Lessons from the Field Building the Capacity of Local Organizations in Reproductive Health: Nepal Case Study
This report describes the process World Neighbors used to partner with local non-governmental organizations in developing a reproductive health component in Terai, a rural area in the southeastern plains of Nepal. The Terai program was initiated in 2000 with support from the Bill and Melinda Gates Foundation. This document describes the setting, design, and unique aspects of the program, as well as its key accomplishments and lessons learned. Preface and Acknowledgements Preface Reproductive health is a key aspect of World Neighbors integrated development program strategy. In 2000, with the support of the Bill and Melinda Gates Foundation, World Neighbors began a systematic effort to develop and document the lessons learned from its program experience in Terai, Nepal. The program in Nepal was one of six programs in which World Neighbors sought to strengthen and expand reproductive health and to develop a model that would have broader application. This document describes the process of developing and implementing reproductive health activities in the rural, southeastern plains of Nepal, called the Terai1 (see map on page 6). It includes the programmatic framework applied in these six World Neighbors program sites, which was developed and modified over the implementation period.
Acknowledgements We would like to acknowledge the staff of our partners - local non-governmental organizations (NGOs) - and the community volunteers for their enthusiastic efforts to build the capacity of communities to meet their reproductive health needs. Not only have the local NGOs played an effective role in working with the communities, they have also maintained records and undertaken careful documentation, which has been critical to the success of the activities. Our local NGO partners and the people in the communities deserve our sincere thanks for their support of our efforts to systematically document the success they achieved through the participatory integrated development programs, including the reproductive health component in the Terai districts of Dhanusha, Mahottari, Sarlahi and also in Sindhuli, part of the inner Terai. It is through this documentation process that we have been able to capture key lessons that have contributed to the develoment of a model applicable to World Neighbors programs globally. Ms. Saraswati Gautam, the World Neighbors health coordinator, deserves special acknowledgement for her efforts to support the training of local NGO staff and community volunteers. She has closely and regularly monitored and supported the program work. The achievements described here are largely due to her commitment and dedication. In addition, World Neighbors South Asia’s present and former staff – Subarna Hari Shrestha, Hari Bahaudr Thapa, Tanka Gurung, Shanta Jirel, Prem Moktan, Amrit Thapa, Purna Sinjali, Nanikaji Maharjan and Surya Bahadur Majhi, have contributed to the program’s success. Finally, the World Neighbors Nepal program team wishes to express their heartfelt appreciation to World Neighbors headquarters for supporting their efforts to adapt the approach developed in the hills of Nepal and apply it to the plains region of Nepal and Bihar, India with support from the Bill and Melinda Gates Foundation.
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Jagdish Ghimire, Gopal Nakarmi, Catharine McKaig, Building the Capacity of Local Organizations in Reproductive Health: Nepal Case Study, (Oklahoma City: World Neighbors, 2005).
Published by World Neighbors, Oklahoma City, Oklahoma 73120 @ 2005 by World Neighbors ISBN 0942716-23-X
1 The Terai are the plains which run across the length of southern Nepal, along the border of India. Table of Contents Introduction ...... 2 Program Context ...... 4 Program Objectives ...... 10 Special Program Initiatives ...... 14 Key Accomplishments ...... 20 Lessons Learned ...... 28 Conclusions ...... 30 Appendices ...... 31 Appendix 1: Individual Member Information Card ...... 31 Appendix 2: Mini-Survey ...... 32 Appendix 3: Trend Analysis- related issues ...... 33 Appendix 4: Savings and Credit Group Progress Report – completed by NGOs ...... 35 Appendix 5: Savings and Credit Cooperative Progress Report ...... 36 Appendix 6: Clinic Self-Reliance Progress Report...... 39 Appendix 7: RH/CH Service Report...... 40 Appendix 8: Clinical Checklist...... 43 Appendix 9: Check List for Partner Clinic Quality Monitoring ...... 45
1 Introduction Nepal is among the poorest and least developed rendered nearly half a million displaced. Most of this countries in the world, with 40% of its population displacement is from rural areas. Restoring peace, living below the poverty line. Agriculture is the democracy and human rights is the country’s biggest mainstay of the economy, providing a livelihood for challenge for which overcoming poverty is a over 80% of the population and accounting for 40% of prerequisite. the gross domestic product. In the United Nations’ 2004 Human Development Report, Nepal’s human As a result of the combined effects over the several development rating (HDI)2 is 0.499, placing the country decades of feudalism, bad governance, political near the bottom of all countries ranked (143 of 177). mismanagement, insurgency, corruption, opportunism of the elites, and the Maoist insurgency, Nepal is Eighty-two percent of Nepal’s 24 million people live in passing through a series of unprecedented political and rural areas lacking basic infrastructure and services, constitutional crises. typically relying on subsistence farming for their livelihoods. Eighty-three percent live on less than two dollars a day3.
Educational opportunities are limited. While current primary school enrollment is 70%, adult literacy is only 44%, with even lower literacy rates for women. Acronyms
Overall life expectancy in Nepal is 59.6 years, and ANM auxiliary nurse midwife health indicators are poor. Infant and child mortality BBP Baudha Bahunipati Family Welfare Project are 66/1,000 and 91/1000, respectively. Almost half CBO community-based organization (48%) of all Nepalese children under five are CMA community medical assistant underweight for their age, and 21% of infants are born FP family planning with low birth weight. The adjusted maternal FPAN Family Planning Association of Nepal mortality ratio is 540 deaths per 100,000 live births. MOH Ministry of Health NGO non-governmental organization The total fertility rate of Nepal is 4.3. Population RH reproductive health growth in Nepal has outstripped per capita food RTI reproductive tract infection production, contributed to increased pressure on STI sexually transmitted infection cultivable land and forest resources, and hampered the TBA traditional birth attendant nation’s ability to provide basic social services. This TSS Tamakoshi Service Society presents a serious challenge to the attainment of TTBA trained traditional birth attendant peoples’ right to a better life. UTI urinary tract infection VDC Village Development Committee The overall socio-economic and development WN World Neighbors indicators are worse in the rural areas compared to the urban and semi-urban areas, with the exception of selected slum areas. The situation in remote areas is further worsening as a result of ten years of the Maoist “people’s war” which has claimed over 15,000 lives and
2 Index score composed of health, education and income statistics. 3 All statistics on this page are taken from the United Nations’ 2004 Human Development Report.
2 The Setting, Terai
3 Program Context World Neighbors has been implementing rural program. In the same year, in response to the development programs in Nepal since 1973. Currently, communities’ requests, the program began to obtain World Neighbors partners with eight local Nepali non- and sell medicines at reasonable prices. By 1992, eight governmental organizations (NGOs) to promote self- NGOs were officially registered and carrying out these reliance in the areas of food security, reproductive activities. In 1994, all BBP activities were handed over health (RH) and women’s empowerment. In keeping to the eight NGOs to continue implementation. The with World Neighbors philosophy and reflecting the BBP staff played a role in networking, facilitating the complexity of rural community needs, programs exchange of ideas and experiences among the NGOs, integrate various livelihood, health and development and providing training and other important information. activities. The NGOs were encouraged to develop collaborative relationships with government agencies, particularly World Neighbors strategy in Nepal has been focused on with the district health office. These relationships strengthening the ability of local community-based enabled the NGOs to receive contraceptives and to groups’ to implement and manage integrated activities provide specialized outreach services, training, and by working in partnership with the local NGOs. An other basic commodities free of cost. early program was the expansion of the Boudha Bahunipati Project (BBP). BBP was initiated by the The joint World Neighbors and FPAN program, BBP, Family Planning Association of Nepal (FPAN) in 1973. has served as a learning site for many governmental, With World Neighbors support, it expanded to local and international non-governmental development Sindhupalchok and Kabhre districts in 1975. At that agencies regarding participatory integrated community time, participatory needs assessments demonstrated development in partnership with local marginalized community priorities to be the attainment of drinking communities. In the 1980s and 1990s, BBP was able to water and adequate fodder for animals. These needs draw the attention of international organizations like are largely felt by women, who often must travel long the International Planned Parenthood Association, the distances to obtain clean water and to gather fodder for United Nations Population Fund, and the Ford feeding animals. World Neighbors initial efforts to Foundation. The Ford Foundation conducted various respond to the community identified needs generated evaluations of BBP’s strategies and impacts. The trust, thus laying the foundation for eventual results in evaluations consistently confirmed the effectiveness of family planning (FP) and community capacity building. BBP’s strategy to integrate reproductive health, agro- forestry and women’s capacity building in achieving From early on, a key organizational element of BBP holistic development at the grassroots level. was the formation and strengthening of community- based groups. A variety of groups were formed World Neighbors has applied this successful model of including farmers, water supply, and women’s savings integrated participatory development in other parts of and credit groups. Over time, the women’s savings and Nepal. The first expansion was conducted with the credit groups were seen to have been the most effective Tamakoshi Service Society (TSS) in 1985, in the and enduring of all these groups. Ramechhap district in the eastern mid-hills of Nepal. The model continued to be adapted and refined in the World Neighbors, in partnership with FPAN, tried Ramechhap program. different strategies to sustain the programs and to transition program ownership to local people. In 1984, The second expansion, which is the topic of this case World Neighbors introduced a participatory strategy to study, took place in 2000, with support from the Bill develop, plan, implement, and monitor the program. In and Melinda Gates Foundation. At that time, World 1988, leaders of the various groups were encouraged to Neighbors expanded activities working in southeastern establish and register as local NGOs to carry out the Nepal across the border into one of the neediest areas 4 Program Context of the world: Bihar, India. These areas were selected 1. The consultants provided a short list of the five based on the following factors: best NGOs collected from other development • The need for reproductive health (RH) services in agencies. the areas, 2. The NGOs were verified with district government • The logistical feasibility of operating the program, authorities and different international and local NGOs. • The presence of established, interested and capable NGOs, and 3. The candidate NGO program sites were visited to observe the impact of activities. • The cross-border similarities (geographical, cultural, and environmental) with the Madhubani area in 4. Beneficiaries were interviewed and their views Bihar, India. considered as to the NGO’s effectiveness and commitment. A consulting firm was hired to study local NGOs working in the eight southeastern districts of Nepal and Through this process, seven local NGOs were to recommend suitable partners to World Neighbors4. identified as partners. Table 1 summarizes their key In order to do this, the following steps were followed: characteristics. While there have been some changes over time, the large majority of the local NGO partners remain those identified through the consulting process in 2000.
Table 1: Partners by district, number of Village Development Councils (VDCs) and activities prior to World Neighbors partnership
Ltlaco NGO Name DCcirtsi # fo VD E nitsix g A eitivitc s
CHETANA* sgnivaS na d elbaniatsus,ycaretil,tiderc ,kcotsevil,erutlucirga no -n ihalraS 2 (Aw )ssenera it m slliks,yrtserofreb oleved pm tne
sgnivaS na d ,tiderc w usreta p oitagirri,ylp ,ycaretil,n no it-n m reb D nah ahsu eS wa aS (itim D )SS D5nah hsu a 1 slliks,yrtserof oleved pm elbaniatsus,tne kcotsevil,erutlucirga
detargetnI R laru D oleve pm tne W usreta p ,ylp yraniretev hcs,secivres o oclo oitcurtsn sgnivas,n na d M5ha iratto S yteico RI( D )S ,tiderc elbaniatsus,cinilclatned kcotsevil,erutlucirga
R laru Commu ytin D oleve pm tne W usreta p ,ylp yraniretev hcs,secivres o oclo oitcurtsn sgnivas,n na d M6ha iratto ecivreS Cou R(licn CDS )C elbaniatsus,tiderc kcotsevil,erutlucirga na d p ytrevo ile oitanim n
Wom s'ne C larutlu D oleve pm tne sgnivas,sthgirlagel,ycaretiL na d ,tiderc nah elbaniatsus,stfarcid M4ha iratto C ertne (WCD )C ,erutlucirga p ytrevo ile oitanim na,n d .kcotsevil
sthgiR aw slliks,ssenera oleved pm gniniarttne rof wom ,ycaretil,ne R laru Wom s'ne U tfilp A oitaicoss n ihalraS 1sgnivas na d ,tiderc nah seitivitca,stfarcid ehtrof ,delbasid R( WU )A elbaniatsus na,erutlucirga d .kcotsevil
niS dh detargetnIilu D oleve pm tne sgnivas,ycaretiL na d slliks,tiderc oleved pm elbaniatsus,tne niSdh ilu 3 IS(secivreS D )S ,kcotsevil,erutlucirga p ytrevo ile oitanim n
* partner added in 2001
4 Ram Krishna Neupane, Center for Development and Management Studies, NGO Assessment Study Report, January 2000. 5 Program Context
IRDS CHETANA SIDS RCDSC DSS RWUA WCDC
The four districts in which the NGOs work have a The overall program area is characterized by very low combined total population of over two million people. status of women and conservative social practices such Table 2 summarizes the population by village as purdah,6 dowry, and a caste system. Many women’s development committee (VDC)5 for the 38 VDCs in lives are characterized by early age at marriage and which the NGO partners are working. early age at first birth. Preference for male children drives fertility in the area. The fundamental problems Table 2: Number of VDCs and population by NGO partner addressed by the program relate to RH, poverty, and the process of active marginalization of disadvantaged # fo Pop oitalu n people. These problems are summarized by the NtGO D cirtsi VDCs Mssela Flem ela T ato following findings from a survey conducted with 960 women in the program area: CiHETANA halraS 253,01 973,01 8 37,02 7 • Early age at marriage: 60% of women reported DaSS D1nah hsu 1954,8321,63 685,47 5 being married by the age of 17. • RIDS M69ha ratto i05,81 98,71 804,63 7 Early age at first birth: 84% of the married women gave birth to their first child by age 20. RiCDSC M71ha ratto 29,2339,92 258,26 3 • Low modern contraceptive use and male RiWUA halraS 331,21 956,11 2 97,32 1 sterilization: female sterilization 22%, pills 0.2%, ISDS niSdh lu i 339,32 8 58,32 0 87,74 8 Depo Provera 12%, condom use 1%, and male sterilization 0.5%. WiCDC M69ha ratto 10,7253,52 173,25 0
T8lato 3443,36181,551 735,813 1
5 VCDs are a structure created by the Nepali government to coordinate local level development. 6 Purdah is a practice related to women’s use of veils to cover their faces and limiting their mobility outside the home. 6 Program Context • Unmet FP need: 38% of women in the program area were using FP methods at the time of the “The in-laws and husbands behaved in a cruel survey. However, 30% of women said that they manner in the past since girls got married at the age wanted to use contraceptives but that FP services of 12 or so. These innocent girls would not know were not easily accessible. how to do the household chores properly or please • Low use of prenatal care: 41% of pregnant women their husbands and in-laws and thus got beaten. did not receive prenatal care. Women these days are more aware and educated, • Low use of post-natal care: 73% of women did not and domestic violence has decreased significantly.” receive post-natal care services 24-48 hours after — Pachgachhiya women’s group the delivery. • Few births assisted by skilled personnel: 70% of births were not attended by skilled personnel. • Low rate of colostrum feeding after birth: only 46% of mothers fed colostrum to their babies within 1- 12 hours of delivery. Another 6% fed colostrum to their babies within 24 hours of delivery. • Reported gynecological problems: 29% of women experienced gynecological problems, including excessive vaginal discharge, lower abdominal pain, urinary tract infections (UTIs), reproductive track infections (RTIs), pelvic inflammatory disease, and uterine prolapse. • High levels of illiteracy: 49% of men and 77% of women are illiterate. • Gender-based violence: 18% (179) of women in the program area reported that their husbands had beaten them in the past year. Only 15% (27 women out of 179) of those battered women sought social or legal help. • Women’s access to money for health care: although 86% of women surveyed said they could use household money for health care, in fact only 19.5% ever had.
7 Program Context Identifying Needs After selecting partner NGOs, World Neighbors World Neighbors trained partner NGOs to use simple worked with them to identify and prioritize community tools in conducting participatory needs assessments needs in their areas. A four day orientation training on with the community. In particular, women were how to conduct a needs assessment was carried out. involved in leading the process of needs identification The training included: in the program areas. The felt needs were then • Observation and exchange: Staff and volunteers classified and prioritized with the help of the 8 were taken for observation to other program sites in community. order to get first hand practical knowledge of the integrated, participatory development approach Findings demonstrated that at the start of the Terai developed in BBP. program RH services were felt to be needed and generally were not available. In response to women’s • Community work: Discussion groups of desires to space and limit the number of children and community members were organized. Sixteen RH the absence of RH services, the provision of health issue picture cards7 were shown to stimulate information and services were identified as priorities. discussion. In each picture, six questions were posed. These were: 1.What do we see in the picture? 2. What is happening? 3. Does it happen in our community, too? 4. Why does it happen? 5. Who would feel the effects of this issue more – men or women? 6. What can we do to reduce or eliminate this issue? • Health service analysis: The accessibility of reproductive health services, including estimates of the monetary and time costs and the quality of services were analyzed with communities.
7 Issue pictures included vaginal discharge, uterine prolapse, multiple pregnancies, delivery complications, girls education, violence against women, unsafe sexual behavior, women’s roles and status, labor migration, alcohol abuse, infertility, infant and child mortality, HIV/AIDS, etc. For a full description of this exercise see, Caudill, D. Responding to Reproductive Needs, World Neighbors, 2001. p.12 8 Caudill, D. Responding to Reproductive Health Needs: A Participatory Approach for Analysis and Action; revised edition edited by Linda Temple, Oklahoma City: World Neighbors 2001. 8 World Neighbors and DSS Clinic Staff, Dhanusha
9 Program Objectives The central strategy of the program model is to support • To decrease borrowing from local money lenders by RH through women’s empowerment. A key element is providing lower interest loans through self-help the provision of RH services through local NGO-run groups, and clinics and outreach services using female providers. • To increase group capacity to manage themselves. The specific program objectives related to RH clinic In 2002, World Neighbors supported an additional set and outreach services were: of activities aimed at increasing food security, fodder • To increase contraceptive prevalence in response to and fuel supply. unmet need, The following table describes how the program design • To reduce unwanted pregnancies, addressed the key elements of the World Neighbors • To improve the spacing of wanted children, integrated development program approach for RH. • To increase women’s age at first pregnancy, and Key elements used to guide all of World Neighbors reproductive health efforts include: integration • To increase prenatal, delivery and postnatal care by linkages, information and counseling, quality trained personnel. reproductive health services, community and local In keeping with the holistic approach of the program capacity building, action learning, gender equity and other objectives included: efforts to address the needs of special populations.
Table 3: Implementing the World Neighbors RH key element framework
Key elE me stn How ele me stn era im elp me etn d ni ht e orp arg m?
etnI oitarg :n nI eht T eht,iare RH seitivitca w ere detaitini htiw pleh-fles org u sp taht deirrac o tu sm elacs-lla ocni me gnitareneg .seitivitca T eseh org u sp w ere yllaitini oc mp deso ylevisulcxe fo wom ne na d desu How si siht rieht sgnivas sa eht sisab gnitatorrof .snaol T eseh sm elacslla snaol w ere desu m tso oc mmo yln rof occa m dehsilp na d orp d ,evitcu detaler-erutlucirga ,seitivitca b tu osla sa m snae ot yap hcs o seeflo ylralucitrap( rof )slrig ?derutcurts na d ot yap htlaeh ecivres .seef
B desa on us qesb tneu sdeen na d ytilibisaef ssessa m ,stne a elbaniatsus erutlucirga oc mpo tnen w sa detargetni ni 02 0 .2 An o evitcejb detaler ot of d red na d usleuf p ylp w procnisa .detaro
RH rofni m oita n and B hto ehtta scinilc na d orht hgu o hcaertu deniart,secivres NGO arap m ekilscide yrailixua n -esru coun niles :g m di seviw (ANM) na d oc mmu ytin m lacide stnatsissa C( MA )s orp ediv ecaf-ot-ecaf rofni m oita n na d oc u gnilesn ot eht tneilc ro oc u .elp E stroff era nekat ot erusne oc ytilaitnedifn na d ,ycavirp neve ni How rofnisi m oita n o hcaertu .sgnittes na d oc u gnilesn orp ?dediv T eh 61 erutcip sdrac debircsed( on egap )8 era desu ot its m etalu org up oissucsid sn fo cificeps seussi na d ot etaulave .ssergorp
T eh detcele sredael fo eht sgnivas na d tiderc org u sp eviecer da oitid gniniartlan ni RH na d evres sa a oser ecru ehtrof org up ehtta oc mmu ytin .level
D gniru ygolocenyg ac m ,sp ffatslacinilc orp ediv rofni m oita n na d oc u .gnilen
deniarT oitidart lan htrib netta stnad T( TBA )s orp ediv oc mmu desab-ytin oc u gnilesn na d roflarrefer m lanreta htlaeh af,secivres m yli nalp orper,gnin d evitcu oitcefnitcart sn na d rehto oc .snrecn
10 Program Objectives
Key elE me stn How ele me stn era im elp me etn d ni ht e orp arg m?
Qu ytila RH S civre se A ehtt oc mmu ytin deniart,level TBAs edivorp os me cisab secivres hcus sa latan-erp ,erac naelc na d efas yreviled ,ecnatsissa p latan-tso af,erac m yli nalp gnin na d .slarrefer
rentraP NGOs era detsissa ot hsilbatse cisab scinilc ur n yb arap m .ffatslacide T eseh scinilc orp ediv > Commu ytin af m yli nalp gnin taert,secivres oc mmon sessenlli na d orp ediv m lanreta htlaeh na d yreviled erac > O hcaertu secivres ot eht oc mmu nilseitin dek htiw eht pleh-fles org u .sp T yeh edivorp eseht secivres on a -eef > H htlae ytilicaf slevel ecivres-rof sisab ot erusne eht ytilibaniatsus fo eht .scinilc
How era secivres NGO arap m ffatslacide orp ediv oirep cid o hcaertu secivres ot oc mmu seitin w ereh eht pleh-fles orp dediv esehtta org u sp era .detacol U yllaus eseht era mo ylhtn o hcaertu .secivres ?slevel lareveS fo eht NGOs ezinagro na n lau ygolocenyg" ac m "sp w ereh a aet m fo of otru evif stsigolocenyg orp ediv yrassecen secivreslacigrus hcus sa ut oitagillab sn na d riaper fo eniretu .espalorp
Capa ytic B nidliu g T eh m nia ygetarts rof yticapac b gnidliu si ot w kro htiw NGO ffats na d eht oc mmu ytin v ulo sreetn on a yteirav fo :slevel gnidivorp ho deeftsen ,kcab oc evitcurtsn sicitirc ,m na d oitazinagro -fleslan How d seo siht ssessa m tne fo eht seiticapac dedeen rof otua nom .y T sih hs o dlu aeb tnerapsnart ssecorp orf m pa hcaorp dael ot argorp m nalp gnin ot bu .gnitegd yticapac b gnidliu ni RH? An irehto mp tnatro tcepsa fo eht pa hcaorp w sa oleved gnip eht yticapac fo eht sgnivas na d tiderc org u .sp nI m tso sesac eht org up si rofsnart m de otni a oc mmu desab-ytin oitazinagro ,n yllausu a sgnivas na d tiderc oc o ,evitarep w hcih si i-fles,tnailer-fles m orp gniv na d -fles gnidaerps laicnanif na d oitutitsnilaicos n ni eht oc mmu .ytin
E yrev xis mo shtn lla stcepsa fo NGO rofrep m ecna era pa desiarp yb W dlro N hgie b sro ffats ni a yrotapicitrap m na .ren T eh yek saera fo htped-ni ulcnisisylana :ed )1 NGO pihsredael /m lairegana ,ssenevitceffe )2 oc s'rotanidro ,ssenevitceffe )3 sgnivas na d tiderc org u ,ssenevitceffe'sp )4 sgnivas na d tiderc oc o evitarep ,ssenevitceffe )5 RH argorp m ,ssenevitceffe )6 elbaniatsus erutlucirga ,ssenevitceffe laicnanif)7 m egana m ,tne )8 cinilc ytilibaniatsus nert ,d )9 d uco m oitatne n na d per gnitro na d 1 )0 oitazilitu n fo ,lacolrehto oitan oitanretni,lan oserlan .secru T eh NGOs etar eht m sevles on eseht stcepsa na d eht W dlro N hgie b sro aet m osla sngissa .sgnitar T eh sgnitar era neht oc m derap na d ,dessucsid na d eht saera qertaht eriu gninehtgnerts era .deifitnedi
A yteirav fo yrotapicitrap sesicrexe na d ot slo era desu ni oitazinagro .gninehtgnertslan T eseh ulcni :ed m ,yevrus-ini yticapac ssessa m ,tne lacinilc m egana m tne roflocotorp cinilc osrep n ,len na d a cinilc q -ytilau mo gnirotin .tsilkcehc C( o seip fo eseht ot slo era orp dediv ni pa nep secid ).9-1
11 Program Objectives
Key elE me stn How ele me stn era im elp me etn d ni ht e orp arg m?
A oitc n el ra nin g yrotapicitraP oitca n gninrael seitivitca desab on eht elpicnirp fo derutcurts ssessa-fles m tne era oc nd detcu htiw b hto eht NGOs na d eht pleh-fles org u sp yreve xis m .shto T eseh ulcni ed How si AL ulcni ded ni yrotapicitrap -fles ssessa m stne htiw NGOs axe m gnini yek yticapac saera na d cinilc uf oitcn ,gnin na d eht argorp m? m syevrus-ini htiw eht pleh-fles org u sp na d eht axe m oitani n fo segnahc na d argorp m im .tcap A lativ stneve retsiger fo ,shtrib ,shtaed m oitargi ,n m ,segairra na d rofnirehto m oita n ba o tu mem sreb nac eb desu rof oc m osirap .n
nI da oitid ,n enilesab na d ollof w u- p oitces-ssorc syevruslan w ere deirrac o tu htiw o en NGO .rentrap
Gend -re R etale d T eh pa hcaorp ocne segaru wom ne ot rof m pleh-fles org u sp na d oc nd tcu gnivas na d tiderc .seitivitca Aspe stc nI da oitid n ot gniniag ecneirepxe ni m gnigana uf n sd na d oisiced n m eht,gnika ,sredaeltceles who evah dah elttil opp utro ytin rof oc mmu ytin ,pihsredael niag .ecneirepxe M yna yrtserof-orga seitivitca How si neg nekatred - gnihsilbatse eert n ,seiresru oitatnalp of,sn d red oitcelloc n na d -esu evah oitidart yllan neeb otni oc oitaredisn n ni oc deredisn wom ojs'ne .sb An detargetni RH na d elbaniatsus erutlucirga argorp m da sesserd a rediw eht argorp m? egnar fo wom s'ne .sdeen A num reb fo oc mmu seitin evah m s'ne pleh-fles org u nisp da oitid n ot wom .s'ne M yna fo eht pleh-fles org u sp era m dexi na d eht m ne na d wom ne fo eht oc mmu ytin w kro otrehtegot evlos rieht oc mmon orp elb m .s Emp sisisah decalp on gnitatilicaf segnahcxe teb w nee m ne na d wom ne ni eht org u sp on a yteirav fo ot ulcniscip gnid af m yli nalp ,gnin neg detalerred ,ecneloiv ocla h lo ba ,esu na d af m yli oisiced n m .gnika
Spe laic G or ups Ad rofnI:stnecselo m oita n on RH ulcni gnid HIV/AIDS si orp dediv ot hcs-ni o lo na d o hcs-fo-tu o lo da .stnecselo T yeh osla eviecer oc u gnilesn na d secivres orht hgu eht NGO .s Some da stnecselo evah Who era eht laiceps rof m de pleh-fles org u sp na d detaitini ocni me gnitareneg .seitivitca Some hcs-ni o lo da stnecselo evah org u ?sp dezinagro RH oissucsid n oisses sn rof o hcs-fo-tu o lo reep da nistnecselo rieht oc mmu .seitin llA RH oc u gnilesn na d ecivres seitivitca detaler ot da stnecselo era desucof qe yllau on b syo na d .slrig How era rieht sdeen m ?te D stila na d ni negid o su org u :sp T ereh era org u sp fo stilad ro yllaicos ulcxe ded oep elp na d ni negid o su oep selp who orhttifeneb hgu eht org u sp na d era orb otnithgu eht argorp m m aertsnia m.
12 Sakunti is 19 years old with a new infant that is one month old. This is her third child, as she was married at 15. Her other children are three and two years old. Her husband works in India (right across the border) as a bicycle mechanic.
Sakunti didn’t have any prenatal care for her prior pregnancies. With this pregnancy, she visited the RCDSC clinic for prenatal care. The ANM also assisted her during delivery, ensuring that she had a safe delivery kit (a basic kit with a clean razor blade, plastic sheet and bandages for cord care). She says she felt more confident with this last pregnancy because of the care she had.
13 Special Program Initiatives Within this framework there are several unique aspects records (minutes, records of incomes and expenditures, of the World Neighbors program in the Terai that merit and member’s passbooks). They felt it would require special emphasis. These include: working with local too much staff effort and were also quite doubtful of NGOs that have little or no RH experience; the strategy itself. But when the leaders of the new establishing NGO-run self-reliant, rural clinics; NGO partners were taken to the successful older providing outreach services linked with self-help program areas like BBP and TSS for cross visits, they groups; the development of formal savings and credit observed successful examples of grassroots capacity cooperatives (which, in turn, support the clinics); the building and they were motivated to work with the supportive approach to monitoring and supervision, groups to try out the approach. As they have worked and addressing the practical needs of rural women. through the process, they have gained confidence in These aspects are described in more detail here. supporting the groups. a) Working with local NGOs with little or no RH experience WN works in partnership with district based local b) Establishing NGO-managed, self-reliant, rural NGOs. A local NGO is registered at the district level clinics: (as opposed to registering in Kathmandu, the capital The need for quality health care is very evident from city, and operating in many districts), and is owned and the poor health statistics for Nepal described earlier. led by local people. The leaders and members live in While government clinics are often described in the program communities and are well placed to planning documents along with well-defined catchment understand the problems, their root causes and populations, the reality is that in many parts of rural practical ways and means to address them. Nepal there are few functioning health services. Even where government health services exist, shortages of The initial four-day long orientation described earlier is personnel and drugs make for very poor quality critical in order to build commitment to reproductive services. Faced with this reality, World Neighbors health and to help NGO staff develop confidence and approach evolved beyond simply ensuring access to skills in assessing needs, prioritizing and problem information and the exploration of health needs to solving with their communities. ensuring quality, convenient health services. Thus the rural NGO clinic emerged as a key aspect of the Initial misgivings about the program approach are strategy. addressed during the orientation period. For example, at first the NGOs found it difficult to charge for The process of establishing rural clinics involves services and medicines. Their view was that people exposing partner NGO leaders to another NGO’s would not be able to pay for services or for medicines, functioning clinic that operates in program areas so these things should be subsidized. Through a cross formerly supported by World Neighbors. Once the new visit, they observed other World Neighbors partner partner NGO is able to assess the feasibility of and NGOs charging and providing quality services. displays the commitment to starting clinical operations Through the fees they collected the other NGOs were in its area, staff members are trained in basic able to ensure the sustainability of their services. management skills. The NGO clinics are intended to provide a basic level of health care. A description is Initially the NGOs were also concerned that the self- provided in box 1. help groups wouldn’t be able to keep the necessary
14 Special Program Initiatives
Box 1: Description of Typical NGO Clinic eventually come to an end and the Staffing: Two paramedical staff (either ANMs and/or CMAs), one cleaner/ assistant activities would stop. Experience demonstrated that self-help savings Medicine: A stock of basic medicine, valued between $1000-1200, and a and credit groups were more self- three-month supply of contraceptives are maintained at the clinic. reliant than NGOs. Thus, working with the local NGOs, World Equipment: This includes very basic, but limited equipment such as a blood pressure cuff, stethoscope, and examining table. Neighbors assisted the self-help savings and credit groups to build Services provided: Basic clinical care, prenatal care, delivery care, post-partum their capacity, to expand and to care, family planning, pregnancy testing, ring pessaries, other RH services, and develop into multi-purpose basic laboratory tests. cooperatives. This was a long but Hours of operation: Most clinics are open for a period of 7 hours (10 am to ultimately rewarding process. The 5 pm). However, because the clinic staff lives on site, some services are savings and credit cooperatives available 24 hours. were created by the NGOs in the same communities where the clinics Location: Usually two to three rooms rented in a building. existed. Therefore, because the self-help groups had worked with the clinics and had benefited from the services, the Another key aspect of the approach has been an sense of ownership was already present. The emphasis on the sustainability of services and making cooperatives began using some of the earnings from the clinics self-reliant. Over the years, a great deal of savings and credit activities to support the clinics. The progress has been made in the area of cost-recovery most outstanding example is the case of TSS in through registration fees and the sale of medicine. Ramehchhap. In 2002, the local cooperative provided These strategies have reduced the recurrent costs to $10,000 to run the 10-bed hospital. The hospital was about $1,000 a year or about the salary of the ANM. initiated in 1985 with World Neighbors support as a The challenge has been to identify local sources of small clinic with only one paramedical staff. support to provide for these costs.
The clinic service charges are subsidized for group members. NGOs involve the group members in determining the prices of medicines and the service charges for clinics and outreach services. Normally the medicines are sold at the company- recommended maximum retail price. The NGOs purchase medicines from the manufacturers, avoiding the middle person, receiving a discount for bulk purchases. They also receive other promotional benefits. These activities enable the NGOs to make about a 20% gross profit on the sale of medicines.
While World Neighbors has greatly valued its partnership with local NGOs, unless they have a permanent source of income from investments or endowments, any external project funding would WCDC Clinic 15 Special Program Initiatives The Terai program provides the most Table 4: Sustainability plan for seven NGO clinics in Terai, Nepal in US dollars recent example of NGOs mobilizing the local savings and credit cooperatives to S5o secru fo nI come 0-400-50 60-60 7 0-70 8 support clinics. The evolution from a self- tiforP m nigra orf m eht elas fo 687,676,8 177,01 1 43,11 3 help group to a cooperative takes place m enicide when the group membership increases to R oitartsige n seef 27,19 01,2 085,2 6 78,2 1 more than 25 people and savings has surpassed $1,000. By registering with the ecivreS segrahc 74,31 05,4 084,5 6 19,5 4 government as a cooperative, the group orftseretnI m ped nitiso -oc 709,126,3 104,5 0 81,7 6 can increase its savings and can charge o evitarep interest. They also open their O ocnireht me 45,13 01,2 058,2 7 14,3 4 membership to the wider community and include members from other villages. Supp orftro m oc o evitarep 87,16 54,3 724,6 9 70,8 1 The cooperatives have the objective of G orftnar m W dlro N hgie b sro 895,82 018,92 461,13 0 focusing on the welfare of the members and the communities. Currently, fourteen T0nIlato come 28,5452,45 996,46 3 97,83 9 cooperatives have been established in the E5xpen serutid 0-400-50 60-60 7 0-70 8 Terai, although only 10 have officially been registered. About three fourths of yralaS fo ANM /s CMAs 52,125 78,22 256,42 7 72,42 2 the cooperatives and their boards are yralaS srehto ffats 45,31 37,3 970,4 9 01,4 8 female. cinilC tner 93,33 52,3 673,3 0 70,2 0 The following table describes how various cinilC oenallecsim su sesnepxe 29,29 01,3 392,3 3 34,3 6 sources of income will be applied to the T8lato Expen erutid 11,1379,23 093,53 9 88,33 6 operating costs of the clinics over the next five years. Support from the tiforP07,41 282,12 992,92 4 19,4 3 cooperatives increases over time, as does income from registration fees and service charges. The profit is accumulated in Table 5: Comparison between 12 month planned and 6-month incomes for IRDS savings accounts where it also collects clinic in from July 2004-June 2005 interest. alP nned A utc la D ereffi n ec So secru fo nI come o( ne )raey 6( mo )shtn U $S Table 5 below provides an example of the U $S U $S careful monitoring of clinic expenses and revenue. It provides a comparison M0nigra orf m M senicide 00,174 6425( ) between the planned one-year income and R7oitartsige n eeF 5352 899( ) the actual income for a six-month period ecivreSC segrah 70,1 177 7492( ) for the clinic run by IRDS in Mahottari. From this table, it appears that the clinic tseretnI82 6 0682( ) will meet its goal of becoming self-reliant O6ocnIreht me 863)05( in the next two years. S4upp orftro m Coo evitarep 12 0412( )
G3orftnar m W dlro N hgie b sro 49,466,2 2182,2( )
T7lato 59,702,4 9847,3( )
16 Special Program Initiatives c) Outreach services linked with self-help groups interest rates on these debts range from 36% to over 100%. The debts are passed from generation to Service delivery is critical because in the remote, rural generation. Despite in-kind labor and repayments on areas where World Neighbors programs operate, the original loan, the interest on the principal continues essential RH services often are not available. It is to increase. In time, the borrower’s family may be widely known that services do not exist in the rural turned into bonded labor, tied to the moneylender for areas and the available, urban-based services are generations. accessible only to the few who can afford the luxury of traveling to them in the nearby towns. So, in addition In order to reverse this impoverishing practice, the to locating NGO clinics in rural locations, the strategy program worked with small groups, encouraging them also includes making outreach services accessible in the to save their own funds. In this way, group members program areas at affordable costs. Counseling and could borrow from this fund at lower interest rates that service delivery are carried out in the villages adjacent they determined themselves. Again, there was a lot of to the clinics by the NGO paramedical staff. Every initial skepticism on the part of NGO partners and month, the NGO clinic paramedics spend several days community members as to the effectiveness of this trekking to the adjacent villages where the self-help approach. Cross-visits to successful groups were an groups are located. important activity in building enthusiasm for the activity. These self-help groups are a fundamental part Generally traveling in groups of two, the paramedical of World Neighbors approach in Nepal, and their staff provides basic preventative and curative services, success has been demonstrated repeatedly in a variety including family planning, at a designated health station of program settings. in each village. The outreach session is organized by self-help group members but is open to any community One of the problems identified by women was member. Generally, about one third of clients in inaccessibility of funds to use for RH services. Thus, outreach sessions are from non-member families. A when the women’s groups were able to save funds and small fee is charged for the services. to make loans for income generating activities, they also had some funds at their disposal for basic RH One limitation is that not all services can be provided. needs. In addition, they also used the loans for related Some of the necessary equipment, medicines and issues, such as supporting the education of their contraceptives cannot be transported on foot. daughters. However, the basic services provided ensure minimal levels of care and provide opportunities for health The self-help savings and credit groups are central to education, counseling, follow-up and referral to clinics. the program approach. All programs are implemented The dates for the monthly visits are finalized in through group members, for group members and by participation with the groups. group members. Groups have a stronger potential to becoming self-sustaining using local resources, whereas d) Self-help savings and credit groups NGO activities are dependent on the participation of The creation of self-help savings and credit groups the groups and outside funding. helps reverse the marginalization process by reducing and eliminating borrowing from local moneylenders and by supporting the development of local leadership and collective organization. Poor people traditionally borrow money from local moneylenders at very high interest rates. This often is the beginning of a downward spiral into further debt and poverty. Annual 17 Special Program Initiatives e) Transition to a savings and credit cooperative basis and for visiting the surrounding villages frequently. (See Appendices 4-7 for the monitoring As discussed earlier, the formal registration of the self- tools and reports used by NGO coordinators). help groups as savings and credit cooperatives contributes to the sustainability of both the clinics and In addition, World Neighbors team members visit all the savings and credit activities. This transition occurs NGO partners and their programs at least once a year. when group membership exceeds 20 people and the In practice, the World Neighbors team often visits group accumulates more than $1,000 in savings. When clinics more than three times per year. During these the groups have grown sufficiently in terms of funds visits, World Neighbors team members use clinical and managerial capacity, the partner NGOs assist them checklists as reporting tools for monitoring partners’ in this registration. To date, there have been 14 savings clinics, and they also verify the completion of other and credit cooperatives established, and 10 have been reports (see appendices 8 and 9). registered and recognized officially. In World Neighbors experience, the bringing together of groups g) Addressing the needs of rural women into a cooperative enhances sustainability at a higher level of empowerment and performance. The needs of rural, marginalized women are multi- faceted and include the need for economic When a group grows in terms of funds and capacities, empowerment as well as the means to ensure good it needs to operate as a bank for its members. While health. World Neighbors experience indicates that the savings and credit group is an informal assisting marginalized women to form self-help groups arrangement, a savings and credit cooperative is a and enabling them to respond to their priority needs has formal institution with legal rights that enables it to had a transformative effect on then and on their protect the investments of its members. communities. The success of the savings and credit groups and the increased demand for reproductive Moreover, savings and credit cooperatives can be health services are testament to this transformation. active in civil society and community development, and they can donate profits to a cause acceptable to their A critical aspect of holistically addressing the needs of members. In numerous cases, cooperatives have taken rural women has been strengthening the capacity of the wider social responsibility such as supporting the local groups. This work is done through the NGO staff and clinics with their own resources. In the Terai, these the group leaders, and it includes support for needs cooperatives have decided to contribute US $1,786 in assessment, problem identification, priority setting, the coming year to support the running of the NGO planning, implementation and self-assessment. Using clinics. This fact also speaks to the acute need in rural this process, the groups develop skills in identifying and areas for quality health services. addressing issues of importance to them. f) WN support supervision and follow-up Initially, the approach included reproductive health, income generation and agro-forestry activities. NGO field workers visit the self-help groups at least Integration of other activities such as sustainable once a month and report to the NGO coordinator. The agriculture, functional literacy, drinking water, and NGO coordinator is responsible for all World development of local credit unions has enabled the Neighbors-supported activities. Thus, if there are any participants to meet their basic needs and to improve problems to be addressed in the field, the coordinators their quality of life. In each of these activities, NGO are immediately informed by staff and/or community field staff raises awareness about gender-related issues, members. The coordinators are responsible for leading to improved couple communication and action reporting and monitoring clinic operations on a daily to address gender inequity.
18 Special Program Initiatives Several aspects of the approach have been important in effectively reaching marginalized women. These include: • Carrying out a participatory needs assessment using the tools described earlier, which allows participants to overcome cultural barriers and inhibitions. • The hands-on approach to prioritizing problems and identifying feasible solutions at the grassroots level, such as creating a cash fund by pooling small amounts of savings together. • The effective capacity building of the savings and credit groups including the judicious mobilization of funds, conducting monthly meetings, and keeping minutes and financial records, all of which reinforce the camaraderie among the women group members. • The almost immediate results produced by the savings and credit group and its activities. • The realization that the rural women involved are serious, honest, straightforward, hardworking, and capable of managing their own affairs.
“When women are united, men cannot dominate us. Women’s group makes rules to stop drinking alcohol and gambling so that there is less violence against women.” — Pachgachhiya women’s group
19 Key Accomplishments The major accomplishments of the program are a) Maternal health care presented using six sources of information. These are: During this short implementation period, there were 1) the evaluation findings from a December 2002 increases in key maternal care indicators. These survey of 864 women of reproductive age, 2) service included increases in prenatal care use, iron folate statistics for the seven clinics supported by the supplementation and trained delivery assistance. Table program, 3) clinic sustainability indicators, including 6 summarizes findings for maternal health care. cost recovery through sales of medicine and fees for service use, 4) rural livelihood indicators for the self- Because the services are available to the entire help groups, 5) key aspects of social change, and 6) community, not just the group members, the program self-assessment capacity indicators for NGO partners. sought to verify if non-group members living in the program villages also had improved RH indicators. 1. EVALUATION FINDINGS Thus the survey compared savings and credit group An evaluation survey was conducted with 864 women members to non-members using key variables. For of reproductive age.9 An external consulting group prenatal care, 69% of members reported using prenatal conducted the cross-sectional survey and compared the care during their most recent pregnancy, versus 65% of findings to an earlier baseline survey of 960 women. It non-group members. These rates compared very should be noted that the implementation period favorably to the district average of 17% at the time of between the two surveys was only 18 months, as the the survey as reported by the Ministry of Health. baseline data was collected in January 20019 and the evaluation was conducted in July 2002. Nonetheless, changes in reported service use and other practices were noted. Findings are presented by topic. Table 6: Comparison of maternal health care findings between baseline and evaluation in Mahottari district, Nepal
K ye niF nid sg
M nreta la h htlae airav selb aJ nu yra 1002 yluJ 2002 A etulosb change % % %
eraclatanerP d tsalgniru ycnangerp 8.85.66 3.7 5
A egarev eraclatanerp stisiv .27 .2 9.0 2
nateT dioxotsu immu oitazin n d tsalgniru ycnangerp 976 91
orI n etalof d tsalgniru ycnangerp 2227 9
D yrevile ta htlaeh ytilicaf .35 .4 4.0 9
TTBA detsissa yreviled ta home 173 241
U es fo naelc yreviled tik ta home 8.91.72 8 8
D yrevile ta home netta ded yb delliks osrep n A(len NM/CM )A .28 .5 0.2 2
A egarev p eraclatan-tso (stisiv m nae num )reb .31 .3 2.0 1
9 Valley Research Group, Evaluation Study on Reproductive Health Awareness, Attitudes and Practice of Women in the WN Support Project Areas of Mahottari District. December 2002. 10 Valley Research Group, Baseline Survey on Reproductive Health Awareness, Attitudes and Practice of Women in the WN Supported Project Areas of Mahottari District, April 2001. 20 Key Accomplishments
Figure 1: Assisted deliveries comparing program area, districts and national data
Program Area Districts National 8.4% 9.9% 19.71% 12.5% 9.05%
29.94%
Not Assisted by TTBA 50.35% 81.7% 78.45% by Health Personnel
The most significant finding Table 7: Comparison of family planning findings between baseline and evaluation surveys in has been the increase in use of Mahottari district, Nepal trained assistants at delivery. niF nid sg This trend has continued as Fam yli alp n nin g airav selb evidenced through comparing aJ nu yra 1002 yluJ 2002 A etulosb Change district level data from the % % % 11 Ministry of Health to service U es fo yna mo nred m hte od .636 34 9.2 data in the program area. oitnetnI n ot esu a af ylim nalp gnin Figure 1 presents the findings 0.95.76 5.8 5 m hte od based on the averages from all seven of the partner NGOs. Unm te deen afrof ylim nalp gnin .030 .72 3.2- 7 b) Family planning More recent data demonstrates different patterns for the other three districts. Figure 2 indicates that both As indicated in table 7, there was an increase in family savings and credit group members and non-group planning use and in the intention to use family planning members within the same communities demonstrate between January 2001 and July 2002. Also, the unmet higher rates of contraceptive use than the averages for need for family planning decreased somewhat. Table 7 Dhanusha, Sarlahi and Sindhuli districts. summarizes the survey findings for family planning. c) Use of Household Money for RH Needs After disaggregating the survey data by group and non- group members, it was evident that group members had A key element of the program approach is the support a higher family planning use rate (52%) in comparison for women’s self-help savings and credit groups. The to the non-group members (33%). At that time, the changes with regard to the use of household money for rate of family planning use in non-group members was RH purposes are notable and speak to the need for very comparable to the average district rate as women to be able to access funds to meet their RH calculated by the Ministry of Health (31%). needs. Table 8 presents the survey findings.
11 Department of Health Services, Annual Report, 2003/2004 21 Key Accomplishments
Figure 2: Contraceptive prevalence rates (CPR) for the districts, “Now that we have women’s group we can easily get loans non-group members and group members in December 2004 at very low interest from our group. We do not need to go 80 to moneylenders. We meet once a month and talk about various women-related issues like RH, kitchen gardening, 70 goat raising, poultry-raising and so on.” —— women’s 60 group in Pachgachhiya 50 they have to work without remuneration to pay the 40 interest, with no hope of paying the loan back. 30 Through their membership in savings and credit groups, 20 women are able to access and pay back small amounts of funds at interest rates set by the group. Additionally, 10 qualitative information indicates that women are more 0 valued in household and community decision making Dhanusha Mahottari Sarlahi Sindhuli process because they have their own income. District CPR Non-group Member CPR Group Members CPR 2. SERVICES PROVIDED BY THE NGO CLINICS Table 8: Comparison of use of household resource findings between baseline and evaluation surveys in Mahottari district, Nepal Table 9 summarizes by year the services provided by the seven clinics. While the largest increase for most K ye niF nid sg services appears to be from the first year to the second, family planning services increased dramatically Ho esu h dlo mon ye esu airav selb aJ nu yra yluJ A etulosb 1002 2002 Change between years two and three. Prior to program % % % activities, treatment for uterine prolapse, UTIs and RTIs were not available in the area. Similarly, there Wom ne gnisu ho hesu dlo mo yen d tsalgniru ycnangerp a( mo gn ht eso 4.25.67 0.32 6 were no safe delivery services or maternal health care who dah reve )desu services available.
E rev desu ho hesu dlo mo yen rof RH 5.91.05 2.03 7 The partners also analyze their service data by average sdeen age and average number of children in order to examine Small but regular savings over time have been very trends in service use. Tables 10 and 11 present the helpful to these underserved communities. This has new acceptors of family planning by age and number of been particularly true for women, as they can use their children for the RCDSC clinic. own savings when they need money. Group members are encouraged to use the loans to increase their The two tables present trends in key characteristics of income, but funds can also be used for non-productive new family planning clients at the clinic. Although the purposes, such as girls’ education or health care. samples are small, they do show a trend in new users being younger women with fewer children. The By having their own funds, the group members are not collection and analysis of this information is important dependent on local moneylenders for small loans. as it provides information with regard to progress Thus, they are able to escape from the vicious cycle of toward the objectives. The fact that the clinic seems to debt and deepening poverty. Moneylenders commonly be serving a steady number of new and younger users charge high interest rates. Poor people who are unable would seem to indicate that progress is being made to repay the loan find themselves in a situation where toward addressing unmet needs. 22 Key Accomplishments
Table 9: Client visits for the seven NGO clinics by year and by service
.SN .o ecivreS s
RH etaler- d secivres Y2rae 1 Y3rae Y4rae Y rae
1 D yrevile detsissa yb arap m fatslacide f 316 23 505 8 34 6
2seraclatanerP tisiv 804,124,3 004,4 3 51,4 8
3sP latan-tso tisiv 29129 118 8 78 7
4eeniretU spalorp 84282 342 0 22 5
5dgniR etresniseirusseP 75151 171 3 21 8
6dgniR seirusseP egnahc 86142 383 6 93 9
7sR S/sIT IT 65821,1 858 9 67 7
8sU IT 99215 895 4 44 4
9glanigav/civleP nideelb 53133 864 0 74 1
01Co oitatlusn n s 74233 184 5 07 4
11tsaerB secsba s 688 6151 151 9
21tilitrefnI y 2442 330 5
31O reht RH esac s 81154 902 9 73 0
T lato RH secivres 70,44 23,8 813,9 8 81,9 8
1sR larrefe 928 23 106 1 93 2
2eG larene htlaeh civres 649,729,81 499,42 1 51,91 3
3eT lato FP civres 490 43,3 767,6 3 75,7 8
4eT ballato yrotaro civres 616 18 807 0 08 4
T lato 424,3137,13 873,24 3 11,73 5
Table 10: New family planning clients by year and number or children
N .o fo C erdlih n Ysrae eilC tn Ltow tse Hegi h se A arev g
Y5rae 1 41 1 92.4 9
Y4rae 2 41 1 76.3 5
Y2rae 3 31 0 62.3 9
Y6rae 4 31 0 72.3 7
Y2rae 5 41 1 71.3 8
23 Key Accomplishments
Table 11: New family planning clients by year and age “Before RWUA health personnel started providing Ysrae eilCtn Ytoung se tOedl se A arev g health care services to our village, women did not Y5rae 1 4115 740 0.43 know that they should go for prenatal or postnatal care. In the future we hope that mothers-in-law will Y4rae 2 4110 740 1.92 help their daughters-in-law to go for regular check- Y2rae 3 3119 737 4.82 ups.” ——Pachgachhiya women’s group
Y6rae 4 3111 742 7.52 Figure 3: Registration fees for seven clinics over a four-year period Y2rae 5 4110 847 4.02
3. CLINIC SUSTAINABILITY 1400 1200 1270 An important aspect of the program has been the 1194 1141 emphasis on clinic sustainability. For the program, 1000 sustainability means that services currently being 800 provided by the clinics will be continued into the future 600 without any reduction in quality. In order to achieve 614 this, the NGO-run clinics need to be financially sound 400 and have managerial capacity. Clinics aim to recover as much of their costs as possible. Cost recovery is done 200 in two key ways; 1) through the funds generated from 0 the sale of medicines, and 2) through fees for Year 1 Year 2 Year 3 Year 4 registration and services.
Clinic registration fees are set by the NGO in collaboration with local groups and communities. The Figure 4: Service charges for seven clinics over a four-year period fees differ among the NGOs, as do the payment schedules. Two of the NGOs collect registration fees yearly, and others collect fees every four months. 3500
Service charges are also set in the same way and vary 3000 3273 from clinic to clinic. 2500
Figures 3 and 4 describe the evolution of income from 2000 registration fees and service charges over the four-year 1834 1877 period. These trends are positive. It is notable that 1500 income from service fees is continuing to increase, 1000 while registration fees appear to have leveled out. 892 500
Table 12 provides details of the revolving fund for 0 medicine. Both the sales and purchases have grown Year 1 Year 2 Year 3 Year 4 over the four-year period, and have shown a positive margin.
24 Key Accomplishments Table 12: Revolving funds for medicines increased their capacity to accumulate savings over time. This increases their capacity to mobilize loans, P1citra sralu Y2rae Y3rae Y4rae Y rae which will help them plan, implement, monitor M4senicide dlos 95,781,71 823,02 6 78,22 2 effectively, and have greater impact on improving the well-being and livelihoods of members. It also gnisolCkcots 78,4 841,8 670,8 7 59,9 5 demonstrates increased capacity in maintaining simple M senicide 654,832,61 010,61 8 27,81 2 accounts. p desahcru
O5gninep kcots 16,178,4 841,8 6 70,8 7 A tool that World Neighbors uses to estimate trends over time is a well-being analysis whereby each M1*nigra 04,222,4 632,4 9 20,6 8 household is ranked in terms of local criteria for well- * The margin is calculated by adding the medicine sold plus the medicine being12. This exercise provides an estimate of program closing stock and then subtracting the medicine purchased and the medicine opening stock. impact. Figure 5 below demonstrates changes in 4. IMPROVING RURAL LIVELIHOODS household well-being ranking in the SIDS program area. THROUGH LOCAL ASSET BUILDING Figure 5: Household well-being ranking for June 2002 and June 2004 for SIDS program area Another important aspect of the program has been the savings and credit groups. Over the four years, the June 2002 June 2004 19.1 number of groups has almost doubled, as has total 20.8 membership, as shown in table 13. 28 25.5 Well off Well off Table 13: Number of groups and members over the four-year Very poor Very poor period for 7 NGOs Fairly well Fairly well P1citra sralu Y2rae Y3rae Y4rae Y rae off off Poor 25.9 Poor N9.o fo G or u sp 1263 673 2 04 6 26.8 27 N5.o fo Mem sreb 07,373,6 969,6 4 27,7 6 27.1
Table 14: Accumulation of assets, interest and loans mobilized 5. SELECTED ASPECTS OF SOCIAL CHANGE P1citra sralu Y2rae Y3rae Y4rae Y rae Assessments using participatory methods were G6or u 'sp A stess 85,91$38,14$ 085,76$ 2 57,501$ 1 conducted to examine program effects over time on social interactions. Table 15 presents findings from a tseretnIE denra N5 A67$61,2$ 8 67,8$ 2 trend analysis exercise conducted in two villages with L3snao Mo dezilib 35,03$76,98$ 551,59$ 0 03,002$ 6 RWUA. The 12 group members examined the status of communication with their spouses on specific topics Another area of impact has been the accumulation of during a three-year program period. According to the group assets and interest earnings. As the groups have findings, couple communication has increased over grown, so have their assets and the number of loans time for all the topics examined. While RWUA was mobilized. The significance of the information on frequently cited as the most important influence, other table 14 is that women are increasing their savings. It groups also played a role in the change. In particular does not simply indicate that they have increased for post-partum care, the program of another agency assets, but it also shows that the members have was cited as effective. As a cross-reference, the results
12 For a full description of well-being ranking, see Gubbels, P. and C. Koss, 2000, From the Roots Up: Strengthening Organizational Capacity through Guided Self Assessment. World Neighbors. Oklahoma City, Oklahoma. Pp 114-115. 25 Key Accomplishments
Table 15: Trends in couple communication on selected RH and social issues as compared to 2001 (pre-program) as reported by program participants
Comp osira n b te w ee n P ca hg ca h ayih & ReH ssI u se Chang F srotca /So secru fo Change K ca hha ayid
RWU ,A TBA ,s T ,V R ,oida P ,sretso G or up M iero m devorp ni hcaghcaP ayih naht K hca ,ayidah eraclatan-erPesaercnI d Mem ,sreb Demo oitartsn n E .cte,tceff deifirev orht hgu dleif o oitavresb n
aF ylim nalp gnin RWU ,A TBA ,s T ,V R ,oida P ,sretso H htlae M iero m devorp ni hcaghcaP ayih naht K hca ,ayidah desaercnI ecnatpecca P .cte,tso deifirev orht hgu dleif o oitavresb n
N oitirtu n RWU ,A TBA ,s T ,V R ,oida P ,sretso H htlae M iero m devorp ni hcaghcaP ayih naht K hca ,ayidah -nitatcal/tnangerp desaercnI P ,tso C dlih N oitirtu n argorP m .cte deifirev orht hgu dleif o oitavresb n g wom ne
W daolkro d gniru RWU ,A TBA ,s T ,V R ,oida P ,sretso H htlae M iero m devorp ni hcaghcaP ayih naht K hca ,ayidah desaercnI ycnangerp P ,tso C dlih N oitirtu n argorP m .cte deifirev orht hgu dleif o oitavresb n
RWU ,A TBA ,s C dlih N oitirtu n argorP ,m M iero m devorp ni hcaghcaP ayih naht K hca ,ayidah Pderaclatan-tso esaercnI G or up Mem .cte,sreb deifirev orht hgu dleif o oitavresb n
Num reb fo M iero m devorp ni hcaghcaP ayih naht K hca ,ayidah desaercnI RWU ,A TBA ,s G or up Mem cte,sreb . nerdlihc deifirev orht hgu dleif o oitavresb n
RWU ,A Ed oitacu n D trape m ,tne M ,aide nI b hto ereht,segalliv w desaercniere num sreb fo de'slriGoitacu n esaercnI d hcS o ,lo Demo oitartsn n E .cte,tceff slrig netta gnid hcs o .lo
RWU ,A M ,aide G or up Mem ,sreb M iero m devorp ni hcaghcaP ayih naht K hca ,ayidah Mdelbaegairra ega esaercnI Demo oitartsn n E .cte,tceff deifirev orht hgu dleif o oitavresb n
S gnicap fo RWU ,A M ,aide H htlae P ,tso G or up M iero m devorp ni hcaghcaP ayih naht K hca ,ayidah desaercnI nerdlihc Mem ,sreb Demo oitartsn n E .cte,tceff deifirev orht hgu dleif o oitavresb n
RWU ,A M ,aide G or up Mem ,sreb M iero m devorp ni hcaghcaP ayih naht K hca ,ayidah Ddow yr esaercnI Demo oitartsn n E .cte,tceff deifirev orht hgu dleif o oitavresb n
A ecnatsiss d gniru RWU ,A M ,aide H htlae P ,tso G or up M iero m devorp ni hcaghcaP ayih naht K hca ,ayidah desaercnI yreviled Mem ,sreb Demo oitartsn n E .cte,tceff deifirev orht hgu dleif o oitavresb n in the village (Pachgachhiya) were compared with a neighboring area (Kachgachhiya). A similar exercise was also completed for decision-making, which also demonstrated positive trends.
6. NGO PARTNERS CAPACITY ASSESSMENT Tables 16 and 17 present summaries of capacity capacity assessment in October 2002 and table 17 assessments carried out with the partners over a three- represents a February 2005 assessment. Although year period. The scores are established through a criteria change over the period, there is a relatively process of NGO self-ranking and discussion with the small gap of nine points between the highest rated World Neighbors team. Table 16 describes an initial NGOs and the lowest.
26 Key Accomplishments
Table 16: Terai NGO partners’ assessment by capacity, October 2002
CHETAN- CSRITERIA ISD DAS SRWU ICRDS WCCD RCDS A
1ss'pihsredaeL senevitceffe 800 80808560707
2sdleiF oc rotanidro senevitceffe 800 50856080705
3tffatS oc m tim m ne 800 70708565506
4nhekatS oitcafsitasredlo 705 70757050505
5lcinilC evelytilibaniatsus 405 65403550555
6nE oserlanretx ecru mo oitazilib 700 80707070757
7tQ ytilau fo cinilc m egana m ne 700 80707085756
8 O laicnanifllarev m egana m tne na d cnerapsnart y 800 80808080707
9sO llarev argorp m senevitceffe 800 80808080808
01Im ga e 800 80808080808
A arev ge 734 75.2775 1.07 65 7.56
RANK 1 2 3 4 5 6 7
Table 17: Terai NGO partners’ assessment by capacity, February 2005
CSRITERIA ISD DAS SRAWU CSHETAN ICRD WCCD RCDS
1 V ulo pihsredaelreetn /m egana m tne enevitceffe s 847 81808382808
2sdleiF oc rotanidro senevitceffe 950 87806489818
3ssgnivaS na d tiderc org up 900 98878889888
4esgnivaS na d tiderc oc o vitarep 879 85895780948
5sR orpe d evitcu htlaeh eitivitca 990 83858495868
6sS elbaniatsu erutlucirga eitivitca 960 80896085796
7tlaicnaniF m egana m ne 901 90909090909
8dcinilC ytilibaniatsus nert 882 72609290857
9nR pe gnitro na d d uco m oitatne 900 96819689858
01 U es fo ,lacolrehto oitan oitanretni,lan oserlan ecru s 881 84877484888
A arev ge 878 .68.28 6.87 8.68 8 .58 3 .28 6
RANK 1 3 5 7 2 4 5
27 Lessons Learned There is demand in these rural areas for quality Linking savings and credit with reproductive RH services if they can be provided at a health. One of the main objectives of the savings and reasonable cost and within a reasonable distance. credit groups is to facilitate access to RH services. The The increases in RH service use observed by this local NGOs have established clinics that provide program indicate that the program model meets an quality services with reasonable charges. NGO staff unmet need in rural areas. It further confirms the also provides RH outreach services carried out in important linkage between supply and demand as this collaboration with the self-help groups. model works effectively on both aspects. The savings and credit groups provide a means by Local NGOs can provide quality RH services, and which women can access money for RH services. the services can be sustainable. The NGOs Women may not have money for RH services for a continue to make progress toward ensuring number of reasons. The funds may not be available sustainability as demonstrated by their efforts at cost within the household, or the head of the household recovery. These are all local NGOs with no prior may not see RH needs as a priority. The savings and experience in providing clinical services. As a result of credit groups have helped to reduce, if not totally their partnership with World Neighbors, clinics and eliminate the problem of accessing necessary funds. outreach services have become an important part of Because of their participation in the savings and credit their development work. groups, in the case of an emergency or other pressing need, they can borrow funds based on their own Despite much effort to raise awareness and advocate request. for rights, the government’s service delivery system remains only theoretically operational in many areas. The NGOs offer an alternative means of providing sustainable, quality health services. With the support of the local cooperatives, these services have the potential to be completely sustainable.
Early cross-visits to successful programs facilitate learning and overcoming obstacles. The cross- visits to successful programs have been a key factor in building the capacity of local NGOs. These visits enable NGO leaders to observe and discuss program approaches with others. This kind of exposure to other operational programs helps them to envision how the approach would work in their own settings.
Female providers are important in service use by rural women. The program found that service provision using female providers makes the service more culturally acceptable in Nepal generally, but particularly in the Terai. Traditionally, in this region, women are not supposed to talk openly with men about sexual or reproductive health issues. The program approach demonstrated that it is feasible to hire female paramedics to provide services in a cost-effective way. 28 World Neighbors and NGO staff, Terai
29 Conclusions One of the key aspects of the program is the demonstrated viability of the BBP model and its “We have chosen group formation as our most applicability to other settings. This model provides a important activity. As the impact flow chart shows, needed alternative to public sector services, and, in from the group we were able to access services such contrast to other private-sector models, it focuses on as medical treatment, family planning, low interest meeting the needs of the poor. The linkage with self- loans, training, literacy and opportunity for cross- help groups and the careful monitoring of program visits. The group is an important medium to get activities helps to ensure that even the poorest women opportunities to learn many things. Because of our have access. group work, women from neighboring villages are also eager to form such a group. It is always good to Another important aspect of the approach is the social work together.” — Pachgachhiya Women’s group change that has resulted through the program efforts. The design supports initiatives related to women’s autonomy, such as increased couple communication, use of household money, and participation in groups. Indicators for these variables have changed substantially in favor of enhanced women’s status and well-being.
In remote areas, just creating awareness without increasing the accessibility of services is not enough, particularly with regard to reproductive health. Many obstacles, including financial and cultural issues, prevent women from using services. Although information on reproductive health topics may be well disseminated, unless services are also made available in underserved communities, women and their families will not be able to benefit.
Finally, the approach of supporting the capacity building of women’s groups at the grassroots level has been successful in helping them become self reliant. Additionally, building the capacity of the community organizations has bolstered the sustainability of the financial and health services they provide to their members and the wider community. World Neighbors and the partner NGOs have played a catalytic role in this process. It is worth noting that the approach is not only in demand in the communities in Nepal, but has also been successfully applied in Madhubani District in neighboring Bihar.
30 Appendices Appendix 1: Individual Member Information Card These forms are used to organize information on individual group members. These cards provide a composite view of group members.
Ho esu n orf.o m tsil Name fo ho hesu dlo daeh : Mem pihsreb num reb
Name fo wom :na
Hno esu w htlae gniknar Edd oitacu C niegnah hilevil oo Mem nireb wom s'ne org up
Yose N
R orpe d evitcu ega M utatslatira s nangerP t A rotpecc fo FP m hte od
ABCDYoe s NsYoe N
Num reb fo nerdlihc b :nro Num reb fo nerdlihc evila :
Son Dnethgua r So D ethgua r
tsaL yreviled
W :ereh A detsiss yb :
L:nao nekat H:ow m hcu P pru eso
H:ow m :hcu P pru eso
O reht RH oitpircsed :n
O ireht mp rofnitnatro m oita :n
A = Unmarried Girl, B = Married, C = Widow, D = Divorced
Household Card
Ho esu num orfreb m tsil Name fo ho hesu dlo aeh d
Ho esu w htlae gniknar G or up mem pihsreb num eb r
argorP m vniytivitca evlo m :tne
The Household Cards were half the size of Individual Member Info Cards. The color of these cards differed from one village to another, which facilitated quick recognition and would avoid mixing of the cards with one another.
31 Appendices Appendix 2: Mini-Survey The mini-survey is a simple participatory technique. The NGO coordinator and WN teams work with key informants in the community to complete a matrix regarding key events for each household in the community (see below). These mini-surveys are conducted once every six months in communities comparing group and non-group member households. In this way, the program collects information on births, deaths, migration, contraceptive use, etc. It also provides information for comparison between group and non-group members. Group member mini-survey, RCDSC Mahottari
Mini-Survey Matrix Name of the Group: Address of the Group: Date: Group Id. #:
Sd# Ho hesu lo G or up 4-01-5 44-51 4 54 + Th ato ltriBDn tae hMeoitargi lbigilE FP Rem skra H dae Mem reb Cou elp A .tcc
Y NBGMFMFMFMFSu m BGMFn ItOu
Y = Yes, N = No, B = Boy, G = Girl, M = Male, F = Female
32 Appendices Appendix 3: Trend Analysis- related issues This exercise requires 8 to 10 participants.
1) Along with cards and markers, the facilitator should also have the pictures of a happy face, a sad face and a plain face. After the participants recognize the happy, sad and plain faces explain to them that they mean ‘progress’, ‘no progress’ and ‘no change’ respectively.
2) Ask the women to come up with issues related to them such as education, childbirth, fodder and household work – place them in order of importance.
3) For each issue ask the participants if they think the situation has improved, gotten worse or remained the same compared to the past and place the appropriate picture next to it.
4) Ask them the reasons for the changes in each issue including the role of the group members and the people of the community in bringing about such changes.
The results from the village Sakhuwa were as follows:
eserP tn utiS oita n ssI u se N eto s
G nitte g B rette Age ta m airra ge D eu ot de oitacu n na d aw ssenera amo gn oep eht,elp m elbaegairra siega now 81 rof slrig na d 22 rof b .syo
G nivi g htrib ot ba seib T eseh syad htlaeh scinilc na d sgurd era elbaliava yreve w .ereh TBAs na d htlaeh ffats edivorp su .secivres RWUA sedivorp do d-ot-ro o ro secivres na d tnangerp wom ne teg u-kcehc sp yreve mo htn ot erusne ehttaht ybab na d eht m rehto era yhtlaeh na d .efas We og ot scinilc rof yreviled rof b hto n ro m la na d oc m detacilp .sesac Wom ne eseht syad osla evig htrib ot ef w re nerdlihc oc m derap ot eht .tsap
Ta nik g erac fo c erdlih n D eu ot aw ssenera na d de oitacu ,n oep elp now know ba o aftu ylim nalp gnin m hte o .sd T eseh syad oc u knihtselp laediehttaht num reb fo nerdlihc si 2 ot 3 siht- w ya a dlihc nac eb dedivorp htiw og od de oitacu sehtolc,n na d .erac
G nir nid g M lli nI eht ,tsap we did n to evah sllim - we desu otaJ nirg( gnid ots .)en M slli evah m reisae,retsaftieda na d m ero oc ottneinevn nirg d .sniarg
Edu oitac n nI eht ereht,tsap w ere o yln a ef w hcs o slo na d yeht w ere orfraf m siht egalliv na d oep elp did n to know eht eulav fo de oitacu .n Now ereht era nrevog m tne na d etavirp hcs o nislo hgien b gniro segalliv siereht- no orp elb m rof o ru nerdlihc ot og ot hcs o .lo
V ulo reetn h htlae ecivres nI eht ,tsap nobo yd un otsred od ieht mp ecnatro fo v ulo yratn w kro yeht- w ere o yln degagne ni rieht osrep lan w .kro Now os me oep elp era gnidivorp v ulo yratn niecivres htlaeh na d .sdleifrehto
33 Appendices
eserP tn utiS oita n ssI u se N eto s
G nitte g B rette P cru h nisa g goods fI oy u evah mo yen signihtyreve ta oy ru do petsro na d oy u do t'n deen ot w kla m otseli teg oy ru oc mmo .seitid B tu oep elp evah ot og ot otseitic b yu of o sehtolc,d na d .sniarg T eseh syad sepyttnereffid fo osaes stiurflan na d selbategev era osla elbaliava raen o ru .egalliv
Fodd re nI eht ,tsap we neped ded o yln on eht ottserof deef o ru ina m .sla We neve bo thgu yah ot deef o ru b .seolaffu Now we evah detnalp tnereffid seiceps fo of d red nisgnildees o nalru sd na d we evah ylevitaler ysae otssecca of d .red
A ssecc ot of od eti ms nI eht tsap we dah ot b orro w ecir orf m o ru hgien b .sro Now nalyrd sd evah oceb me w te esuaceb oitagirrifo n na d oyreve en org ws .ecir We nac osla og ot eht m ottekra b yu yna nik d fo of o neve,d m .tae
A cirg erutlu nI eht rehtie,tsap oep elp d gu dleifrieht eht m sevles ro desu olp .shgu T eseh syad we esu srotcart na d tsevrah m ero niarg naht ni eht .tsap We now evah oitagirriretteb n etsys ms na d esu ehc ,srezilitreflacim sedicitsep na d og od sdees rof rafretteb .gnim
Same Dom citse eloiv n ec E isignihtyrev m nignivorp siht egalliv tpecxe dom citse .ecneloiv M ne llits knird ocla h nalo d riehttaeb .seviw We evah n to neeb elba ot der ecu ecneloiv tsniaga wom ne ni siht .egalliv
G nitte g W esro Ho esu h dlo ch sero rof T daoleh fo ho hesu dlo hc sero desaercnisah - wom ne now neps d m ero it me women ni eht nehctik naht ni eht .tsap We evah ot eraperp aet m yna it m se a yad rof stseug sa w salle af m yli mem .sreb We neve eraperp m ero of od eti m nahts ni eht .tsap We evig m ero it me rof o ru osrep lan eneigyh - ho sesu era tpek .renaelc We evah ot w hsa s'nerdlihc hcs o lo sesserd na d eraperp of od rof eht .m D etipse ehtlla aw ssenera na d ,sdeen wom s'ne w kro .desaercnisah M ne do n to erahs eht dom citse hc ero htiw wom .ne
34 Appendices Appendix 4: Savings and Credit Group Progress Report – completed by NGOs
Name of Partner NGO:
Period covered by this report: From: To:
P citra sralu Wpome s'n G or up Mpe s'n G or u Mlexi d G or u T ato
N .o fo SCGs
N .o fo Mem sreb
fleS R ecnaile SCGs
N .o fo SCGs ord p dep )deniatsus(
N .o fo en w SCGs rof m de
N .o fo A occ u etaretiltn SCGs
SC s'G ucca m detalu Fund (W hti o )tseretnitu
SCG ocni's me orf m tseretni na d osrehto secru
T stessalato fo SCGs
Lhsnao desu R orpe d evitcu H tlae ocnIme G oitarene n Olreht sT ato
iTme Aemoun tiTm Ae moun tiTm Aemoun tiTm Amoun t
SCG = Savings and Credit Group
35 Appendices Appendix 5: Savings and Credit Cooperative Progress Report
Name of the SC Cooperative:
Address:
Name of Supporting Organization:
Reporting Period: From: To:
P citra sralu Etreilra Rep ro t Tlsih Rep ro T ato
M ela
)1 Sh era h dlo sre eF m ela
T lato
u-diaP p C latipa )2 Ca latip & Fun sd R devrese Fund
R raluge sgnivaS
N .o fo srevaS
oireP lacid gnivaS )3 nivaS sg C oitcello n N .o fo srevaS
O reht srevaS
N .o fo srevaS
R raluge sgnivaS
oireP lacid sgnivaS
)4 nivaS sg R nrute ed O reht sgnivaS
R raluge sgnivaS
N .o fo srevaS
oireP lacid sgnivaS
)5 B ala n ec fo nivaS sg ot be R rute ned N .o fo srevaS O reht sgnivaS
N .o fo srevaS
)6 B orro wed by O gr a oitazin n
)7 R nrute ed ag tsnia B orro wed by O gr a oitazin n
36 Appendices
P citra sralu Etreilra Rep ro t Tlsih Rep ro T ato
L snao nihtiw it me
)8 B ala n ec fo B orro wed by W nihti 6 mo shtn revo O gr a oitazin n W nihti 1 raey revo
O rev 1 itraey me
F ro A erutlucirg
N .o fo B orro w sre
F ro B ssenisu
N .o fo B orro w sre
F ro eriH P esahcru
N .o fo B orro w sre )9 L ao sn ot Dep srotiso F ro ecivreS B ssenisu
N .o fo B orro w sre
F ro Ho gnisu
N .o fo B orro w sre
F ro Ed oitacu n
N .o fo B orro w sre
A tsniag A erutlucirg
N .o fo osreP sn R diape
A tsniag B ssenisu
N .o fo osreP sn R diape
A tsniag eriH P esahcru
N .o fo osreP sn R diape
)01 L ao sn Rep dia A tsniag ecivreS P esahcru
N .o fo osreP sn R diape
A tsniag Ho gnisu
N .o fo osreP sn R diape
A tsniag Ed oitacu n
N .o fo osreP sn R diape
37 Appendices
P citra sralu Etreilra Rep ro t Tlsih Rep ro T ato
C hsa
)11 qiL ytidiu B kna
Bon sd
L snao nihtiw it me
W nihti 6 mo shtn revo )21 Rem nia ed L ao sn W nihti 1 raey revo
O rev 1 itraey me
tseretnI E denra orf m B kna
)31 nI come orftseretnI m L snao ecivreS C segrah
E ecnartn C segrah
tseretnI diaP on L snao )41 Expen erutid nediviD d
deruceS Fund
ffatS Bon su Fund
L tso C gnirevo Fund
Mem reb Ed oitacu n )51 Comp yroslu Fun sd Fund
Dou luftb D tbe Fund
O oitazinagr n D .ve Fund
S laico W erafle Fund
1% rof on it me L snao
01 % rof 6 mo shtn )61 oisivorP n fo ksiR 05 % rof 1 raey
001 % rof revo 1 raey
Provide other essential information: Note: Trial Balance, Income & Expenditure Statement and Balance Sheet should be enclosed along with this report. Prepared By: Name: Designation: Date: Approved By: Name: Designation: Date: Official Stamp 38 Appendices Appendix 6: Clinic Self-Reliance Progress Report
Name of Partner NGO:
Period covered by this report: From: To:
Income and Expenditure Statement
nI come Expen erutid s
P citra sralu Amount P citra ralu s Amount
tneserP m enicide kcots M enicide esahcrup
Am uo tn fo m senicide gnisolC kcots fo tsaleht raey oc detubirtn /do detan etaluclac( ta gniliaverp ecirp fo m )enicide
M enicide selas
O ocnireht me on m senicide O reht sesnepxe on m senicide
T nIlato come T lato Expen rutid e
nI come orf m me nicid se (T nilato come - T lato expen )erutid
O ht re nI com :se R oitartsige n seef
ecivreS R(segrahc orpe lareneg/evitcud ,htlaeh F )secivres.cte,bal,P
O oitazinagr s'n ocnirehto m (se mem pihsreb ener w ,eefla knab ,tseretni do oitan ).cte,sn
T nIlato come
39 Appendices Appendix 7: RH/CH Service Report
Name of Partner NGO:
Period covered by this report: From: To:
1. Reproductive Health and General Health Services
Ac eveih me stn
secivreS dleiF cinilC T lato (O caertu h )cinilC
)a Re orp du evitc H htlae secivreS
D yrevile yb ANMs
D yrevile yb deniarT TBAs
ANC
PNC
suretU despalorP
gniR yrasseP detresnI
gniR yrasseP C degnah
R orpe d evitcu oitcefnItcarT n
U yranir oitcefnItcarT n
PV gnideelB
tsaerB A /ssecsb orP elb ms
ytilitrefnI
O reht RH secivreS
T lato
40 Appendices
Ac eveih me stn
secivreS dleiF cinilC T lato (O caertu h )cinilC
)b R slarrefe
D yrevile
ANC
suretU despalorP
PV gnideelB
tsaerB A /ssecsb orP elb ms
ytilitrefnI
eF m ela oitaziliretS n
M ela oitaziliretS n
O reht RH secivreS
G larene H htlae R slarrefe
T lato
)c T lato Gen lare H htlae secivreS
)d T lato FP secivreS
)e T lato Lab secivreS
T orflato m e-a
Condom D birtsi oitu n ni U stin
2. Laboratory Services
Ntame fo T tse Nt.o fo T se Ntame fo T se Nt.o fo T se Ntame fo T se N .o fo T se
.1 T ,C DC .4 Sp utu m .7 otS ol
.2 ESR .5 cnangerP y .8 U nir e
.3 HB .6 eS men .9 O reht s
T lato p osre sn ben ettife d T stsetlato done
Note: If more than the above mentioned tests have been performed, please write them on a separate page and attach.
41 Appendices 3. Pregnant Women, ANC/PNC and Ring Pessuries Change
Ppcitra sralu disnIe G or u O distu e G or u pT ato l
N .o fo tnangerp wom ne Oen ec Teciw Tecirh ht4 it me ro m ro
disnI e O distu e disnI e O distu e disnI e O distu e disnI e O distu e G or up G or up G or up G or up G or up G or up G or up G or up
ANC nekat
PNC nekat
gniR seirassep degnahc
T lato
4. Family Planning
Fam yli alP n nin g Ndew Oel Co nitn u M hte od disnIe G or up Opdistu e G or u pdisnIe G or u Opdistu e G or u pdisnIe G or u O distu e G or u p
D pe arevorP-o
Condom
slliP
IUD
N tnalpro
eF m ela oitaziliretS n
M ela oitaziliretS n
O reht FP m hte od
T lato
N .o fo elitref wom ne ni eht org u :p Mem sreb
N .o fo org up mem sreb gnitpecca af ylim nalp :gnin … osreP sn
5. Reproductive Health Education for In-School Youths
.SN. Name fo cS hoo lN .o fo P picitra a tn s A arev ge m skra o niatb ed A arev ge m skra o niatb ed ni tset-erp ni p tset-tso
Bssyo G lri
T lato
42 Appendices Appendix 8: Clinical Checklist Name of Partner NGO:
alP n irof m evorp me htfi,tn e A sn w re .S N. P citra sralu (Qu oitse sn ) a sn w sire NO Yose NeBmy wh itta m By who
.I aS oitatin :n
.1Sm eko eerf eciffo erp esim s
.2naelC eliot t
.3ssenilnaelC ora und eht inilc c
.4 ssecorP da o detp rof psid gniso desu gniht s
.5 nissenilnaelC eciffo or om gniniart/s ehctik/erots/llah n
.6orP rep m ecnanetnia fo qe piu m ne t
.7H na d w gnihsa eitilicaf s
.II lacinilC :secivreS
.1 Good otlliks axe enim lareneg tneitap s
.2 U es fo pa orp etairp m qelacide piu m ot/tne lo s
.3Good roivaheb htiw tneitap s
.4 W ocle gnim ta m pso ereh na d oc oclaitnedifn u nilesn g
.5 lacitcarP esu fo orftnraellliks m niniart g
.6F ollo w u- p fo gnir yrassep esac s
.7 D yrevile fo RH secivres sa rep ocotorp l
.8orP rep nisserd g
.9 U es fo yrassecen m senicide htiw tcerroc d eso s
.01 orP rep egnarra m tne fo yreviled or om
.11 orP rep m egana m tne fo qelacinilc piu m tne na d m laireta s
.21 orP nalarreferrep d ollof w u- p etsys m
.31 orP nalarreferrep d ollof w u- p etsys m F( P)
.III Me nicid :se
Ad oitartsinim n fo m nisenicide a tcerroc w ya na d orp rep oc u gnilesn .1 on p elbisso stceffe-edis orf m sgurd
.2etsyS m cita egarots fo m enicide s
.3 iT m yle nruter fo m senicide htiw nahtssel 4 mo yripxe'shtn tad e
.4 Co evitpecartn us p seilp qeda etau rof 3 mo htn s
43 Appendices
alP n irof m evorp me htfi,tn e A sn w re .S N. P citra sralu (Qu oitse sn ) a sn w sire NO Yose NeBmy wh itta m By who
I .V O gr a oitazin s'n Imag :e
.1 Good oc mm stne orf m eiraicifeneb s
.2Good roivaheb fo fats f
.3Good roivaheb fo v ulo reetn s
.4Good orftluser m eht argorp m
.V R ce nidro g er/ p nitro :g
.1 iT m yle nignidrocer debircserp rof ms na d rof m ta s
.2 iT m yle per gnitro ot eht oc denrecn htua tiro y
V .C.E.I.I
orP rep gnicalp fo htlaeh detaler p sretso na d ap mp nistelh eht w gnitia .1 or om
.2 H htlae de oitacu n ot /stneilc tneitap s
V .II O ht fi,sre any
.1 A etn n lata erac
orI n etalof birtsid detu ot yreve tneilc yreve mo htn
nateT dioxotsu
.2 P ntso lata erac
Imm etaide gnideef-tsaerb ituagiB( d )htu
P axelacisyh oitanim n
Immu oitazin n
birtsiD oitu n orifo n etalof rof 1 mo htn
Ad oitartsinim n fo a d eso fo atiV 'A'nim
aF ylim nalp gnin oc u gnilesn
.3 Neon lata erac
R oitaticsuse n lliks
C dro erac
Monitored by: Signature: Date: Note: After completing the form, a meeting is held with the concerned members of the organization to review comments, solicit their response and document meeting outcomes. 44 Appendices Appendix 9: Check List for Partner Clinic Quality Monitoring
Name of Partner NGO: Address: Date of clinic initiation:
.SN .o Ptcitra ralu sEdellecx n Vd yre Goo Gyoo rotcafsitaSPsoo rRem kra
.IecivreS divorp ed by inilc c
.1 D yrevile
.2 STD
.3 R IT
.4 gniR detresniseirassep
.5 gniR seirassep degnahc
.6 ANC
.7 PNC
.8 FP esu( na )teehsrehto
.9 tsaerB orp elb ms
.01 U IT
.11 gnideelB
ralugerrI.21 m oitaurtsne n
.31 ycnangerP tset
.41 O reht RH
.51 O taertreht m tne
IIsecivreS divorP ed orf m leif d
.1 D yrevile
.2 ANC
.3 PNC
.4 FP esu( na )teehsrehto
.5 O reht RH
.6 O reht RH
45 Appendices
.SN .o Ptcitra ralu sEdellecx n Vd yre Goo Gyoo rotcafsitaSPsoo rRem kra
.IIIR larrefe ecivreS s
.1 D yrevile
ytilitrefnI.2
.3 FP esu( na )teehsrehto
.4 O reht RH
.5 O reht oc n oitid sn
Rem skra fo eht mo gnirotin osrep :n
Date: Signature:
Note: After completing the form, a meeting is held with the concerned members of the organization to review comments, solicit their response and document meeting outcomes.
46 47
More Integration Resources from World Neighbors Evaluating an Integrated Reproductive Health Program: India Case Study This report details the methods and findings of a participatory evaluation of inte- grated reproductive health programs in two villages in India, with comparisons to a third village that had no reproductive health programming. The results suggest that the integrated approach used by World Neighbors - India and its partners is effective in achieving high rates of reproductive health knowledge and positive practice, im- provements in women’s status, and significant benefits from participation in savings and credit programs. 60 pp, available in English. $10.00 plus shipping.
Integration of Population & Environment This collection of articles explores the creative ways in which World Neighbors and other organizations are addressing population and environmental issues at the community level. Articles include case studies of integrated programs and discussions on organizational needs and funding trends. These papers were originally presented at the American Public Health Association’s 125th Annual Meeting in 1997. The authors represent a range of organizations involved in efforts to link population and environment, including Population Action International, The Summit Foundation, The University of Michigan Population-Environment Dynamics Project, World Neighbors, and World Wildlife Fund. 69 pages, available in English. $5.00 plus shipping.
Integration of Population & Environment II: Ecuador Case Study This report presents the findings of a three-year Operations Research Project carried out in partnership by World Neighbors and the Ecuadorian family planning organization CEMOPLAF. The results support a compelling argument for implementing an integrated approach which combines reproductive health and agricultural/natural resource management programming to address population and environmental issues at the community level. Published with the University of Michigan Population- Environment Fellows Program. 26 pp; English.
World Neighbors In Action: Understanding NRM & RH in the Philippines This issue of World Neighbors In Action presents key aspects of design organization and findings of a workshop held in the Philippines for NGOs to share experiences in integrating reproductive health and natural resources management.
Workshop participants explored common issues for integrated RH/NRM, common assumptions and next steps for working together on priority issues identified. 8 pp; English/French/Spanish; $2.00 plus shipping; 2003. World Neighbors is an international development organization that works with some of the most remote and marginalized communities in ecologically fragile areas of Asia, Africa and Latin America. We transform communities by helping people address hunger, poverty, disease and other challenges that undermine their livelihood, and by inspiring lasting leadership and collective action. Since 1951 we have helped more than 25 million people in 45 nations improve their lives and the communities in which they live.
World Neighbors World Neighbors South Asia Area Office International Headquarters House No. 60 4127 NW 122nd Street Shanti Marga, Koteshwor OKC, OK 73118 U.S.A. Kathmandu tel: (405) 752-9700 NEPAL fax: (405) 752-9393 tel: 011-977-15-546688 email:[email protected] [email protected]
World Neighbors inspires people and strengthens communities to find lasting solutions to hunger, poverty and disease and to promote a healthy environment.
For more information about World Neighbors, please visit our website at www.wn.org