nue Share&Care in some of our have proved that it is possible. There was commit- program villages indirectly increased the leadership ment and willingness to support the program from in the surrounding villages, as the leaders realized district and local health system personnel.However, that they really had to and assume responsibility.

Karuna Founda on : First Phase in Nepal 17 Key Achievements of SC Program 2008-2013

Community Based Health Insurance • Nearly 64,753 person years*(21.3%) out of 303,326 person years were fi nancially protected through health insurance scheme from 2008-2013. • Nearly 242,661 person years (80% of total person years) u lized the improved health care services. Out of this 58,278 (24%) person years were the members and 184,383 (76%) person years were non-members. • A total of 1,818 members out of 64,753 members in 6 years (2.8%) got fi nancial pro- tec on for hospital referral expenses. • A total of 497 families (4.5 % of total households in project villages) below poverty line received loans which they u lized for income genera on. • We tried to include as many households as possible in the system (25% of the total households and 40% of households within reach of Health Facili es are now mem- bers) • We covered an en re region or cluster of villages so that adjacent villages share ideas and learn from each other, and the program opera on also becomes easier. • Now, the local health systems in the program villages accept it as their regular busi- ness. Preven on &Rehabilita on • A total of 342 persons with disability were iden fi ed through screening/health camps leading to early management and referral. • A total of 479 children with disabili es have been iden fi ed in Share&Care program villages. All of these children have been receiving a comprehensive community based rehabilita on services on health, educa on, livelihood, empowerment and social skills through village level facilitators. When needed, children are referred to special- ized health care. Out of total iden fi ed children, 91 children (19%) with disabili es have been fully rehabilitated. All the other children are s ll in the community based rehabilita ons program tailored to their needs, barriers in the communi es are bro- ken down and children are being included and accepted in their communi es. • Our experiences show that the CBR program could be organized eff ec vely and at a lower cost if a wide range of stakeholders are involved. • CBR approach can create an immense impact in the life of children with disabili es and their families, as well as the community as a whole .

* If one person is enrolled into the program for 5 years, it is counted as 5 person years

18 The below fi gure shows diff erent sources of that Karuna Founda on’s approach to local income in the years since the implementa- capacity building, leadership and ins tu onal on of the SC program in Bhokraha Village of strengthening , has been able to gather local Sunsari district,the fi rst village in Sunsari that resources. On the basis of high par cipa- implemented the SC program. Upon exit of on and con nua on of membership in cur- fi nancial support from Karuna Founda on in rent program villages, the KFN team is very the fourth year, Bhokraha VDC has success- op mis c that current project villages are fully implemented the program using local re- moving in the direc on of a aining fi nancial sources. The number of member households sustainability and are on their way to estab- is on the rise: 165 in the fi rst year, 451 in the lishing themselves as self-sustained health 2nd year, 564 in the 3rd year and 595 in the care ins tu ons. 4th year (Table page 15).These data depict

Year-by-year Income by source in a SC village (Bhokraha)

100 NPR = 1 euro Acronyms: DDC= District Development Commi e,DHO = District Health Offi ce, VDC = Village Development Commi ee

Karuna Founda on : First Phase in Nepal 19 Running costs in a SC Village (Bhokraha)

Acronyms- Admin- Administra ve cost, D&L: Addi onal drugs and lab expenses, Refer: Referral cost HR-Human Resource cost HPDP- Health Promo on and Disability preven on ac vi es, CBR-Community Based Rehabilita on, OD- Organiza onal Development, Amb- Ambulance, Livel-Livelihood cost

Major expenses in the village consisted of gram staff has to closely monitor the “refer- ambulance, human resources, referral and ral” expenditures as it could go beyond the drugs costs. On an average, a program re- expected budget. Un l now, due to regular quired an annual running cost of NPR 1.5 monitoring and necessary interven on from million (15.000 euro). However, the average the program authori es, the overall program program cost may vary between the program cost has remained within the budget. areas. On the expenditure heads, the pro-

20 A New life is born! A Case Study from Aurabani Sub Health Post, Sunsari District

Karuna Founda on started the Share&Care Ms. Lalita Uraw, 28, a non-formal literate resi- program in the Aurabani Sub-health Post dent of the same VDC was pleased to have in 2011. At that me people had to travel delivered her baby boy in the local health for hours for ins tu onal delivery and many facility - without any discomfort! It was a chose to deliver at home under risky condi- normal delivery. When asked why she chose ons. Observing a need to have a birthing to come here for the delivery, she replied, “I center in the village, Karuna Founda on and could have gone to the Koshi Zonal Hospital Rural Reconstruc on Nepal (RRN) joined as I did for my previous delivery, but as I came hands to provide the necessary support. A er to know that the birthing center had been the establishment of the birthing center, days established and is very close to my home, I were passing. Suddenly, early in the morning chose to come here.” Responding to a ques- of 2nd April, 2014, good news came:The fi rst on about how she felt regarding the services and second delivery in the newly established and behavior of health professionals involved birthing center took place on the same day! in the delivery, she replied: “The behavior of

The happy couple with their baby Newborn baby with the mother

Karuna Founda on : First Phase in Nepal 21 the staff is really appreciable. I’m very much mitment to their duty. Kanchan Chaudhary, touched. No wrong impression came to my Amrita Thandar and Ranju Yadav – three of mind even for a single second. They treated the nursing staff members remarked:“We me in such a good way! I got very personal are very happy about this success. And the care. I’m thankful to them.” According to Lal- birthing center has been geared up!” “We ita’s husband, Mr. Santosh Uraw, Lalita got all learned in the Interpersonal Communica- the necessary care and support from him and tion training conducted by Karuna Foun- all the family members, during her pregnan- dation Nepal about how much the health cy. And, he said, “I did;, and I will always take professionals’ behavior means to the life care of my wife and children to the best of of patients. Hence we tried and will always my capacity. If my wife is happy and healthy, try to behave as supportive as possible all of our family members will be happy and towards those who come to the Sub Health healthy!” Post. Technical knowledge and behavior should go together. Thanks to all who have All of this is possible because of capable and shown their trust in us.” confident health professionals with com-

Nursing staff at the Aurabani SHP

22 Project II: Training of Professionals

Training of Professionals (ToP) aimed to de- is followed by selec on of health ins tu ons velop professional competence of commu- to par cipate in phase-wise trainings. A fi ve- nity-level health workers in order to reduce day long workshop is organized for the se- the gap between the exis ng and the desired lected par cipants. The training broadly has health situa on indicated by the Health Man- three components –exchange and enhance agement Informa on System (HMIS). The knowledge on disability, and on causes and training project, implemented from 2008- preven on of childhood disability; analyze 2011, focused on strengthening skills in pri- the current situa on of HMIS indicators in ori za on, project planning, resource mobi- the vicinity of the health facility (focusing on liza on, and repor ng and extending service maternal and child-health indicators); and fi - accessibility by rou ne situa on analysis. nally, develop a plan to improve the situa on. At the end of the workshop, health workers Process develop a proposal for a preven on project The process of ToP starts with an agreement for their local health ins tu on, which is with the District Health Offi ce (DHO), which then endorsed by the Health Management

Leadership and Management Training to the Village Development Rehabilita on Commi ee members in Rasuwa

Karuna Founda on : First Phase in Nepal 23 Commi ee before its implementa on. Karu- improving maternal and child health indica- na Founda on provides a seed fund of NRS tors. One village from Kavre locally gener- 20,000- (200 euro) to each Health Ins tu- ated NPR 75,000- (750 Euro)in addi on to on through the District Health offi ce for the the seed money from Karuna Founda on and implementa on of the project. Integrated used the fund for strengthening outreach supervision with the District Health Offi ce is clinics. These clinics operate once a month done to assess the progress of the preven- in a designated place close to communi es on project. Par cipa on of the Health Com- and provide maternal and child health ser- mi ee during supervision, onsite feedback, vices and other general health care. In 2011, annual review of the preven on projects, the responsibility for this training program and awards to the best performing health was handed over to the DHOs of Kavre and ins tu ons are part of the evalua on of the Sunsari district,who will now ensure the con- preven on projects. Ten health ins tu ons nua on of supervision and preven on care. from Kavre were awarded for signifi cantly Thus KFN’s eff orts for this program have been reduced since 2012. Process of Training of Professionals (ToP)

Partnership with DHO and other stakeholders

Selec on of trainees

Training of Professionals (5 days workshop)

Preven on Project Development, Endorsement Implementa on

Community Increase preven ve awareness in Incorporate preven on in services u liza on by preven on their daily prac ce the community

Based on the real Need Local Resource Mobiliza on Joint Venture of Health Professionals and HFOMC of S/HP Supervision and Monitoring by DHO, HFOMC, KFN

Acronyms: DHO-District Health Offi ce, HFOMC-Health Facility Opera on and Management Commi ee, S/HP-Sub/Health Post

24 Impact Assessment of ToP

ToP evalua on was carried out by an inde- nifi cant improvement in maternal and child pendent public health consultant in 2013/14 health indicators in the districts. The follow- to iden fy the impacts of ToP program on ing fi gure shows the improvements in indica- health workers,health facili es and commu- tors in Kavre District. ni es.The evalua on report showed a sig-

Change in health indicators before and a er ToP in Kavre District (ToP Evalua on Report)

Training and Capacity Building Posi ve change is possible if people from all The main aim of the training and leadership segments of society are effi cient, mo vat- development ac vi es in Karuna Founda- ed, result oriented and willing to join hands on is to produce skilled, knowledgeable and construc vely towards common objec ves. mo vated human resources at every level This can happen only when there is invest- by crea ng a conducive environment for ment in the people in order to achieve on- learning and ul mately resul ng in the pro- going improvement. mo on of good governance. Hence, Karuna

Karuna Founda on : First Phase in Nepal 25 Social Mobiliza on Training to Karuna staff s

Founda on considers capacity building as a awareness raising material, etc). An ac on process input for be er results. In this con- plan with clear roles and responsibili es text, Karuna Founda on’s capacity building along with specifi ed meline is prepared for ac vi es can be broadly classifi ed into 3 cat- most of the capacity building ac vi es. These egories: capacity building of partners (HFO- ac vi es serve as a founda on for follow up MC, VDRC, Health Professionals),capacity ac vi es. Later, the capacity building ac vi- building of the community (families, group es undergo evalua ons during various phases members, Child Club Members) and capacity (short, intermediate and long term) to assess building of staff . their eff ec veness in crea ng the desired re- sult. All capacity building ac vi es are designed and executed on the basis of a needs assess- KFN’S capacity building ac vi es are car- ment followed by prepara on of appropriate ried out following a par cipatory learning material (curriculum, manual, community approach and respec ng local needs and

26 values. Our facilitators always appreciate standing and skills of community members, the needs, interest and experience of par- management commi ees (HFOMC,VDRC) cipants. Besides, the facilitator’s respec ul and Community Based Rehabilita on Facilita- behaviour towards the par cipants, and the tors. Furthermore, leadership development, two-way learning process makes knowledge program management, apprecia ve inquiry, and skill transfer simple. Furthermore, Karu- accoun ng and record keeping, group man- na’s capacity building ac vi es are carried agement, interpersonal communica on and out in collabora on with like-minded organi- accountability trainings were organized in or- za ons and individuals. der to build up the capacity of management commi ees, staff and village level facilita- In this context, diff erent orienta on/training tors. The below diagrams show how capac- programs on disability preven on, disability ity building has been considered as a process rehabilita on and community based health input and the next fi gure shows the result insurance were organized to enhance under- cycle of capacity building.

Capacity Building: A process input

Karuna Founda on : First Phase in Nepal 27 Key Achievements of Training of Professionals Project

• 457 health workers from 150 diff erent villages were trained in three districts (all health facili es of Kavre and Sunsari districts and 5 facili es of Rasuwa dis- trict); • 150 preven on projects were designed and implemented by the health profes- sionals; • 22 birthing centres were established and strengthened; and • More than 750 births defects prevented due to ToP (Calcula on based on contri- bu on of increase in maternal and child health indicators towards birth defect preven on according to March of Dime’s report) Capacity Building Achievements • 182 par cipants (Health Management Commi ees Village Development Re- habilita on Commi ees, including Community Based Rehabilita onFacilitator) received training and orienta on on disability and rehabilita on; • 68 par cipants represen ng partners par cipated in social training; • 89 community people (community leaders, group members, married couple, etc) par cipated in diff erent training ac vi es; • 71 KFN staff received opportunity for capacity development through trainings and workshops. • During the period 1 training manual and 3 awareness raising materials were prepared.

28 Project III: Inspire2Care Project (formerly Preven on & Rehabilita on Project)

Two years have passed since Karuna Foun- on iden fying children with disabili es, mak- da on started the Inspire2Care project. ing assessments, and developing and imple- Ac vi es of this project are similar to the men ng individual rehabilita on plans for Share&Care project, except for the Health In- the child. This sets out the social, medical surance component. It is developed as a box and educa onal goals for the child, and how within the box, i.e. Inspire2Care is a box with- to achieve them. In addi on, investments in the bigger box of Share&Care. This project are made in entrepreneurship and lending includes Health Promo on and Childhood to the families of children with disabili es so Disability Preven on ac vi es, which focus that they improve their livelihood. All together on awareness raising ac vi es and improv- these ac vi es lead towards a more inclusive ing maternal and child health. CBR is focused and disability sensi ve community and society.

Karuna Founda on : First Phase in Nepal 29 Process es implemented in the district. The Village This project has been implemented as per Disability Rehabilita on Commi ee (VDRC) is the CBR guidelines of Government of Ne- the implemen ng partner at the VDC level. pal. Before launching a program, KFN signs a The VDRC, composed of VDC offi cials, health MoU (Memorandum of Understanding) with professionals, and parents of children with the Community Based Rehabilita on District disabili es, persons with disabili es, teach- Coordina on Commi ee (CBR-DCC) at the ers and poli cal leaders, is responsible for im- district level. CBR-DCC is a commi ee chaired plementa on of the project in coordina on by the Chief District Offi cer (CDO), with the with the Health Management Commi ee. Women and Children Development Offi cer In every VDC, there is a Community Based (WCDO) as the member secretary, along with Rehabilita on Facilitator (CBRF) selected by other district authori es like the Local Devel- the VDRC and the CBR-DCC, and trained by opment Offi cer (LDO), District Health Offi cer Karuna Founda on, which plays a central (DHO), and District Educa on Offi cer (DEO). role in facilita ng and leading the project as Representa ves from CBR organiza ons and a secretary of the commi ee. The project is other related organiza ons are also members. currently implemented in three villages in Sunsari: Baklauri, Madhuvan and Dumraha; This commi ee is responsible for monitoring and four villages in Rasuwa: Laharepauwa, and supervision of all disability related ac vi- Bhorle, Dhaibung and Ramchhe.

Key Achievements of Inspire2Care project from 2011-2013 in 7 VDCs of Sunsari and Rasuwa • Birthing centres have been supported in 7 sites. • Outreach Clinics have been Strengthened in 6 villages by ensuring si ng arrange- ments, privacy for health check-up and through addi onal equipments. • Day celebra ons, street drama presenta ons and orienta on on reproduc ve health issues were conducted in project VDCs. • A total of 59 School Health Educa on classes were run. • A total of 32 newly married couples were given orienta on on disablity preven on measures. • A total of 268 children with disabili es have been iden fi ed in Inspire2Care villages and have been receiving rehabilita on services through the CBR approach. Out of this, 17 children have been successfully rehabilitated in their communi es. • In 2013, P&R project was further developed into Inspire2Care which is now ready to be scaled up.

30 Income and Expenses in Inspire2Care villages

The local Village Disability Rehabilita on creased in comparison to the fi rst year due Commi ees (VDRC) are demonstra ng re- to added ac vi es. For the ongoing agree- sponsibility and developing leadership skills. ment year (3rd agreement year) a commit- For the fi rst year, KFN contributed nearly ment of an average of NPR 259,979 (2500 80%, and nearly 19.4% of the total fund was euro) has been received from program vil- generated locally, amoun ng to NPR 493,150 lages. Increased fi nancial commitment from (4500 euro). In the second year, local re- local bodies indicates ownership and accept- source genera on increased and reached ance of the program. To further increase the an average of NPR 103,270 per village (1000 propor on of local resources as the program euro). KFN’s share in the total income was re- evolves, VDRCs and Self Help Groups are lob- duced from over 80% to 76%) in the second bying and advoca ng for adequate budget al- year. The investment expenses decreased loca on at local level; and KFN is lobbying at in the second year, while running costs in- central level. Average expenses in Inspire2Care villages in the First and Second year

Acronyms: Admin-Administra ve cost, HPDP-Health Promo on and Childhood Disability Preven on CBR-Community Based Rehabilita on,HR-Human Resources

Karuna Founda on : First Phase in Nepal 31 Community Based Rehabilita on (CBR)

CBR is a strategy for community-based in- takes the role to create awareness about UN- clusive development in order to mainstream CRPD, empowering persons with disabili es, disability in development ini a ves, and in and strengthen state par es in fulfi lling the par cular, to reduce poverty, and to meet the UNCRPD targets. Karuna Founda on follows basic needs and enhance the quality of life of the CBR Matrix developed by the WHO for people with disabili es and their families. rehabilita on of children with disabili es. (WHO;CBR guideline, 2010).This is a common The matrix consists of fi ve key components: component both for the Share&Care and In- health, educa on, livelihoods, social context spire2Care programs of Karuna Founda on at and empowerment. As per local needs, pri- the VDC level. ori es and resources, the CBR program has been designed and implemented by local- CBR is a grassroot strategy to implement the communi es of KFN program VDCs following United Na ons Conven on on the Rights the above-men oned fi ve key components of of Persons with Disabili es (UNCRPD). CBR the CBR Matrix.

Children with disability within their communi es and families

32 CBR Matrix

Health INCLUSION

PARTICIPATION

Social Empowerment Educa on

SELF-ADVOCACY

Livelihood SUSTAINIBILITY

Process sector coordina on and collabora on is im- CBR Facilitators, together with children with portant in providing diff erent rehabilita on disabili es and their families, develop ap- services and implemen ng CBR programs propriate and holis c rehabilita on plans so in cost eff ec ve ways, and for sustainability. that the children are ensured to medical care, Sensi za on on disability, empowerment of rehabilita on, educa on, social par cipa on persons with disability and their families and and inclusion,while also ensuring equal rights the local communi es is equally important to diff erent facili es and opportuni es, thus for leadership and ownership by the local nurturing their enormous capabili es. Mul - community, and for fund-raising and sustain- ability of CBR.

Karuna Founda on : First Phase in Nepal 33 The CBR program is implemented following ordina on with government and non-govern- the spirit of the UN Conven on on the Rights ment stakeholders will be emphasized in car- of the Persons with Disabili es, which re- rying out the Inspire2Care program; so will quires us to promote, protect, and ensure the resources from village and district authori es full enjoyment of all human rights and funda- be con nued to be mobilized so that the pro- mental freedom by persons with disabili es gram orients towards sustainability from the and ensure that they enjoy full equality un- very fi rst day. Karuna Founda on will provide der the law. fi nancial support for the ini al three years, and technical support for fi ve years. As al- Principles of KFN & way forward ways, the Blue Guideline will be the mantra Our learning from past experiences has fur- of Karuna Founda on to direct the program ther reinforced our principles and we can by innova vely blending development and fi rmly say that these principles have been business approaches. People will always tested and are evidence-based in the Nep- remain at the centre, whether it is in plan- alese context. Therefore, our upcoming ning of the program or taking leadership. programs will con nue on the basis of our Karuna Foundation will act merely as the proven philosophical founda ons. Hence, co- facilitator.

Tricycle helps Rabindra in his daily life and social ac vi es

34 Unveiling a young entrepreneur through Inspire2Care Program: Jamuna’s road to success

Jamuna Waiba, 18, lives in Laharepauwa-5, of in it. I want to pursue this career in future. My Rasuwa district. At the tender age of 6, her friends and even my teachers come to my tai- family clearly no ced that she had a hear- lor shop and ask to make dresses for them. I am ing and speech problem. Her family took her very happy that everyone is suppor ng me.” to a hospital and enrolled her in a sign lan- guage class. In the class, Jamuna was always When asked about her daughter’s status, stressed and couldn’t make friends. She even her mother replied, “I tried everything to had many episodes of mood swings and dif- make her engage in social activities and fi culty in expressing her emo ons. She fi rst schooling, but she was always hostile. After came in contact with the Inspire2Care pro- this program came to our community, she gram in Rasuwa through an assessment camp got the chance to meet other kids in the in 2011. A er the assessment camp, CBR fa- children’s club and even got training. Af- cilitators regularly visited her home. Subse- ter the training her whole personality has quently, she was enrolled in the voca onal changed. She now smiles and is always will- tailoring training. Her family was enrolled in a ing to work. This makes me very happy.” livelihood program as well, and she rejoined her school, Shree Navabijayai Secondary School.

Currently, Jamuna is studying in class 8 and pursuing her tailoring career as well. Her fam- ily bought her a sewing machine and she is earning 5-6 thousand rupees a month from the tailoring business. A er a constant follow up and lobby by the CBR facilitators, Jamuna has now been selected for another 3 months of special tailoring training organized by CTEVT (Council for Technical Educa on and Voca onal Training). When asked about the Inspire2Care program, she wrote: “Before, I was angry all the me that I couldn’t read or write as good as my friends, and used to think that everyone is making fun of me. But, a er Jamuna with her mother I got the tailoring training, I found my passion

Karuna Founda on : First Phase in Nepal 35 Overall Achievements of CBR program

# the sum of current children in 2013, and children with given outcomes do not add up to the total num- ber of iden fi ed children due to discon nua on of the program in some VDCs

The CBR program has provided a mul tude of 1 pages 5-20). The abstract can be accessed facili es to children with disabili es through through h p://dcidj.org/ar cle/view/299. a comprehensive approach within their com- Conclusion part of the paper states: muni es and families. Children have hugely “CBR has brought posi ve changes in the lives benefi ted-the results shown above dem- of the majority of the children. The changes onstrates their all-round development. Not were not similar to the impact experienced only short-term results and outcomes are a er CBR. The major changes occurred in observed, but an overall improvement in physical health, while the impact was mainly their quality of life has been documented. experienced on a social level, in empower- A Masters of Health Science student from ment and in the level of independence. Chil- VU University, the Netherlands conducted a dren men oned that they had more friends, qualita ve study to assess the impact of the experienced less discrimina on, a ended CBR program on the lives of children with school more o en and therefore felt more disability from Chapakhori village of Kavre independent and were more posi ve about district, and Bhokraha and Madhesa villages their future. Due to this impact, children and of Sunsari district. The study highlights the their families felt happier and more confi dent changes the CBR program brought to the lives about themselves. These fi ndings emphasise of children with disabili es. The fi ndings of this the importance of paying adequate a en on research are published in ‘Disability, CBR and In- to improving the physical health and func- clusive Development’ (2014- Volume 25, Issue oning of children with disabili es.”

36 Key Achievements of CBR

Health • All children (N=747) have received some form of medical treat- ment in a hospital or at a specialized center. • Physiotherapy and training in daily living ac vi es has been pro- vided tochildren at home and also at specialized centers. • A total of 209 children have received assis ve devices such as wheelchairs, prosthesis, and hearing aid. • 52 children were assessed with malnutri on. They were coun- selled, supported with nutri onal food, and some were referred to nutri onal rehabilita on centers . • 108 children were fully rehabilitated, o en through medical and social interven on. These children do not have any func onal limita on and restric on in social par cipa on and inclusion.

Educa on • A total 276 children are regularly a ending school and most of the school going children have been ge ng regular scholarships from the government. • 644 children have received educa onal support like textbooks and uniforms to encourage and mo vate them for be er perfor- mance in educa on. • 42 children were enrolled in integrated and special schools. 18 children with hearing, visual and intellectual disabili es were en- rolled in special schools.

Livelihood • 82 families of children with disability received voca onal training. • 52 families of children with disabili es have received an entre- preneurial training and 144 families of children with disabili es received loan support to start income genera ng ac vi es. • The families of children with disability are also members of the Share&Care insurance and therefore are protected against fi nan- cial risk arising due to health problems.

Karuna Founda on : First Phase in Nepal 37 Social Inclusion and Empowerment • 626 children got disability iden fi ca on cards from the government. It en tles them to certain provisions and allowances and allows them to claim their rights, such as disability allowance, scholarship, and many more. • 24 Self-help groups with 368 families of chil- dren with disabili es were formed in the 7 P&R program villages and 6 SC program vil- lages and 140 families have been involved in savings and credit ac vi es in a group. • 14 VDRCs have been formed and trained for their capacity development. • 13 inclusive Child Clubs have been formed and 148 children are par cipa ng in clubs. • 53 leadership and skill development train- ings were conducted and 86 children par- cipated in the trainings. • 40 children with disability have been trained in diff erent skill development trainings. The trainings helped them build their capacity and confi dence. • 372 awareness raising events through post- ers, wall pain ngs, informa on sessions in communi es for teachers, local health volunteers, school children and women’s groups, etc., were organized. It helped peo- ple to get knowledge on disability, its pre- ven on, CBR and other related issues of dis- abili es. • 15 ramps were constructed in public places like schools, public offi ces, and health posts for easy access and mobility in services place, etc.

38 Shrawan’s Story: A milestone for CBR approach

4 year old Shrawan Kumar Mandal from Mad- had a delayed development, and therefore huban village, Sunsari,was born with cerebral the treatment needed to focus more on palsy. His parents took him to a local Primary s mula on of developmental milestones. Health Care Center, where the health worker Shrawan’s parents provided him with regular advised that the child had delayed develop- physiotherapy in direct follow up and guid- ment and was referred to a higher centre. ance of the CBR facilitator. They built a home- But, the parents believed that the child made rotator to use as an assis ve device. Af- would not improve, so they did not take the ter regular exercise, now Shrawan can sit and child to the doctor. stand with support. He has been prac cing to walk with the help of rotator and started to The child came in contact with the Inspire- play with his toys and friends. 2Care program at the age of one and half year old. He was unable to sit and stand at Now, the community people are also helping the me of assessment done by CBR Facili- his parents in his rehabilita on process. His tators. As per the rehabilita on plan, he was parents are more than happy with the pro- taken to a neurological camp organized by gress and are willing to see more progress in Karuna and SGCP, Dhapakhel, in Sunsari. The the life of their child. They want to send him doctor advised regular exercise, as Shrawan to a nearby ECD center for pre-schooling.

Before A er

Karuna Founda on : First Phase in Nepal 39 CBR program helped unleash the talents in Manju

le the school. She could not con nue her study because of lack of special school with sign language in her home district or a nearby district. She was keen on doing some- thing and family members also requested for voca onal training. Share&Care program supported her with training fee and food allowance. She completed a 6 month long sewing, tailoring and knit- ng training along with sign language training in Aanda 16 year old Manju Maya Tamang is from Apanga Technical Voca onal Chapakhori, Kavre. Her family is dependent Skill Development Training Centre, Kri pur, on farming. At the age of 3, she fell from a in 2011. The trainers were very happy with ladder and had regular bleeding from both her performance and encouraged her to be ears. She slowly lost her hearing and later lost a role model for the community. She decided her speech as well. to take an advanced course on sewing, tailor- ing, kni ng training at the same training cen- The Share&Care program had just begun at tre on her own cost, and also joined a profes- the Sub Health Post, Chapakhori, in 2009. sional tailoring center in Lalitpur. Because of Manju came in contact with Share&Care pro- her commitment, and competence she found gram through the baseline survey. Her dis- a job at the same tailoring center. Now, she ability assessment was done by a pediatrician holds a job and also runs her own business and a CBR expert. The pediatrician referred through which she is able to fi nancially sup- her to Dhulikhel Hospital for inves ga on port her family. and treatment. She was then referred to TU Teaching Hospital, Maharajgunj. The ENT Expressing gra tude to the Share&Care pro- doctor said that it was impossible to restore gram, her parents say, “We would have never her hearing even with a hearing aid. perceived and understood her ability and in- terest, and would never see her in present She tried very hard in her studies and complet- stage if there was no Share&Care - Community ed grade 5 at the local inclusive school, then Based Rehabilita on program in our village.”

40 Project IV- Policy, Networking, Coordina on & Advocacy/Awareness (PAAN) Looking back at these years, we are proud key stakeholders to bring eff ec ve and mean- that we have been able to establish work- ingful changes in the lives of children with ing rela onships with key government min- disabili es and their families; and at scaling istries and departments at the local, district up community health services so that it is and na onal levels. This ac vity has always owned by the popula on and quality service aimed at establishing strong linkages with is accessible to all. the concerned government bodies and other

A central level Networking mee ng with stakeholders

Over the years, we have been able to make Some major accomplishments of PAAN over some signifi cant achievements in terms of the period are: coordina on and collabora on with vari- • Publica on of Disability Resource Book ous stakeholders. We have also emerged as together with the Ministry of Women, one of the main organiza ons in the areas Children and Social Welfare (MoWCSW). of strengthening community health systems By 2013, it has already been published and successfully introducing Community for the 4th consecu ve year, incorporat- Based Health Insurance in Nepal. ing disability related provision and facility,

Karuna Founda on : First Phase in Nepal 41 program and plan, policy, acts, and guide- • A consultancy assignment was executed lines of the government. This book has by Swiss Health Centre and Deutsche Ge- been well received and highly appreciated sellscha fur Interna onale Zusammenar- by stakeholders and its demand is ever in- beid (GIZ) (commissioned by the Ministry creasing. of Health and Popula on, Nepal) for an inves ga on with respect to coverage, • The fi naliza on of ‘Na onal CBR Guide- and access to care, fi nancial sustainability line’ was supported by MoWCSW. The and empowerment of community based guideline is expected to be endorsed in health insurance schemes, including our 2014. Share&Care program and other organi- • Various Project Advisory Commi ee meet- za ons implemen ng health insurance ings have been held, both at central and schemes in Nepal. Share&Care emerged district levels, for feedbacks, comments as the best model. More informa on is and commitments on our work. available at:h p://www.swisstph.ch/fi le- • The fi naliza on of Accessibility Guideline admin/user_upload/Pdfs/SCIH/2013_04_ has been supported and facilitated. Karu- Nepal_CBHI_GIZ_report.pdf0.pdf na was a part of the commi ee for de- • In November, 2012, Karuna was awarded veloping the guideline. The guideline has the Jobena Award for its approach and for been endorsed by the Government of Ne- the SC project, which uses self-develop- pal and mostly focuses on the accessibility ment both as a method and an objec ve. of physical infrastructures. It was distributed in Nepal in the form of

Persons with disabili es registering their CVs Par cipants in Career Expo-2013 in Career Expo

42 a Mini-Jobena Award to deserving health ported to succeed to fi nd a job a er the workers, village commi ees, CBR workers Career expo in 2012. and civil servants. • A er the success of 1st Career Expo, the • Within the Associa on of Interna onal trend con nued in 2013 also, when, on Non Governmental Organiza on (AIN), a 13th December, 2013, the 2nd Career Expo Disability Working Group was formed for was held. eff ec ve collabora ve and coordinated • Country Director, Karuna Founda on Nepal, work in Nepal in the area of disability. has been elected and re-elected for second • On 5th December, 2012, the fi rst ever ca- me as a Steering Commi ee Member of reer expo for persons with disabili es was Associa on of Interna onal Non Govern- organized together with key stakeholders mental Organiza ons (AIN) for 2nd consecu- like MoWCSW, AIN, NFDN,FNCCI, Federa- ve year, and is contact person for disability on of Nepalese Journalists, and Merojob. and health working group. com. Many governmental organisa ons, • A public hearing program was organized in development organisa ons, private com- Bhokraha in coordina on with Watchdog panies, banks, etc were involved. More Media Service Pvt. Ltd. in May, 2013. than 50 persons with a disability were re-

Partnership To accomplish our fundamental goal, we Our partnership with medical ins tu ons has have partnered with various governmental also been remarkable in bringing signifi cant and non- governmental organiza ons. And it changes in the health status of communi es wouldn’t be wrong to say that we wouldn’t and children with disabili es. We have been have been at this stage without the help and partnering with HRDC in orthopedic surgery support of our diff erent partners.Our major and other disability related camps. BP Koirala partners at the na onal level are: MoWCSW, Ins tute of Health Sciences, (BPKIHS), Kath- & MoHP. Our partners at the district level are: mandu Model Hospital, Dhulikhel Hospital, District Health Offi ce, DDC, CBR-DCC, and at and Nobel Hospital, Biratnagar, are referral the local level: Health Management Commit- hospitals for our CBHI scheme. Besides lo- tees and Village Development Rehabilita on cal and na onal level partnerships, we were Commi ees. We believe that we need to fo- entrusted by some Interna onal organiza- cus on strengthening our partnership with ons, such as Madat Nepal, WfW(Women for the government system in order to have a Women), FEMI Founda on, GIZ Nepal, S cht- sustainable project in the future. ing Beter ter Been , Enablement, and others.

Karuna Founda on : First Phase in Nepal 43 Training before Uterus Prolapses camp in partenership with Women for Women,Netherlands

Major partnerships Karuna was a part of in the past Six years

S N. Partners Ac vity and Year 1 Resource Center for Reha- Implement CBR in 5 VDCs of Rasuwa bilita on and Development CBR training for CBRFs (RCRD) 2 Help for Change,Nepal, (HCN) Help organize community ac vi es and awareness raising programs in Timal, Kavre (2008-2012) 3 PHECT Nepal Medical interven on for children with disabili es (2010-2011) 4 CBR Biratnagar Assis ve devices for children with disabili es (2010-2012) Training and orthopedic shoes produc on for for children with disabili es through Beter ter Been (BtB) (2013) 5 Spinal Injury Rehabilita on Sponsor for the rehabilita on of people with spinal Center (SIRC) injury who have poor economic background (2011-2012)

44 6 MADAT Nepal -Kusheshwor Drinking water project in Mechchhe, Kavre, 2012 Higher Secondary School Wa- Health Camp in Kavre- 2013 . ter Project 7 Rural Reconstruc on Nepal Supported construc on of Birthing Centre in Aura- (RRN) bani Sub-health post Sunsari- 2011 8Na onal Federa on of the Diff erent disability movement, support for organiza- Disabled Nepal (NFDN) onal development and offi ce equipment- 2012 Organized two annual Career Expos in 2012 and 2013 with huge enthusiasm and achievements. 9 Self Help Group for Cerebral Organize health camp, training and capacity building Palsy (SGCP) of rehabilita on facilitator, advocacy and network- ing for diff erent disability issues- 2012 and 2013. Organized health camp for children with neurologi- cal problem in Kavre,Rasuwa and Sunsari in 2012 and 2013. 10 Deutsche Gesellscha für Financial support for con nua on and strengthen- Interna onale Zusammenar- ing of Inspire2CareProgram- 2012 beit (GiZ) 11 NDRS Wheelchair and tricycle support to children/per- son with disability in Sunsari and Rasuwa- 2012 and 2013 12 Impact Nepal Technical and medicine Support to conduct school health camp in Kavre and treatment and surgery of ear problem of children with disability from Sunsari in Lahan Hospital, Saptari- 2012 and 2013. 13 DHO Dhulikhel and Dhulikhel Specialized health camp (Dental, Gynecological, Hospital ENT) organized in Sub-Health post, Mechchhe- 2012 14 Women For Women, the Screening of Uterus prolapsed women and provide Netherlands appropriate treatment according to their need i.e. counseling, legal exercise, ring inser on and sur- gery- 2012 and 2013 15 BP Koirala Ins tute of Health Referral hospitals for our Community Based Health Sciences, (BPKIHS)-Dharan, Insurance scheme (2008-2013). Kathmandu Model Hospital- Kathmandu, Dhulikhel Hos- pital-Kavre, and Nobel Hospi- tal, Biratnagar

Karuna Founda on : First Phase in Nepal 45 Financial Summary

In the fi rst phase of the project (2007-2013), eff ec ve control over expenditure, manuals Karuna Founda on spent a total of NPR and policies of the organiza on have been re- 138,062,658 (1.38 million Euro). The expend- vised in a mely manner. iture mainly concentrated on the SC and In- spire2Care programs, covering 44% of total Karuna Foundation has been able to main- expenditure, Administra ve cost covered tain a transparent financial management 17% , training expenses were 11%, partner- system throughout the period. There has ship expenses were 10% and combined ex- been yearly auditing of the country office, penses of M&E, CBR, PAAN, Expansion, Misc, field office and accounts of Health Facil- Fixed Cost were 17%. During the last 6 years, ity Managemetnt Committee and Village it was observed that the expenditure growth Disability Rehabilitation Committee. The accelerated around the middle of the project budget to the community was released period, i.e in 2010 and 2011. The rise was on a monthly basis against the approved observed because CBR and ToP expenses in- plan and activity of that particular month. curred since 2010 and the P&R program in- Health Facility Management committee curred expenses since 2011. and Village Disability Rehabilitation Com- mittees report to KFN field offices on It was observed that the CBHI component monthly basis. And the compiled report is of SC dras cally increased the expenditure forwarded to the Country office and to the pa ern of the program. To incorporate this Head office each month. component in the next phase of the program, organiza on requires huge fundraising. The KFN has fully covered basic ini al invest- program also has high recurring cost com- ments costs as it can be a gesture to build up pared to start up cost. This means a funding rapport with the community and make the commitment of longer dura on needs to be environment suitable for the program. The sought. However, the total amount of the ex- running cost of the program was shared on penditure throughout the years is average. propor onate basis by KFN with the commu- This informa on gives us the opportunity to nity. KFN fi nancially supported only for the strategize our next phase budge ng. To have ini al 3 years of the program.

46 0 2,458,654 1,952,322 1,299,478 3,083,497 4,161,627 1,487,667 14,443,246 1,499,340 16,873,577 22,800,530 26,160,006 24,471,489 22,232,777 24,151,257 138,188,976 on, on (CBR) 0 427,882 1,087,926 853,556 1,156,297 3,525,661 on (M&E) 0 458,830 1,921,711 1,957,308 1,193,566 682,633 753,668 6,967,716 on 6,321,870 6,321,870 es Cost Cost 0 es ve Cost Cost ve 546,051 2,401,904 3,246,973 4,088,853 4,297,305 4,816,943 4,173,071 23,571,100 vi culars culars 2007 2008 2009 2010 2011 2012 2013(NPR) Total on Step Forward, GIZ, MADAT Nepal) GIZ, MADAT Forward, on Step Project Ac Project 1. Share and Care and Care 1. Share Project 2. Inspire2Care (ToP) of Professionals 3. Training and Evalua 4. Monitoring 4,026 4,003,039 142,337 3,993,249 5,874,395 1,452,315 10,750,255 11,952,588 1,312,205 11,399,491 1,010,997 8,704,060 513,284 5,603,732 54,426,858 12,289,115 1,308,600 2,432,790 2,673,787 6,415,177 5. Community Based Rehabilita 6. PAAN 7. Training 8. Miscellaneous Expenses 9. Expansion prepara 8,401 140,205 0 0 277,272 258,641 154,263 0 597,592 935,733 0 414,408 944,421 693,021 130,783 1,417,454 4,463,871 1,129,749 815,301 274,053 520,646 2,617,469 10.Partnership (Women for Women, Foun- Women, for (Women 10.Partnership da Total Expenditure (B) Expenditure Total Fund Balance (A-B) By Fund Balance Represented Cash & Bank Loan & Advances Payable 1,104,233 Fund Balance 16,335,548 23,316,047 395,107 23,343,788 25,242,287 1,693,848 23,883,980 1,183,420 24,836,775 5,252,205 138,062,658 393,100 2,007 4,800,658 575,760 5,319,762 1,579,721 5,153,844 1,231,110 198,303 395,107 23,798,844 1,096,216 1,693,848 5,117,613 2,195,997 1,183,420 2,901,934 2,050,011 5,252,205 -461,633 4,122,585 3,694,695 4,800,658 3,309,742 11,236,888 -245,993 5,319,762 17,231,906 -961,624 5,153,844 23,798,844 -297,273 -852,834 -1,850,592 -4,669,950 Par Income Fund 1.Opening Founda Karuna from 2. Fund Received Expenditure the Netherlands and Miscellaneous Income 3. Partnership Income (A) Total 0 Cost Fixed 252,904 Administra 5,089 128,389 902,915 1,499,340 18,029,396 1,693,848 319,251 24,499,467 28,595,993 2,307,599 2,170,307 30,042,945 5,252,205 29,203,742 519,600 403,418 29,990,619 4,800,658 161,861,502 844,258 3,395,540 5,319,762 20,276,987 576,674 277,970 15,540 2,900 84,516 2,205,276 Financial Summary 2007-2013

Karuna Founda on : First Phase in Nepal 47 Annual Expenses from 2007-2013

Acronyms: SC-Share&Care, P&R- Preven on and Rehabilita on, ToP-Training of Professionals, M&E- Monitoring and Evalua on, CBR- Community Based Rehabilita on, PAAN- Policy Advocacy and Networking

48 Major Evalua on Studies conducted during the period

1. SWC Evalua on -Mid-term evalua- in rural health sector. It however is faced with on, (2010) problems and challenges too. The CBHI model Mid-term evalua on of Karuna Founda on’s works as proven by Bokraha SHP and Mad- SC project was completed in 2010 by a team hesa SHP to a greater extent. KFN however of fi ve members represen ng public health should revisit its approach, strategy, review ins tu on, SWC and accoun ng. A small sec- them and make needful amendments in- on from the summary and conclusions high- formed by fi eld study for replica on.” lights the uniqueness and challenges of the 3. Evalua on of the Community Based project: Rehabilita on Projects (2012) : “The assessment result demonstrated that An expert in the fi eld of disability from the given the newness of the project, a two year Netherlands, Huib Cornielje, conducted an project design in one VDC was too short to evalua on of CBR program implemented by achieve intended achievements. But at the KFN. Highligh ng KFN’s CBR approach,the re- same me the scheme has off ered a forum port concludes: for the Local Health Facility Opera on Man- agement Commi ee and also to the commu- “The CBR work done by the Karuna Founda- nity to know about the benefi ts of such an on is highly appreciated by the community en rely new concept. It can be hoped that at large,its leadership,and the immediate slowly the benefi ciary groups will be keen to benefi ciaries. The strength of the programme share their contribu on for a be er and en- is formed by the integral approach. It is not sured health services in their community and just focusing on disabled children but views referral hospitals with specifi c packages. The children in their context and tries to infl u- success of the pilot project can set an exam- ence that context also in order to contribute ple and perhaps encourage the Ministry of towards a more inclusive society (which is Health and Popula on to formulate the Com- the main goal of CBR). As such the work of munity Based Health Insurance policy to rep- the Karuna Founda on in the fi eld of CBR is licate in other districts too” dis nctly diff erent from the more individual oriented child assistance provided.” 2. Share&Care, Rapid Assessment Survey (2012) 4. SWC Evalua on -Final Evalua- A survey carried out to assess situa on and on(2013) advise on the way forward for improving the A team of four people represen ng the So- Share&Care program concludes: cial Welfare Council, the Ministry of Health “As a pilot program Community Based Health and Popula on, and a fi nancial expert, under Insurance has been successful to make a dent the leadership of an independent consult-

Karuna Founda on : First Phase in Nepal 49 ant, carried out the fi nal evalua on of Karuna at local birthing centers. The number of home Founda on’s fi rst phase of program.The con- delivery cases has declined dras cally. Unlike clusion sec on of the fi nal evalua on report Share&Care, Inspire2Care is yet to show its tan- about SC project states: gible impact. Especially in the preven on com- “The project implemented in seven villages ponent, it is too early to show results or assess found success ranging from 42 percent to progress. But, as far as its rehabilita on compo- 104 percent of the targeted households. The nent is concerned, there have been some tangi- project in Bhaluwa village of Sunsari District ble outcomes. Some disabled children are now has achieved more than the target. However, ge ng allowances and scholarships. Some of Bhokraha and Mechhe achieved below fi y them have been rehabilitated, too.” The en re percent. The overall performance of the tar- impact assessment report can be downloaded get was found to be 63 percent and marginal- through h p://service.scep.nl/karuna/pags/ ized family inclusion who need subsidy range download/Impact%20Assessment-Final.pdf. from 14 to 36.” 6. ToP Evalua on (2013) 5. Share&Care and Inspire2Care Im- An independent public health consultant pact assessment (2013) conducted an impact assessment of ToP pro- Two journalists conducted an Impact Assess- gram in Sunsari and Kavre districts at the end ment of Share&Care in four VDCs of Sunsari of 2013. Underlining the key achievements and one VDC of Rasuwa; and that of Inspire- and sugges ons for program replica on, the 2Care in one VDC of Sunsari and two VDCs of report summarizes: Rasuwa. Following is an excerpt from the as- “Overall, Training of Professional was found sessment report. to improve 15 selected maternal and child “The most outstanding feature of Share&Care health indicators by an average of 13.4% in is its func oning. Unlike many other projects, Kavre and 5.3% in Sunsari in selected facili- Share&Care has discarded the top-down ap- es. Undoubtedly, Training of Professional is proach and adopted the bo om-up approach. a program with an innova ve concept. It It is indeed run by the community people, not aimed to prevent birth defects and childhood KFN. KFN has only facilitated the community disability in community through improvement people to get organized and run the project on of immuniza on, nutri on and safe mother- their own. Within just a few years, Share&Care hood indicators. It is necessary to implement has succeeded in encouraging more people this program in other districts with direct to visit local health facili es. More pregnant involvement of local community and FCHVs. women are now ge ng Ante Natal Care (ANC), Further, ToP might have brought greater im- Post Natal Care (PNC), Vitamin-A, Albendajol pact if intensive follow up of health workers and Iron Tablets than ever before. Most im- and strict monitoring and supervision system portantly, more women are delivering babies had been put in place.”

50 The Organiza on Nepal Led by Deepak Raj Sapkota as the Country Di- rector, Karuna Founda on Nepal is a team of twenty one commi ed and competent team members who spend a large por on of their me in the villages. Karuna team is a blend of professionals from diverse development sec- tors like child right, rural development, soci- ology, popula on studies, public health, and business studies.

Sunsari Offi ce Team

The Senior Management Team of Karuna Founda on Nepal consists of Deepak Raj Sap- kota (Country Director), Mandar Shikhar Ban- dyopadhyaya (Technical Director), Yogendra Giri (Program Director), Manju Singh Rana Country Offi ce Team (Manager -Training and Leadership Develop- ment), Deep Silwal Bha arai (Manager -Fi- Their contribu ons range from the policy nance, Admin,HR) and Yuba Raj Paudel (Sr. level to the grassroots level. Members of Offi cer - Monitoring and Evalua on). this dedicated team have embraced the vi- sion, mission and goals of the organiza on, Learning by doing along with a fi rm convic on for the promis- The Karuna team has a learning attitude ing future of Karuna Founda on. The team and experiences of the past have taught has a learning a tude, is convinced of the vi- us a lot in shaping our future programs. sion and philosophy of Karuna, and is highly Our full-time partnership with the com- mo vated. Our Country offi ce is located in munity has enlightened us that local ca- Baluwatar, Kathmandu. There are also small pacity-building has to be at the centre of regional offi ces in Inaruwa, Sunsari, and Dhai- all development efforts if sustainability is bung, Rasuwa. desired. Further, to garner full community involvement and ownership financial par-

Karuna Founda on : First Phase in Nepal 51 ticipation from community is needed. Our Our Donors constant perseverance and determination Our philosophy is that the invested money despite several ups and downs and innu- should create measurable social impact. By merous tough times has created a ‘Dare to mobilizing communi es and coordina ng Confront!’feeling in our team. Challenges with like-minded organiza ons to par cipate and obstacles on the way towards the goal fi nancially and technically, we strive to mul- do not motivate us to swerve from our path; ply our eff ects and generate sustainability. instead we try alternatives, since we have a strong faith in ongoing improvement. Karuna Founda on has had a number of do- nors in its journey in Nepal between 2007 and The Netherlands 2013. The generous support from our donors The Dutch organiza on has Be eke de Gaay helped us reach the most deprived sec ons Fortman as the General Director, supported of our communi es and improve the quality by regular professional advice from Merel of their lives. Schreurs, a consultant. There is intensive and regular consulta on between the man- agement of Karuna Netherlands and Karuna Nepal. The General Director and Country Di- rector, Nepal, have regular contact on opera- www.giesbersgroep.nl onal, strategic, fi nancial, and policy issues. This leads to the desired changes in policy Giesbers Groep brings together six compa- and strategy. nies involved in construc on and property de- velopment. With offi ces in Wijchen, Arnhem, Board Nijmegen, Ro erdam and Naarden-Ves ng, it The Board is composed of its founder, René operates across a large part of the Netherlands. aan de Stegge (Chairman), Toon Kasdorp For Giesbers Groep, corporate social responsi- (Secretary), and Huub Timmer (Treasurer). bility means contribu ng to sustainable devel- opment processes in developing countries such Informally, we receive regular and valuable as Nepal. Giesbers Groep decided to support advice from different experts in the field of Karuna Founda on on a structural basis using development and disability: Brigitte aan de its entrepreneurial approach. Stegge, Ad van der Woude and some senior managers at the Giesbers Groep, like Mar- Giesbers Groep and René aan de Stegge have tijn Bax. invested venture capital in the fi rst phase of Karuna (2007-2013), covering more than 60% of the total costs.

52 The FEMI Founda on off ers opportuni es to people, young and old, to achieve a more (www.impulsis.nl) dignifi ed existence in a more sustainable man- Impulsis is an ini a ve of Edukans, ICCO, www.femi.org ner. It off ers inspira- and Kerk in Ac e (Church in Ac on). It has on based on mutual respect and equality in a support department for Dutch companies collabora on and rapport towards ac ve in- and entrepreneurs who want to promote lo- volvement and crea vity. It ini ates and con- cal entrepreneurship and entrepreneurial nects in every area of well-being and welfare approaches in developing countries. Since while recognizing everybody’s own responsi- 2008, Karuna Founda on has entered a part- bili es and individuality. nership with Impulsis by being a recipient of its grants. Impulsis grants supported the im- In 2012, the coopera on/partnership with plementa on of Share&Care, Inspire2Care, the Dutch FEMI Founda on con nued a er ToP and advocacy projects of Karuna Founda- the feasibility study in 2011 in Tanzania. FEMI on Nepal. is interested in working together with Karuna in Sunsari district, Nepal, to implement an in- tegrated approach to development in a most disadvantaged dalit community. The work is set to start in 2014.

In addi on, private funds supplement the rest Eureko Achmea Founda on (EAF) aims to of the budget for Karuna Founda on. The Start ac vely contribute to a sustainable improve- Fund of Fred Founda on (www.fredfounda on. ment of the socio-economic environment of org) in the Netherlands, the Dr. Hofstee Foun- those in need in socie es both in the Neth- da on (www.hofstees ch ng.nl) the Dutch erlands and abroad, by making fi nancial re- fund Johanna Donk-Grote S ch ng, the S cht- sources available. EAF supports projects ing Weeshuis der Doopsgezinden, Madat Ne- aimed at a structural improvement of disad- pal, S ch ng Vrouwen voor Vrouwen, S ch ng vantaged groups. Beter ter Been also contributed to our eff orts. From me to me, we received smaller individ- ual dona ons as well.

Karuna Founda on : First Phase in Nepal 53 Plan to scale up Inspire2Care (2014-2017)

A er fi ve years, Karuna has proven, through fractures), and community based rehabilita- internal analyses and external evalua ons, on of children with disability, including the that the programs have achieved sustainable awareness and posi ve a tude change in results on health care, improvement in quality communi es. of life of children with disability,maternal and child health indicators as well as community Inspire2Care is a model that directly meets empowerment and leadership. Inspire2Care the needs of the target group, is cost effi cient, has been designed embracing the lessons and both socially and fi nancially sustainable. learned from Share&Care and Inspire2Care A er some me, and on the basis of good projects and borrows ac vi es and processes local leadership and governance as well as from these two projects, which Karuna im- a poli cally conducive environment, the In- plemented in Rasuwa, Kavre and Sunsari dis- spire2Care program will be extended with an tricts in its fi rst phase (2007-2013). insurance component, implemen ng the so- called health insurance model: Share&Care The plan is to scale up Inspire2Care to the developed by Karuna Founda on. whole district of Ilam and Rasuwa. Need in the context of Nepal The goal of the Inspire2Care program is to Safe motherhood and a healthy childhood improve the quality of life of 2,000 children are s ll major challenges in Nepal, especially with a disability, as well as 2,500 adults with a in the rural areas. According to the 2011 Ne- disability, reach about 40,000 young women pal Demographic and Health Survey (NDHS), and mothers with safe pregnancy, safe deliv- the country experiences 54 child deaths per ery and safe infancy ac vi es, and to decrease the incidence of birth defects and disabili es among children by 20%, and develop a replicable model for preven on and rehabilita on.

The ac vi es will focus on prima- ry preven on (safe pregnancy, delivery and infancy), secondary preven on (early detec on and treatment of diseases, malnu- tri on, wounds, infec ons and

Community level awareness program

54 1000 live births, 40% of children under 5 ganized in village development commi ees. years have chronic malnutri on. Low use of With every commi ee, Karuna Nepal has an maternal care prevails and only one-third of agreement based on equal partnership. Karu- the women deliver with assistance. Although na trains and coaches local leaders and the in decreasing trend , maternal mortality rate commi ee, and facilitates the implementa- is s ll high with 229 mothers dying during on process of the program for 5 years. Af- pregnancy and childbirth per 100.000 live ter that period, the community can con nue births according to a survey conducted in the preven on and rehabilita on ac vi es 2008/2009. Health depends on care, and the by themselves with local funds available from u liza on of health care in developing coun- the municipal, district and na onal authori- tries like Nepal depends on the availability, es, as well as from the households. aff ordability and accessibility of services. Al- most 3-5% of the children have disability and In the first 3 years, Karuna invests in the suff er from s gma and exclusion ,leading to direct costs of the program: first year with more poverty, abuse and suff ering. 80%, second year with 50%, and the third year with 30%. In the fourth year, the pro- Process gram is financially sustainable, at which The Inspire2Care program is a community point Karuna only offers technical support run program fully planned, implemented and for 2 more years. After the 5th year, the evaluated by the local leaders, health work- community is able to continue the program ers and rehabilita on workers who are or- without external support.

Mass mee ng with a community group in Sunsari

Karuna Founda on : First Phase in Nepal 55 Coverage Inspire2 Care aims to cover 63 villages of Ilam and Rasuwa districts of Nepal, in coopera on with the Government of Nepal.

Rasuwa District Ilam District

Total popula on 43,300 290,254 Women of childbearing age* 10,514 83,298 Children under 5 years* 3,755 20,494 Children with a disability** 260 1,742 Adults with a disability* 756 5,894 Target popula on 15,285 111,428

* es mated fi gures based on Nepal Census, 2011 ** Data based on Karuna surveys in the project villages

Ward level health educa on in Sunsari

56 The Blue Guideline

René aan de Stegge, owner of Giesbers Apart from sharing an offi ce and facili es in Groep, developed the Blue Guideline, an Arnhem, the Netherlands, both organiza ons entrepreneurial approach regarding process also share the same organiza onal values as and risk management. This philosophy also ongoing improvement, inves ng in people, has been applied by Karuna Founda on from learning by doing, daring to take risks, and its ini a on in 2007, and con nues to be of applying a decentralized structure. great infl uence and inspira on during the im- plementa on of the projects.

Step 1. Analyze the problem Determine who the stakeholders and what their interests are. Look for common interest and synergy but also establish the threats and contradic ons.

Step 2. Defi ne a solu on or interven on in the interest of all Listen carefully to all stakeholders and think- crea ve- innova ve- outside the normal ways (out of the box). Do this together and take me to refl ect. Describe a solu on that has the support of all involved.

Step 3. Determine the chance of success (Con nue Yes/No) Establish is moment when to decide to con nue the project. Is there good chance of achiev- ing sustainable results and success within a reasonable period? But also be prepared to stop a project if the risks are too high or when there is no common interest. If you con nue do this with commitment and take the lead.

Step 4. Manage the process professionally in steps Formulate a higher goal and map the process with other stakeholders. Divide it into steps and defi ne decision moments. be effi cient en eff ec ve. Evaluate the process periodically and adjust where needed.

Karuna Founda on : First Phase in Nepal 57 58 Karuna Founda on : First Phase in Nepal 59 Holland Offi ce Country Offi ce Sunsari Offi ce Ziipendaalseweg 53a Thirbam Sadak, Gate No. 3 Inaruwa Municipality, Ward 5 NL - 6814 CD Arnhem Baluwatar, Kathmandu, Nepal Nagarpalika Chowk T 026-3553198 T +977-1-4413340, 4410687 Sunsari, Nepal W www.karunafounda on.nl F + 977-1-4413719 T +977-25-561735 E info@karunafounda on.nl W www.karunafounda on.com E info@karunafounda on.com

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