CMC- Community Mental Health and Psychosocial Support Programme

Semi-Annual Report January – June 2019

Submitted to: TEAR Australia

Prepared by: Centre for Mental Health and Counselling – Nepal (CMC – Nepal) Thapathali, Kathmandu

Contact: PO Box 5295, Kathmandu, Nepal Email: [email protected] Website: www.cmcnepal.org.np

August 2019

Location of the Project: This project covers following 15 (rural) of the two provinces. Province No 1: Udayapur: Chaudandigadhi, Belaka, Triyuga, Katari and Rautamai Rural Municipality : Molung, Manebhanjyang, Chisangkhugadhi Rural Municipality and Siddhicharan Municipality

Karnali Province: Surkhet: Panchpuri, Lekbesi, Gurvakot Municipality and Chingad Rural Municipality Jajarkot: Bheri and Nalgad Municipality Reporting year: January – June 2019

Name of the Project: Community Mental Health and Psychosocial Support Programme (CMHPSS)

This is the first year of the sixth phase (2019-2021) of the Community Mental Health and Psychosocial Support Programme (CMHPSP), which is being continued in Udayapur and and extended in Surkhet and Jajarkot districts in funding support of Tear Australia. CMC – Nepal has been continuously maintained the collaboration with the Ministry of Health and Population (MoHP) and Department of Health Services (DoHS) and its divisions mainly Epidemiology and Disease Control Division (EDCD) and National Health Training Centre (NHTC) at central level and with the Ministry of Social Development at provincial level. CMC-Nepal has signed Memorandum of Understanding (MoU) with all fifteen (rural) municipality to implement the project and the concerned (rural) municipalities also contributed funds to work in partnership in this project. In the changed federal context, CMC-Nepal is actively collaborating with local and provincial government to make them aware on mental health and psychosocial issues and increase their ownership to continue and sustain mental health and psychosocial service from the selected health facilities of the above mentioned (rural) municipalities.

OUTCOME 1: Community people have increased access to mental health and psychosocial service at local level

CMC-Nepal worked at 4 local level of Surkhet and 2 local level of Jajarkot districts to develop access of mental health and psychosocial service. CMC-Nepal contributed to increase access in additional 6 health facilities of those (rural) municipalities. 8 medical officers and paramedics of the selected health facilities of Jajarkot and Surkhet districts received mhGAP training in this reporting period. This training was organized by Ministry of Social Development of in technical support of CMC-Nepal. CMC-Nepal has made continued effort to strengthen the knowledge and skills of trained health workers of Udayapur and Okhaldhunga districts in mental health and psychosocial support. Mental health clinical supervision and Continued Medical Education (CME) was continued in all project districts to further build the confidence in diagnosis and treatment of people with mental health problems. The supervision conducted by the psychiatrist provided face to face interaction opportunity on the difficulties faced by the trained health workers and further built their confidence on the case management. Mental health service is available in 13 health facilities of 13 (rural) municipalities and CMC-Nepal will develop access in 3 health facilities in the second half of the year. Trained health workers provided mental health services to 3645 clients (1738 new & 1907 old) from their respective health facilities. Psychotropic medicine is made available by the local and provincial level government in 85% of health facilities which covered 70% of total demand. Similarly, trained nurse and Auxiliary Nurse Midwife (non-prescribers) provided psychosocial support to 45 clients in . Gender Based Violence (GBV) Prevention and Response Project, implemented by CMC-Nepal in Udayapur and Okhaldhunga contributed not only in the creating awareness on the importance of mental health and psychosocial health, but also provided mental health and psychosocial counselling service from the One-Stop Crisis Management (OCMC) centre and visiting families.

136 health workers of other than the referral health facilities and ward chairperson received 2 days mental health orientation in 5 (rural) municipalities of Surkhet and Jajarkot districts. The concerned (rural) municipalities organized this orientation in their own funding, where CMC-Nepal provided technical support. They identified and referred 61 people with mental health problems for mental health and psychosocial service in referral centre. Mental Health Social Workers (MHSW) visited 24 families and provided psycho-education and psychosocial support. They also provided psychosocial counselling service to 57 clients through health facilities and home visits.

OUTCOME 2: The people with mental health problems and their families are able to work with communities and network with local government and DPOs to respect, protect and fulfilling their rights.

CMC – Nepal involved in raising public awareness by organizing orientation and training in mental health and psychosocial issues to the people with mental health problems and their family members, members of women cooperative and mother groups, FCHV local stakeholders where 434 community members received such orientation in mental health and stigmatization. In the project district, including old areas nearly 20% of total cases diagnosed at health facilities were referred by mother groups, women cooperative members, FCHVs and members of SHG.

Furthermore, CMC-Nepal conducted orientation to the student, teacher, child club member and CBOs on suicide prevention focusing on early signs and symptoms of suicidal thought and support and care to the persons with suicidal thoughts. 921 students (girls 522 and boys 399) from 9 schools of 6 municipalities of Surkhet and Jajarkot districts received basic orientation in suicide prevention. One peer group in each school is formed and started to capacitate them to know more about the risk of suicidal thoughts and referral mechanism for suicidal cases. Students and teachers have been sensitized in mental health issues and taught to contribute for the protection and fulfilment of the rights of the persons with psychosocial disabilities.

In Udayapur and Okhaldunga districts, Mental Health Social Workers (MHSW) directly worked directly with Self Help Groups (SHG) to empower and make them able to work with communities and network with local government, DPOs to respect, protect and fulfil the rights of the persons with psychosocial disability. MHSW regularly provided management and technical support through attending monthly meeting and reinforcing their knowledge and skills on resource mapping, local fund raising and extending networking with DPOs and other related organizations for advocacy and lobby with the local government to continue mental health service, along with the supply of psychotropic medicine. In Udayapur, joint meetings among DPOs and SHGs were organized and those meetings prepared joint action plan to raise awareness in mental health and psychosocial issues and advocate with the local government to mainstream mental health and psychosocial issues in policies, programs and budget. In new project district, MHSW involved in process of formation of SHG through regular interactions and meeting with the people with mental health problems and their family members and in consultation with health facility and local level.

OUTCOME 3: Government of Nepal upscale community based mental health program at national, province and local level

CMC-Nepal activity engaged to organise the interaction meeting with local and provincial level government in order to sensitize them in mental health issues and ensure their cooperation in project implementation and its sustainability through the allocation of budget in mental health. Furthermore, CMC-Nepal arranged project monitoring visits, along with the participation of duty bearers from the local and provincial level in as part of advocacy and lobby to mainstream mental health into the health, education and development agendas. The regular interactions, meeting and their involvement in project monitoring provided opportunity to the elected representative and government officials to think horizontally and plan programs and allocate budgets in mental health as an initial initiative. As per agreed while signing partnership agreement, the five-municipality contributed NPR. 581,298 (Bheri municipality-156,426, Nalgad municipality-163,000, Gurvakot municipality-92,900, Lekbesi municipality-75,550 and Chingad rural municipality 93,422) for mental health orientation to the health workers, psychotropic medicines and awareness campaigns. Similarly. Ministry of Social Development of Karnali Province contributed NPR 320,000 for mhGAP training for medical officers and paramedics, mental health clinical supervision and psychotropic medicine. This mhGAP training was provided to the health workers of 8 districts of Karnali province in order to upscale community based mental program. 12 local government has included mental health in their annual programs of the year 2019-2020 and allocated budget in a range of NPR 200,000-400,000. CMC- Nepal continued its effort at central level also to integrate mental health into the existing health care delivery system through involvement in development of 10-years mental health strategy and action plan, guideline of mental health telemedicine and rehabilitation of the homeless people with mental health problems. This indicates that the government of all three layers seems sensitized in mental health issues and tried to address it through development of programs and allocation of the budget to implement the plan.

CMC-Nepal carried out baseline survey in Surkhet and Jajarkot to find out the present mental health condition in respective working area and the result of the baseline will be compared at the end of the project cycle to see the effectiveness of the project deliveries in different level i.e. training, supervision, and awareness.

In coming six months period, CMC-Nepal will conduct mhGAP training for the prescribers and basic psychosocial counselling training to non-prescribers. CMC-Nepal will continue supervision in both mental health and psychosocial counselling. The group sessions for the peer support group will be continued and they will be mobilized in prevention of suicide, provide support and care and further refer to the people with suicide thoughts to the service facilities for the intervention. CMC-Nepal will provide technical support in the recruitment of two MHSWs for and shall build their capacity in mental health and psychosocial disability and social mobilization. The SHG will be formed and capacitated to make them able to work with the communities, service providers and local level for the rights of the people with psychosocial disability. An interaction among the SHG representatives, DPOs, National Federation of Disabled Network (NFDN district chapter), health and education authorities at Karnali province will be organised and a loose forum of SHG at province level will be formed. Joint monitoring and review meeting in local and provincial level will be continued. A workshop will be organized at (rural) municipality level to review the existing policies and programs and integrate mental health into the existing health, education and development policies and programs

Reporting Organizations: Telephone:977-1-4102037 Web: www.cmcnepal.org.np Centre for Mental Health and Counselling Nepal (CMC- Nepal) Address: Thapathali, Email: cmcnepal@ mos.com.np Contact Person: Kathmandu Ram Lal Shrestha Post Box No: 5295 Executive Director 1. Right-holders and duty-bearers/beneficiaries

Type of rights-holder New since the Those continuing Total for and duty-bearer / previous from the previous the Total since the beneficiary report reporting period reporting beginning of period* the project (cumulative) TOTAL 3590 1953 5543 5543

*Total for the F M How did they participate? reporting period includes: A. Girls 1175 Girls participate in the orientation of suicide prevention activities, even they have involved in the peer group to create awareness and refer the people to the service facilities, having suicidal risks. They are good carrier of mental health information in the community and referring their family members at health facilities for the treatment of mental health and psychosocial problems. B. Women 2225 65-70% are women representatives in the SHGs and out of them 15-20% are from dalit communities. C. Persons with The people with physical disability, blind and disabilities 29 16 deaf are also participating in project activities. Similarly, person with mental illness has acquired mental illness induced disability (cognitive deficiency) who are invisible and ignored with social stigma. CMC-Nepal is also collaborating with DPOs for the lobby and advocacy at local level for mainstreaming psychosocial disability. The people are coming out to visible and raising their voice by themselves. They are also able to organize meeting and approach with reason to local government agencies for support and for financial resources. D. People living NA NA We do not have disaggregated data of people with hiv and aids living with hiv and aids. We will explore and find it in the next reporting period. E. Indigenous Around 20 – 25% persons with mental health peoples and 1531 916 problems who are in Self Help Groups are from ethnic minorities the indigenous and ethnic minorities. They are actively participating in awareness-raising and advocacy at local level. F. Dalit 741 470 21.9% beneficiaries are from the dalit communities G. Other (Brahmin, 1128 757 Cheetri and Others): 2. Project Implementation

As per guided by the National Health Policy (2015), National Mental Health Policy (1997) and Act Relating to the Human Rights of Person with Disability (2017), CMC-Nepal is implementing community based mental health program and contributing to the access of mental health and psychosocial services at rural communities as stipulated in national level legislation and policies. CMC-Nepal is contributing to build the technical capacities of prescribers in mental health and non-prescribers in psychosocial support) through the training (basic and refresher), clinical supervision conducted at health facilities and from the distance coaching. The trained health workers of the concerned health facilities have been providing mental health and psychosocial services from the usual health care delivery system. The trained health workers consult with CMC-Nepal's psychiatrist and supervisors if they feel difficulty in diagnosis and management of mental health problems. Supervisions are carried out by the psychiatrists and CMC-Nepal’s supervisors for knowledge and skill enhancement in mental health and psychosocial support of trained health workers. The psychiatrist usually validates the diagnosis through review of mental state examination and mental health conditions of the people with mental health problems at the time of mental health clinical supervision. If diagnosis done by the trained health workers is not correct, psychiatrist help for the correct diagnosis and guide them for proper medication. In psychosocial support also, the supervisors from CMC-Nepal directly coach and backstop to the trained ANMs and staff nurse in the case handling and its management.

Mental health coordinator and psychosocial coordinator is lobbying with the local and provincial level government to review the existing policies and program and include mental health components in those policies and programs. The local MHSW, along with the coordinator is sensitizing the elected representatives and other concerned government officials in mental health issues through the orientation, engaging them in project monitoring and inviting them in project activities. CMC-Nepal also assisted (rural) municipality to prepare programs and budget in mental health to include in the annual plan and budget of the year 2019-2020. SHGs were empowered in old project locations to lobby with the local government for the allocation of the budget in mental health and psychosocial issues.

Mental Health Social Workers (MHSW), provided the individual and group psychosocial counseling to needy family through home visit and SHG group meeting. They also supported to the trained ANMs and staff nurse in providing counseling service. Likewise, MHSW is supporting SHGs to conduct regular meetings and build the institutional and technical capacities through meetings, orientations, training and regular backstopping at individual level. They also engaging in formation of SHG in new project locations, linking SHG with DPOs to jointly work on psychosocial disability issue and their recognition and registration in concerned rural/municipalities.

3 Outputs – Activities – Indicators-Targets

The planned activities and the actual progress for the period of January – June 2019 and indicative results are given in the table.

WHAT WAS INDICATORS for 2019 TARGET for 2019 ACTUAL PROGRESS MADE EXPLANATION /COMMENTS SCHEDULED Outcome 1: Community people have increased access to mental health and psychosocial service at local level Output 1.1: The government health workers have increased capacity to address mental health and psychosocial needs of the people Activities to achieve the result 1.1 1.1.1 Train government 24 doctors and paramedical 2-events of 6- 1-event of 6-days basic mental Ministry of Social Development of health workers, staff receive knowledge and days mental health (mhGAP) training Karnali Province organised mental including medical skills in mental health health training for conducted in Surkhet, where 8 health training from their own officers in mental through the basic and prescribers doctors and paramedics from resources. CMC-Nepal provided health refresher training (medical officers Surkhet and Jajarkot were technical support and cost of the paramedics) participated and received consultant psychiatrist and knowledge and skills in diagnosis psychologist was managed from and management of common CMC-Nepal. mental health problems. 16 doctors of Jajarkot, Surkhet and Three events of CME for medical Okhaldhunga received knowledge officers/paramedic were conducted and skills on diagnosis and in Surkhet, Jajarkot and management of seizure, Okhadhunga where 16 medical depression, neurosis and officers attended. psychosis.

2-events of clinical supervision 930 people with mental health were conducted at health facility problems received direct service 4-events of level where 13 trained doctors and from the consultant psychiatrist, clinical paramedics received additional where trained health received wide supervision for knowledge and skill on range of opportunity to learn more doctors and management of cases. about differential diagnosis and paramedics management. conducted in each 1738 new & 1907 old patients health facilities received mental health service from 13 health facilities. 1.1.2 Train staff nurse, 14 government nurse/ANMs 2-events of 5- Not achieved The adjustment of the health Auxiliary Nurse effectively provide basic days basic workers working in the Midwife (ANMs) psychosocial support to the psychosocial government system as per the new and social workers people having psychosocial support and federal structure was not yet in psychosocial problems and refer internal counselling ended, so we delayed to conduct support and or higher-level service training for non- psychosocial counselling training counseling facility if needed prescribers of nurses and AMN and this is now planned at end of third quarter.

Psychosocial Two events of psychosocial As explained above, CMC-Nepal supervision to supervision conducted in did not manage the psychosocial trained health Udayapur. counselling training in the new workers by CMC's project districts in this reporting supervisor year so no supervision planned. 1.1.3 Orientation in 96 health workers working 8-events of 2- Six events of two days mental The cost of the mental health mental health and nearby health facilities will days orientation health orientation program were orientation was fully covered by psychosocial receive basic knowledge on in mental health conducted in Jajarkot (Nalgad and the concerned rural municipality support to health mental health and and psychosocial Bheri municipality), Surkhet e.g. Allowance of participants, workers of psychosocial support and support to health (Gurvakot, Lekbesi municipality consultant fee and vehicle cost, adjoining health refer the people with mental workers of and Chingad rural municipality) stationary, refreshment and facilities of referral health problem to the health adjoining health and Okhaldhunga (Sidhicharan banner. places facilities, where mental facilities of municipality) where 179 health health service is available referral places workers and ward chairperson received the basic knowledge on identification and referral of mentally ill cases. Output (Result) 1.2: Mental health and psychosocial support service is developed in government health facilities in program areas Activities to achieve result 1.2 1.2.1 Meeting with 240 concerned stakeholders Two events of Not progress In most of the health facility, Health Facility at local level will be orientation/review HFOMC is not in full functioning Operation participated in meeting with the thus we did not organize meeting. Management orientation/review meeting HFOMC and This meeting will be conducted in Committee other concerned next reporting period. (HFOMC), stakeholders Municipality and other concerned stakeholders 1.2.2 Mental health and 96 health facility will One set of One set of awareness and Awareness materials will be psychosocial receive one set of awareness awareness and psychosocial promotional distributed to other nearby health promotional and psychosocial psychosocial materials was distributed to 16 facilities in next half materials support to promotional materials promotional referral health facilities the health facilities materials will be distributed to 96 health facilities 1.2.3 Psychotropic Provided psychotropic As per need Psychotropic medicine was Ministry of Social Development of medicine medicines will support to supported in Okhaldhunga Karnali Province supplied continue mental health psychotropic medicine based on service which increases the the request of the health facilities trust of government health of Surkhet and Jajarkot. Similarly, service. 4 municipality of Surkhet, 2 municipality of Jajarkot and 5 municipality of Udayapur also supplied psychotropic medicine. Outcome 2 The people with mental health problems and their families are able to work with communities and network with local government and DPOs to respect, protect and fulfilling their rights (Output) Result 2.1: Communities have improved understanding to respect, protect and fulfilling the rights of the people with psychosocial disabilities

Activities to achieve the result 2.1 2.1.1. Orientation to 200 women cooperative 10 events of 12 events (Okhaldhunga-4, This orientation program was person with psychosocial members, members of mental health Surkhet-6 and Jajarkot-2) of conducted in newly selected disabilities and their mother groups, FCHV, orientation to mental health orientation program (rural)municipality where 313 family members, FCHV traditional healers receive members of were conducted for the members members of women cooperative and mother group, basic knowledge on mental cooperative and of women cooperative and and FCHV received information traditional healer, health and psychosocial FCHV FCHVs. on mental health issue. They teachers and students on support and create identified and referred the 26 cases mental health issue and awareness at community in health facilities for diagnosis social stigma level to reduce stigma and and treatment refer the cases at service facility for treatment. 2.1.2. Interaction among 960 people from the 32 events of 7 events (Okhaldhunga-4 and 121 community level service the people with community service interaction Surkeht-3) of interaction meetings providers realised the need of psychosocial disabilities, providers and local meeting among were conducted with community mental health issue. community government will be people with level service providers along with representative, service sensitized in mental health psychosocial people with psychosocial providers and local issues and initiate to sustain disabilities and disabilities government on mental mental health service community group health issues and social through allocation of stigma resources to continue service. Activities to achieve the result 2.2: Family members, close friends and communities have improved understanding to prevent suicide and provide care and support to those who are in need 2.2.1. Orientation at 1400 community members, 28 events of 9 events (Surkhet-5 and Jajarkot- This activity was conducted in 9 family, schools, local students and family awareness 4) of awareness program on schools of Surkhet and Jajarkot. CBOs and service members receive basic program on suicide prevention conducted Schools were selected in providers level in suicide knowledge on suicide suicidal where 921 students and teachers coordination and support of prevention, care and prevention and support and prevention received basic knowledge on education coordinator of support create awareness in suicide suicidal prevention. concerned (rural) municipality. prevention. 2.2.2 Form peer group at 14 peer groups will be 14 schools 9 peer groups formed and 151 Each peer group will be school, SHGs and other formed, trained and selected and form students selected for the peer capacitated in the second half of CBOs and build their mobilized to prevent 1 peer group in support group. the year on early signs of suicide capacity to find out early suicide. each school and for further response. signs of suicide risk and respond on time to prevent suicide Activities to achieve the result 2.3: SHG are formed and advocates for their rights guaranteed by policy and legislation related to Mental health and Disability 2.3.1 Formation and 320 SHG members will 10 self-help Process orientation and interaction Identification of the people with support for functioning actively involve in the groups will be is conducted with the people with mental health problems and SHGs group. formed from the mental health problems and their service seeking practice of such new project families in 4 health facilities, people in health facilities is locations and where 49 members were gradually increasing. CMC-Nepal altogether 16 participated. will also include those people and SHGs will be their families in the discussion and supported 6 existing SHGs received regular form the group in the coming management and technical support period. 2.3.2 Orientation on 320 SHG members will 16 events of 2 events of orientation on policies policies/legislation receive orientation on meeting and legislation related to mental related mental health and policies and legislation conducted health and disability conducted in disability related to mental health and Udayapur. disability 2.3.3 Livelihood and 32 patient who are in Provide livelihood One patient received livelihood Ministry of Social Development and psychotropic medicine process of recovery will be and psychotropic and two patients received the concerned (rural) municipality is support for poor and benefited from livelihood medicines to 32 psychotropic medicine support. regularly supplying the psychotropic chronic people with and medicine support people medicines to health institutions so mental health problems there was no need to additionally supply the medicines in Surkhet, Jajarkot and Udayapur districts. Activities to achieve the result 2.4 SHGs members are linked with DPOs to ensure their rights and regular functioning of SHGs 2.4.1 Joint 16 events of joint DPO and SHGs 1-event of meeting conducted in SHG group formation is in the meeting/interaction interaction meeting with meet twice year in Udayapur where 13 DPOs and process in new project districts. So, among DPOs and SHGs DPO and SHGs each municipality SHGs members participated and such interaction will be organized in for the actions to ensure received knowledge on the needs the new project location once the the rights of people with psychosocial SHG will be formed. disability and their rights 2.4.2 Joint 16 events of joint 1 events of joint Not achieved This event will be organized in the meeting/interaction with meetings/interactions with meeting/interaction second half of the year. service providers and the service providers and with the service local government for local government organized providers and local resource for the resource allocation government along with SHG allocation/implementatio n in psychosocial disabilities OUTCOME 3: Government of Nepal upscale community based mental health program at national, province and local level

(Output) Result 3.1: CMC-Nepal has increased collaboration with the Government of Nepal (federal and provincial) to formulate and endorse mental health policy/act in the spirit of UNCRPD Activities to achieve the result 3.1 3.1.1 Organizing regular Meeting at federal and 6-events of meeting 1-event of provincial level meeting meetings with the federal provincial level with health will be conducted was conducted in Surkhet where and provincial health authorities for 13 senior officials from Ministry authorities and other mainstreaming the mental of Social Development related stakeholders program in existing health participated. system 3.1.2 Joint monitoring Monitoring visit from the At least two 1-event of monitoring visit was With realization of best practice of visit in the project federal and provincial level monitoring visits conducted by Ministry of Social CMC-Nepal, Ministry of Social districts from the federal conducted will be jointly Development of Karnali Province. Development contributed the cost for provincial and local level conducted the psychiatrist for the clinical for integrating best supervision in two municipalities and also supplied the psychotropic practices in the health medicine as per request of system municipality. 3.1.3 Experience sharing Finding of research-based 1-event of sharing Baseline study is completed and conference/workshop study shared to government workshop the result will be shared in the with government authorities and I/NGOs second half of the year. authorities/(I)NGOs Activities to achieve the result 3.2 CMC-Nepal has strengthened partnership at local level to plan, implement, monitoring and upscale community mental health program 3.2.1 Orientation/ Orientation/Interaction with 320 municipalities 15 events of orientation conducted Interaction with the local the local elected bodies and elected members in all 15 (rural) municipality, elected bodies and concerned authorities of and government where 236 elected representatives, concerned authorities of Local Level about mental officials of local concerned stakeholders and Local Level about mental health issues level understand government officials received mental health health issues knowledge on mental health issue issues and cooperate in project implementation. 3.2.2 Municipality level Municipality level mental 15 events of Not achieved mental health action plan health action plan workshops on preparation workshop preparation workshop action plan preparation 3.2.3 Review meeting at Review meeting at local 15 events of review Not achieved This activity is planned in third and local level level meetings at local fourth quarter of the year. level 3.2.4 Joint project Joint project monitoring 15 events of joint Not achieved This activity is planned for third and monitoring from the local from the local level to monitoring visit fourth quarter of the year. level to integrate best integrate best practice into from the local level practice into Municipality Municipality level planning level planning and and budgeting budgeting

Project Monitoring and Evaluation Activities of Project Monitoring and Evaluation 4.1.1 Review and Review and planning 2-events of meeting 1-event of review and planning planning meeting within meeting conduct among will conduct among meeting was conducted where project team and financial project staffs and financial project staffs sharing progress, learning and partners partner challenges and developed the plan together for next six month. 4.1.2 Monitoring of the Included 3.2.1 - - project activities 4.1.3 Baseline Baseline information as In two new project In both districts (Surkhet and Information Collection stipulated in the project districts baseline Jajarkot) base line data is collected proposal will be collected data will be and filled up the information and used to measure the collected format for analysis outcome/impact at the end of year or project period.

4. Challenges in Project Implementation

In Surkhet and Jajarkot districts, CMC-Nepal is visibly recognized and its expertise in mental health and psychosocial counselling has been acknowledged. CMC-Nepal received request from the provincial government for the management of mass conversion disorder in one of the schools of non-project municipality. CMC-Nepal managed to send the management of mass conversion disorder in technical backstopping of psychologist. The intervention carried out by CMC-Nepal brought positive outcome on management of mass conversion in the schools. Mass conversion problem is commonly happening in many schools and schools and (rural) municipalities are demanding CMC-Nepal's expertise for its management. It is not possible to address their demand with the limited human resources and budget. To mitigate this challenges, CMC-Nepal gives priority to intervene its management in the project location and lobby with them and even the municipality of the non- project location also to allocate the budget for the training of selected teachers in the management of the mass conversion disorder from the (rural) municipality. CMC- Nepal will provide the manual developed by Primary Health Care Revitalization Division (PHCRD), Ministry of Health and Population to to the concerned health coordinators and teachers, which will support for the primary management.

CMC-Nepal was in short-fall in the budget to implement the activities in the full speed in all 15 (rural) municipalities as per plan submitted to Tear Australia. CMC-Nepal approached to Felm from the third quarter of the year 2018 to cover the deficit of this project and requested them to fund in this project as co-funding. It is good that Felm agreed to co-fund NPR 2,124,451 in this project however CMC-Nepal lately received approval of the funds and no activities implemented from the use of the such funds. Apart from this, the health workers adjustment process due to change in federal structure took more time than expected (even not formally ended until now) which delayed in implementation of training and supervision of health workers in mental health and psychosocial counselling. Once the adjustment of health workers ends formally, CMC-Nepal will organize training for both prescribers and non-prescribers and continue supervision as well.

ANNEX

Doctor's impression after mental health training:

"We all assumed in the past that that mental illness means mad (PAGALPAN) but we realized now that it was wrong understanding. We did not have enough knowledge about the other types of mental illness beside of psychosis which we learnt here. We had understanding that only week people commit suicide, stronger person do not commit suicide but it is also wrong. The people who cannot do anything for his life commit suicide but now understood that it is mental health issue. This was very important training and we learnt many new things here which definitely built our confidence. We somehow had managed the mental ill cases and prescribed medicine previously from our limited knowledge but now realized that the management prescribed by us was not right. Thus, this training enhanced our self-confidence to deal with mental illness cases in proper way". PHOTOGRAPHS

Mass conversion management session with affected Mayer of Nalgad municipality, Jajarkot in opening session children of mental health orientation

Ministry of social development supported for mental health camp

Mental healthHealth clinical coordinator supervision is facilitating by psychiatrist MHPSS orientation to FCHV Mental health clinical supervision by psychiatrist

Health coordinator is facilitating mental health orientation program to FCHV FCHV Training

Reflection on the practice of child protection policy in CMC-Nepal

CMC-Nepal usually reflect on the practice of policies and guideline twice in a year in the review and planning with all the staff and board members. The review meeting of this half-year was organized on 17-18 July, 2019 and as usual we discussed on the practice of child protection policies, anti-fraud and corruption polices and integration of cross cutting issues into CMC- Nepal's programs.

Some of the reflections and practices on the Child Protection Policy (CPP) are as follows.  CMC-Nepal has been raising awareness regarding child protection issues in the schools and need of Child Protection Policy (CPP) in the schools under the School Mental Health Program. There is a Child Protection Policy in all 70 schools, where CMC-Nepal is implementing School Mental Health Program. Parenting education, adolescent health awareness, no punishment for children, Gender Based Violence, drop-outs are the topics that we talk during parenting sessions at schools.  This meeting provided the feedback to the program team to add the topic 'about the practice of the CPP and requested to carry out the discussion with the teachers during supervision visit or other visits. There was discussion about to collect such reports from the teachers whether they started such practice of discussion on the implementation of CPP at schools.  There was interesting discussion during the review meeting in regard to the implementation of the CPP. One of the participants reacted that just knowing about the CPP, it is not enough. He added that have we all been implementing all the code of conducts in our daily life? Have we been filing a complaint against any actions again CPP till now? The staff was more requesting to form a responsible authority to receive and address the complaint. This meeting also provided the information about the authorized team to receive and address the complaints.  In Gender Based Violence (GBV) Prevention and Response Project, child marriage has been discouraged through raising awareness in the boys' and girls' groups.  In Bharosa Project: CMC-Nepal will provide orientation to its staff about the safeguarding policy and will implement in this project areas from the next half of the year. The practices will be followed in each visit with the respective counsellors.  The children at risk are sent to school and are protected after intervention in Safer Migration Project (SaMi). The staff presented one case of Terai district. It was about not fulfilling the rights of education by the family members. One child was ready to be admitted in school and all the arrangement were made to take him to the hostel. But the family members were not supportive and did not agree to send him to school. It was reported to the ward office.  It was also suggested that while on providing training, when a minor child accompanies his/her parents, either the child has to be guarded where there are more than 2 or 3 people around because if the child is with only one person, then he/she is at more risk.  It was recommended that the report should be submitted in every monthly report of every activities done regarding these policies. If any child at risk is found, what situation was there, how we intervened, should all be included in the report. We should all be aware whether we have been implementing all these in our daily life and project activities.  In Community MH & PS Support Programme, one of the schools in Surkhet, corporal punishment was common for students, no entertainment, only study. While visiting in the school with the agenda of talking with the teachers regarding this, our MHSW witnessed on students was beaten very badly with pipe. After meeting, he requested to minute that if any teacher found punishing any student, action will be taken against them. It was requested to obtain that minute as evidence.  The meeting decided to review the exiting CPP and formed a task group with leadership of the CPP Focal person Madhu Bilash Khanal and member Himal Gaire and Smriti Ghimire. This team was given the responsibility to include safeguarding of adults who are at risk. The team will work out by the end of August and submit the changes to the Management Team for finalization and will be formally endorsed from the executive board.