CMC- Community Mental Health and Psychosocial Support Programme

Annual Report January – December 2018

Submitted to: Tear Australia, 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 February 2019

Location of the project: This project covers 20 (rural) of 5 districts from 3 as per listed below.

Province No 1: Morang: Letang, Ratuwamai and Belbari Udayapur: Chaudandigadhi, Belaka, Triyuga, and Rautamai Rural Municipality Okhaldhunga: Likhu Rural Municipality and Siddhicharan Municipality

Province No 3: Rasuwa: Kalika, Gosaikunda, Amachhodigmo, Uttargaya and Naukunda Rural Municipality

Province No 7: : Parashuram Municipality, Bhageshowr, Nabadurga, and Rural Municipality. Reporting year: 2018

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

Short description of project’s current situation: This year is the final year of the fifth phase (2016-2018) of the Community Mental Health and Psychosocial Support Programme (CMHPSP), which was being implemented in Morang, Udayapur, Okhaldhunga, Rasuwa and Dadeldhura districts in the funding support of Tear Australia. This program was implemented in 24 health facilities of 20 (rural) municipalities of above mentioned 5 districts based on the signed a Memorandum of Understanding (MoU) with Ministry of Health and Population (MoHP) at central level and with (rural) municipalities at local level.

CMC-Nepal continued backstopping and coaching to the prescribers (medical officers and paramedics) in mental health and non-prescribers (staff nurse & auxiliary nurse midwife) in psychosocial support and counselling in order to build confidence in providing quality mental health and psychosocial service. The senior auxiliary health worker (AHW), health assistants and medical officers are the prescribers who had received training and supervision in mental health and handle the cases with the medication as well. Non-prescribers are mainly ANM who had also received psychosocial counselling training and supervision from CMC-Nepal and involved in providing psychosocial counselling service. Basic trainings in mental health and psychosocial counselling was also organised for the new health workers and refresher training also conducted for the trained health workers of the project areas.

At present, 45 health workers, including 7 medical officers are providing mental health service, whereas 33 ANMs are delivering psychosocial counselling service from 24 health facilities. 22 health facilities are found effective in providing mental health and psychosocial counselling service. Non-prescribers have provided psychosocial counselling service to 351 clients (256 new and 95 old) and prescribers have provided mental health services to 4110 clients (1840 new & 2270 old) in this reporting period.

The training, backstopping supervision and distance coaching supported to increase the confidence of trained health workers in detection of mental disorder, prescribing appropriate

medicine in right dose with adequate education of possible side effects. The self-satisfaction tools used in the research has revealed that the people with mental health problems and their care taker have responded satisfaction with mental health service of health facilities. More than 90% mental patient have expressed positive response with behaviour of health workers in health facility; health workers do listen their problem and service is effective and counselling helped in reducing sufferings and improved daily life functioning.

The follow-up of the service recipients (people with mental health problems) at health facilities have been increased significantly (more than 90%) than previous years due to the effects of awareness activities in another project of CMC-Nepal called ‘GBV prevention and response project and community outreach program of Okhaldhunga Community Hospital. Around 65% people, who had received mental health service from the local health facilities, have improved their mental health wellbeing and engaged in routine activities and 35% are still in the follow- ups at local health facilities. 60% clients in total, who had received psychosocial support/counselling from the health facility, their psychosocial wellbeing has been improved more than 90%. Twenty percentage are still in follow-up sessions and remaining 20% have discontinued follow-up due to more time needed to travel to reach in the health facilities. Around 20% people having symptoms of depression, anxiety disorders and conversion disorder have received both mental health and psychosocial counselling service from the same health facility.

CMC-Nepal organised interaction meeting with new elected representatives and government officials of the local level and sensitized them about the need of involvement of mental health and psychosocial counselling services through planning program and budgeting from the local level to sustain mental health and psychosocial service. As it is the final year of the project we more engaged in organizing follow-up meetings with the (rural) municipalities of Dadeldhura, Rasuwa and Morang districts, along with SHGs and DPO representatives. The joint meetings among the Self-Help Group (SHG) members and members of Disabled People Organisations was also organized at (rural) municipality level to seek cooperation and raise the mental health issues collectively, coming in the common platform as psychosocial disability is included under the UNCRPD and current Disability Act (2017). These regular interactions meeting helped to sensitize the elected members of the local government on the need of mental health and psychosocial service and almost 90% of the (rural) municipality had expressed their commitment to support psychotropic drugs and awareness campaigns in mental health through the allocation of funds in (rural) municipality planning and budgeting. The (rural) municipalities of Dadeldhura, Rasuwa and Morang have allocated the budget for the psychotropic drugs and awareness campaigns. SHG of Dadeldhura have been succeeded to receive funds from local governments (Parsuram municipality Rs. 100,000/-, Ajayameru rural municipality Rs. 50,000/- & Aalital municipality Rs. 100,000/-) for the mental health awareness campaigns and purchasing of psychotropic medicines. In Letang, Belbari and is continuing supply of psychotropic medicine since 2018 January. With realising the need of expansion of mental health service in other health facility, the Chuadhangadi municipality of Udayapur Municipality of Dadeldhura and of Morang allocated the funds for the mental health training of health workers, where CMC-Nepal provided technical support in the training.

CMC – Nepal further involved in reducing social stigma associated with mental illness through organizing orientations for the students, mother groups, Female Community Health Volunteer (FCHVs), traditional healers, people with mental health problems and their families. SHG were mobilized in celebration of the world suicide prevention day, world mental health day and disability day. Nearly 50% of total cases diagnosed at health facilities were referred by SHG

members, community psychosocial workers (of GBV Prevention and Response Project), mother groups and FCHVs and school students & teachers.

CMC-Nepal worked closely with the people with mental health problems, their families, community people and duty bearers to respect, protect and fulfil the rights as stipulated in the Disability Act of Nepal. Four SHG groups were formed in Udayapur and Morang in this reporting period and Mental Health Social Workers (MHSW) regularly attended meetings and provided group sessions, training and backstopping support to 22 SHGs (including 4 new SHGs) in realizing their rights, preparing actions and moving ahead to execute the actions to fulfil their rights as other people. As per our internal observation performed by the SHGs, 6 SHGs from the exit districts (Rasuwa, Dadeldhura and Morang) and 2 SHGs (Udayapur and Okhaldhunga ) from continuing districts seems independent and remaining 14 needs regular support either from CMC-Nepal or DPOs. CMC-Nepal organized exit meeting with the elected representatives and government officials of the concerned (rural) municipalities of Rasuwa, Morang and Dadeldhura and handed over the program to the government.

After the consultation and approval from Tear Australia, CMC-Nepal conducted research to find out the effectiveness of the project deliveries i.e. training, supervision, awareness activities and SHG initiatives. The recommendation from the evaluation research is considered during the development of next phase project document especially in strengthening capacities of health professionals. This report has been submitted to Tear Australia.

With the constant effort at central level, the Government of Nepal had allocated the programmatic funds for the human resource development and awareness raising in mental health in 7 districts of Nepal. On request of the Primary Health Care Revitalization Division of Department of Health Service (DoHS), CMC-Nepal provided technical support in 3 districts to conduct 2-days orientation in psychosocial support to the ANMs and one day orientation in mental health for the Female Community Health Volunteers (FCHVs), traditional healers, teachers, journalists and local level elected members. The MoHP established the Non- Communicable Disease and Mental Health Section in the DoHS to develop and implement the program and coordinate with the NGOs, INGOs and other institutions to upscale mental health service at community level. CMC-Nepal’s representation at central and province level is acknowledged by the government and it has been providing contribution in program planning, development of guideline and materials and policy documents. Reporting organisation: Centre for Telephone & Fax: Web: www. cmcnepal. Mental Health and Counselling Nepal 977-1-4102037 org.np (CMC-Nepal) Address: Thapathali, Kathmandu E-mail: Contact person: Post Box No: 5295 [email protected] Ram Lal Shrestha Executive Director

Budget for the reporting period (NPR): Amount spent during the Expenditure %: reporting period (NPR): 11,309,337 11,227,898 99%

Section A. Context

1. Project Organisation(s)1

There is no as such changes in the programme strategy and its key activities during this reporting year. However, there were changes at district and local level in government partners due to implementation of the federal structure in Nepal. CMC-Nepal had to contact at local level with the health division instead of district level public health office.

There were discussions at organisation and program level of CMC-Nepal about to sensitize to the elected representatives and government officials of the local level in mental health and psychosocial issues and sell the CMC-Nepal’s expertise to them in order to extend mental health and psychosocial service at community level. Even in the project (rural) municipalities, partnership modality was discussed in order to make responsible to the local level in implementation of the project activities, with sharing of the cost in the project. The partnership agreement will be done with the project (rural) municipalities effective from next project cycle, beginning of year 2019.

There was no change of key staff as well as field staff in this reporting period, who was responsible for this project.

2. Project context The new constitution of Nepal has introduced a three-tier structure of federal government (federal, province, and local) with constitutional power to enact laws, prepare budgets, and mobilize their own resources. There is one federal government, seven provincial government and 753 local government in Nepal after the election in year 2017. There is also existence of the districts and currently there is 77 districts and, in each district, there is a District Coordination Committee which has less powers than Local Governments and the committee just coordinate activities of several local governments within it.

There were also big changes in the organizational structure within the Ministry of Health and Population. New divisions within the Ministry of Health and Population (MoHP) were emerged and some were merged within one division to address the public health needs in the changed federal context. The MoHP has given the positive message in the field of mental health through establishing a separate section in mental health, called ‘Non-Communicable Disease and Mental Health Section’. There is one psychiatrist, primarily responsible to prepare plan, develop strategy, implement activities and coordinate with the organizations working in mental health and psychosocial field.

In year 2017-2018, the Primary Health Care Revitalization Division of Department of Health Services, implemented mental health program (training of medical officers and health assistants in mental health, orientation of paramedics and nurse in psychosocial counselling and mental health orientations to the FCHV, political leaders and journalists) in 6 districts of Nepal and further planned to implement such program in 14 districts (two districts from each province). In February, 2018, there was a first international mental health conference organized in Nepal in the leadership of the Government of Nepal and in support of INGO, NGOs and other academic institutions. Furthermore, International conference on child and adolescents mental health was also conducted

1applicant organisation and any other organisation/institution playing a significant role in the project

in Nepal in November 2018. These conferences have widened the level of awareness of the policy level authorities of the government on the need of mental health program with integration of mental health and psychosocial counselling service into the existing health care delivery system.

On the other hand, this year has made disappointed to the organizations working in the field of mental health and psychosocial counselling that the revised version of the National Mental Health Policy 1997 did not come as an approved policy though it was in improved version with international standard. There was policy level decision from the MoHP that they will work to merge all the policies and put it in one named as ‘public health policy’ so there is less likely that there will be a separate policy in mental health. Likewise, the process of working in the mental health legislation did not complete in last year. However, the Government of Nepal has issued Pubic Health Act (2018), which has included mental health service under the basic health care service and has assured to provide such service in free of cost.

At local level, the local government has started to enlist/register the SHGs in the concerned (rural) municipalities after series of discussions with the elected representatives and government officials. One SHG of Udayapur has been enlisted at the local level in year 2018 and remaining are in process for enlisting.

Section B. Implementation

3. Overview of implementation

This project was implemented based on the signed Memorandum of Understanding (MoU) between Ministry of Health and Population and CMC-Nepal. There was also operational level MoU between District Public Health Office and CMC-Nepal and later with the concerned (rural) municipalities for project implementation at district and local level. Five to seven health facilities were selected to build access of mental health and psychosocial service in primary health care delivery system. Project implementation was carried out based on the activity planning with targets and indicators stipulated in Logframe of the approved Project Document. There were two semi-annual review and planning meetings (first was in January and second in July) with all project staff and senior management team and this meeting reviewed the plan of preceding six months and prepared the plan of coming six months. The draft version of activities plan was shared with the district level duty bearers and the right-holders. Review meeting and monitoring visit was organised almost in all project districts and feedback from the stakeholder was considered in re- designing of the project activities and its continuous follow-up to bring the significant changes to the lives of the people with mental health and psychosocial problems.

CMC-Nepal has been following human right based approach and closely working with the people with mental health problems, their families, community people and duty bearers to respect, protect and fulfil the human rights of the people with mental health problems. The MHSW have been attending meeting of Self-Help Group (SHG), sensitizing them about their basic human rights issues and further empowering them to closely work with the community people and duty bearers for the promotion of mental health wellbeing and fulfilling the basic human rights such as health service, livelihood enhancement, education and social service. CMC-Nepal has also collaborated and sensitized directly duty bearers to contribute in protecting basic human rights of the people with mental health problems.

More than 90% of the project activities included in the annual work plan were implemented in this reporting year. Some of the project activities i.e. mental health orientations at schools, follow-up with Self-Help Groups in the forms of the meeting and mental health training to the paramedics were cancelled due to the not availability of sufficient funds to manage those activities.

4. Meeting objectives

4.1 Progress towards Project Impact The expected impact of this project was to improve the work performance of the people with mental health and psychosocial problems through reducing their stresses, trauma and mental illness. A total of 4110 (1840 new and 2270 old cases) people with mental health problems received mental health service in this reporting year from 24 health facilities. A total of 4830 people with mental health problems diagnosed and treated at local level in three years (2016- 2018)), which has crossed the targets of 2500 by 93%. A total of 4757 old clients also received mental health service, which is almost near of pre-set target 6250 (76% of total target).

Around 65% people, who have received mental health service from the local health facilities, have been recovered from the mental illness. Most of the treated people from depression and anxiety symptoms have been engaged in daily household activities and majority of them (around 70%) have been involved actively in income generating activities. 35% people, having mental health problems are in follow-up at health facilities and getting regular service from the trained health workers in the technical supervision of CMC-Nepal.

351 clients (256 new and 95 old follow-up) clients received psychosocial support at health facilities from the trained ANMs. Out of 351, 60% clients' psychosocial wellbeing have been improved as revealed from the feedback of family member and health worker trained in psychosocial support and counselling, including the observation seen during supervision. And 20% are in the follow-up and remaining people having psychosocial problems haven’t continued follow-up sessions. A total of 797 people with psychosocial problems received psychosocial support from the trained staff nurse and ANM in three years-time (106% achieved in total targets).

This program has significantly contributed to reduce the gap between the treatment of mental health problems and resource available. As highlighted in the short-description chapter, there is currently 2 prescribers (medical officers and health assistants) in each project health facility and they are providing reasonably quality mental health service. There is at least one non-prescriber (staff nurse and ANM) in each health facility, they have been involved in providing psychosocial counselling service. The trained health workers, both prescribers and non-prescribers have played a significant role to reduce the stresses and mental health problems through delivery quality mental health and psychosocial counselling service from the existing health care delivery system. Mental health drugs have been made available in more than 80% project health facilities from the government system.

This project has considered the mental health wellbeing of the women, children and people from marginalized & deprived communities. Out of total right-holders, 46% are women and 14% are children (girl). Dalit and Janajati along with ethnic minorities comprised of 13% and 33% respectively of total right-holders. Considering these information CMC – Nepal is able to reach out and provide mental health and psychosocial services for the deprived and marginalized communities.

Mental illness is associated with high rates of unemployment, leading individuals into economic stresses and poverty and depriving them of social networks and status within a community. The economic impacts of mental illness affect personal income, the ability of ill persons – and often their caregivers – to work, productivity in the workplace and contributions to the national economy, as well as the utilization of treatment and support service2. The individuals with mental disabilities may not be able to work during periods of untreated illness, thus limiting their earnings to cover care costs (treatment and service pay payment). To address the economic burden of the mental disorders of the people with mental health problems and their family members (care takers), CMC-Nepal has made linkages at local level and other service providers for the livelihood support, with focus to the people with mental health problems. In some extent, CMC-Nepal also provided livelihood support to the 4 female and 3 male having mental health problems in this reporting year. In this project phase (2016-2018), CMC-Nepal provided support to the 16 people and 95% of them have been engaged in income generating activities and started to earn money and the earned money has been used to cover the treatment cost and daily needs. The engagement of the recovered people in household and income generating activities not only contributed for the families but also contributed to reduce stigma and discrimination in the communities. It also directly supports to mental health well beings.

2 Investing in MENTAL HEALTH, WHO

In addition to the economic burden explained above, those sufferings from mental illness are also victims of human rights violation, stigma and discrimination. To reduce human rights violation, stigma and discrimination, CMC-Nepal has closely worked with community, duty bearers, human right organisations, disabled people organisations and local government through interactions, training and involving them in the monitoring visits at project locations. The local government and health facility have recognised the existence of SHG and they have allocated the budget for the medicine support and awareness raising campaigns. One local SHG have been enlisted at the local level and they have started to consult with them in the local level planning of mental health activities.

CMC-Nepal is directly working with the people with mental health and psychosocial problems and their families to ensure their fundamental rights to health, education, participation, social inclusion and benefits. The rights to mental health service have been ensured through building the access of mental health and psychosocial services at community level, rights of the participation have been promoted through directly working with the people with mental health problems and their families through SHG. The rights of social service have been addressed through facilitating in order to get the disability cards for the people with mental health problems (people having schizophrenia, intellectual disability). 22 (4 Morang, 7 Udayapur, 6 Rasuwa & 5 Dadeldhura) people with psychosocial disability received disability cards in this reporting year.

There is some visible impact on policies or practices at national level towards moving in integration of mental health into the existing health care delivery system in this reporting year. The Ministry of Health and Population has established a separate section called ‘Non- Communicable Disease (NCD) and Mental Health Section’ with the position of psychiatrist under the Epidemiology and Disease Control Division of Department of Health Services, in July 2018. This section has been made responsible for planning, implementation and monitoring of the mental health activities throughout the country.

4.2 Progress towards Project Outcome

Outcome 1: By 2018, people with mental and psychosocial problems of the project districts have improved access to mental health and psychosocial services, that are delivered by trained health staff in the selected health institutions of project areas

A total of 11 medical officers and 21 paramedics (health assistants) received basic mental health training from Rasuwa, Morang, Udayapur and Dadeldhura districts. The average percentage of pre-tests of basic mental health training was 27% whereas post-test score was increased to 73% in the training period. 33 medical officers received additional knowledge and skills in the management of common mental disorders through Continued Medical Education (CME). Twenty- two mental health trained workers received additional knowledge on mental health problems and cases management skills and differential diagnosis on mental illness through refresher training.

34 trained health workers (5 medical officers and 29 paramedics) received supervision inputs from psychiatrist and mental health supervisors during mental health clinical supervision. The trained health workers of 5 project districts received opportunity to jointly examine 1304 people with mental health problems together with psychiatrist, which has increased the confidence of health workers in diagnosis of mental health problems and prescribing right medicine in the right dose. After the basic training, mental health clinical supervision inputs, distance coaching and refresher

training, 7 trained medical officers and 38 paramedics are providing mental health service and 87% of them are reasonably providing quality mental health service than they provided at the beginning without training and supervision inputs. It has contributed to increase the access of mental health service for those who are in need of such service.

A total of 11 staff nurse and ANM of Okhaldhunga, Dadeldhura and Udayapur received basic knowledge and skills in psychosocial support and counselling. Furthermore, 22 trained ANMs from all project districts received additional knowledge and skills on dealing with the cases, with emphasis on having self-harmed and how to deal the negative thought of the client. 28 trained nurses and ANMs benefited with direct coaching and support from CMC-Nepal's psychosocial coordinator. 70 persons with psychosocial problems received direct counselling support during supervision and 28 paper cases were discussed. The basic and refresher training, psychosocial supervision and distance coaching has increased the confidence of the staff nurse and ANM in assessing psychosocial problems and providing psychosocial support and counselling. The trained ANMs/staff nurse of the 20 health facilities are better performing (up to 80%), 2 are satisfactory (up to 60% of competency) and 2 are performing below the satisfactory (less than 25 % of competency). The trained ANMs/staff nurse has maintained the session note; psychosocial assessment and follow-up sessions. 70% trained ANMs have been delivered psychosocial counselling service satisfactory level.

This project has contributed to reduce the gap of mental health service availability through building the access of mental health and psychosocial service in the government health system. Out of 24 health facilities, 22 health facilities performed well. As per recommended mental health strategies by the WHO for the middle- and low-income countries, this project has followed the cost effective, affordable and appropriate mental health care strategies and implemented accordingly. There is convincing impact or proven evidence that the integration of mental health service into the existing health care delivery system is appropriate, affordable and cost effective.

Outcome 2: Improved awareness and advocacy for mental health and psychosocial services at local, district and national levels so that it contributes in reducing stigma against mental illness in community

A total of 21 FCHV, 82 traditional healers, 802 mother groups/women cooperative members, 410 people with mental health problems and their families and 709 students received mental health information. The orientation with families and community people have supported to reduce the stigma against mental illness. A total of 75 SHG members from the 11 SHG received the training in basic psychosocial support, right based approach in mental health, networking and coordination, advocacy and resource mapping and mobilisation.

At present, the previously trained health workers of the health facilities have been transferred to the (rural) municipalities in role of health coordinator and their presence in the (rural) municipality is being useful for the implementation of community mental health program. More than 75% of the (rural) municipalities have supplied the psychotropic medicine up to 45% of total demand. It was only possible after the series of interaction, engaging them in project monitoring visit and supportive behaviour of the health coordinator. CMC-Nepal has purchased around 25% medicine of total demand and provided to the health facilities to distribute to the people with mental health problems and remaining 30% of total demand have been purchased demand by patient themselves.

CMC-Nepal has contributed to prevent mental illness and promote mental health through creating awareness with FCHVs, traditional healers, mothers’ groups, women cooperative, elected

representatives and officials of the local level, school teachers and students and other community people in mental health and psychosocial issues. There is improved awareness in behavioural aspects of care takers, family members and community members towards people with mental health problems. Around 50% people with mental health problems have been referred at health facilities for the mental health treatment through the effects of awareness program conducted at different groups and level. The regular interactions with people with mental health problems and their families have helped reaching out to the people living with mental health problems and psychosocial disabilities and their care takers & family members. The Mental Health Self Help Groups have regularized monthly meeting, involved in creating mental health awareness at community level, referred the people with mental health problems to the health facilities for the service and advocated at local level to ensure the rights of health service, education, employment opportunity, participation and social inclusion. The regular interaction meeting with SHG and awareness campaigns at different level have facilitated the people with mental health problems and their family members together for sharing and caring within their communities. The home- visit of the people with mental health problems have brought positive changes in the behaviour and attitude of the family members, increased inclusion of the people with mental health problems at family and community, reduced isolation and increased self-realisation to be included in the Mental Health SHG. The awareness and advocacy at local level has significantly brought positive changes in reducing social stigma and increasing inclusion of the people with mental health problems in the community development activities. The local government have treated them as right holders after the constant lobby and provided budget for the awareness campaigns and psychotropic medicine supply.

3 Outputs – Activities – Indicators-Targets

The planned activities and the actual progress for the period of January – December 2018 and indicative results are given in the table.

WHAT WAS INDICATORS for 2018 TARGET for ACTUAL PROGRESS EXPLANATION SCHEDULED 2018 MADE /COMMENTS (Output) Result 1 Mental health and psychosocial support workers have increased capacity to address mental health and psychosocial needs of their clients Activities to achieve the result 1 1.1 Train staff nurse, 40 government 3 basic training Conducted three events of 3- The length of basic Auxiliary Nurse nurse/ANMs effectively of 3-days day basic psychosocial psychosocial support training Midwife and social provide basic psychosocial 5 refresher support and counselling was reduced from 5 days to 3 workers in support to the people having training of 2-day training and three events of 2 days and focussed more with psychosocial psychosocial problems and days psychosocial support case discussions through support/counseling refer internal or higher-level refresher training where 11 conducting psychosocial service facility if needed staff nurse/ANM received supervision at field level and knowledge and skill in basic distance coaching. training whereas 22 received additional knowledge and skill on dealing cases having negative thoughts and self- harm. 1.2 Train government 50 paramedical staff receive Three events of Three events of six days basic One event of mental health health workers, knowledge and skills in six-days mental mental health training training for prescribers was including medical mental health through the health and three conducted where 21 conducted in Kathmandu, officers in mental basic and refresher training events of three- paramedics participated and together with the project called health days refresher received knowledge and skills ‘Inclusion and Rights of the training for in diagnosis and management Persons with Psychosocial prescribers of common mental health Disability’ where participants (paramedics) problems. from Rasuwa were invited.

Three events of mental health refresher training conducted for prescribers where 22 (Dadeldhura-2, Udayapur-7, Morang -6, Okhaldhunga-4 and Rasuwa-3) trained mental health workers received additional knowledge on cases management skills and differential diagnosis on mental illness.

Two events of mental health On request of these two orientation were conducted in organisations, CMC-Nepal Dadeldhura (21) with support provided orientations in mental of Epilepsy Association and health. They covered the Okhaldhugna (29) with support training cost partly such as of Okhaldhunga Community stationery, refreshment, rental Hospital. etc and their contribution were not enough to cover the cost of trainers (travel, accommodation etc.) and trainers cost and daily allowance was covered by CMC-Nepal.

25 doctors receive Three events of Three events of mental health Five events of CME for knowledge and skills in 3-day training for training for medical officers medical officers/paramedic mental health doctors conducted, where 11 medical were conducted in project officers (Rasuwa-2, Morang-4, districts where 33 medical Udayapur-4, Dadeldhura-1) officers and 15 paramedics received additional knowledge where participants received and skills in diagnosis and additional knowledge and

management of common skills to diagnose and manage mental health problems on top mental health problems. of what they had in their professional training (MBBS). 1.3 Conduct At least two supervision Total: 10 events 8 events of psychosocial We conducted supervision psychosocial input provided to the supervision, at supervision conducted in based on the availability of supervision trained nurses of 28 health least two events Udayapur, Morang, trained ANM/SN and need of facilities in each project Dadeldhura, Okhaldhunga and support in those respective districts Rasuwa) on psychosocial health facilities so two events support/counselling of psychosocial supervision were not carried out.

40 trained nurses 28 trained nurses and ANMs CMC-Nepal provided (including newly trained) benefited with field level additional input on family tree, from 28 health facilities psychosocial supervision and possible questions (case wise) will be benefited from the case discussions from CMC- for follow up visit, and further direct supervision input Nepal's psychosocial skills on breathing exercise from CMC’s psychosocial supervisor. and lazy eight during the supervisors psychosocial supervision.

100 persons with 70 persons with psychosocial psychosocial problems will problems received direct be directly benefitted at the counselling support during time of direct supervision supervision. Furthermore 28 visit, and 50 persons paper cases were discussed receive psychosocial during supervision. support though home-based approach in psychosocial support

400 people having The staff nurse and ANM Five events (one in each psychosocial problems (non-prescriber) provided district) group counselling receive institutional based institutional based (three sessions for each group)

and 120 people receive psychosocial support and sessions conducted where 151 family based psychosocial counselling to 351 clients people having psychosocial support (New-256 and Old-95). problems were participated and MHSW provided family based they perceived those sessions psychosocial support and useful to heal their counselling to 28 cases where psychosocial problems. 65 family members also benefited. 1.4 Mental health 50 trained paramedical 10 events of 14 events of mental health Two additional mental health clinical supervision staff (including newly mental health clinical supervisions were clinical supervisions in and meetings with trained) receives additional clinical conducted where 5 medical were carried trained doctors and knowledge and skills in supervision, two officers and 29 paramedics out together with the project paramedical staff mental health, thereby events in each received additional knowledge activities of GBV Prevention contribute in minutely project districts and skills from psychiatrist in and Response project in cost assessment and effective case management. sharing basis. Similarly, the management of common visit of Udayapur was also mental health problems. extended in Morang district as well because it is easy to cover 1500 new persons with 1840 new persons with mental in one sweep. mental illness diagnosed, illness diagnosed and treated. treated and referred. 2270 old cases received 1000 old patients received continue service continue service

700 people with mental 700 persons with 1304 (new 840 and old 464) health problems receive mental health people directly received mental direct service at the time of problems health service at the time of clinical supervision clinical supervision. These conducted by CMC cases were discussed with the supervisors/psychiatrist trained health workers during clinical supervision At least 10 trained doctors Not achieved Due to lack of trained medical will be mobilized to validate officers in the concerned rural

the diagnosis and support to municipalities we could not the paramedics to continue able to mobilize them in the treatment health facilities to validate the diagnosis and support to the paramedics to continue treatment. (Output) Result 2 CMC – Nepal with its partners have improved mechanism for mental health and psychosocial services delivery in the programme areas Activities to achieve the result 2 2.1 Coordination/review At least two review 50 events of 22 events of coordination CMC-Nepal is coordinating meeting with the district meeting with the review meeting meeting at local level with local government level level partners stakeholders at local at local level government conducted in the rather than the district level as municipality level will be project districts. the role and responsibility of conducted the district level government stakeholders has shifted to the Plan and progress jointly local level after the practice of discussed and monitored federal ruling in Nepal.

250 members from the local 250 members 263 elected representatives and Parshuram, Aalital, municipalities and other government officials attended Ajayameru, Gosaikunda, stakeholders will be meetings and showed Uttargaya, Kalika, Letang, empowered and proactive to cooperation to implement the Belbari, Ratuwamai, sustain mental health and project activities. Chaudandigadhi, Katari, psychosocial service Triyuga and Siddhicharan (rural) municipality have allocated budget for mental health activities and psychotropic drug in their annual program of this fiscal year 2018/2019

16 paramedics were trained in mental health (prescribers)

Morang, Udayapur and Dadeldhura from the financing of the concerned (rural)municipalities. 2.2 Psychotropic drugs 100 difficult cases with Provide tertiary Cases were managed in 75% of the (rural) support to the needy mental health problems will care service to districts (Rasuwa, Udayapur, municipalities have supplied persons with mental receive tertiary care service 100 difficult cases Morang and Okhaldhunga) the medicine, which covers illness from the higher-level mental with psychotropic from the frequent visit of 45% of demand of total need. health service from the medicines in a psychiatrists and psychotropic psychiatrist need basis medicines were also supported. CMC-Nepal has continued the psychiatrist clinic in Rasuwa Jibjibe PHC in every two 5 chronic patients benefit No need of rescue of chronic month and district hospital and with emergency support mentally ill patient reported in Beltar PHC of Udayapur and provided this year Rumjatar Hospital in Okhaldhunga in every 3 40 patients receive regular 17 people with mental health months. So, cases with medicine support at least for problems of project districts specialized need of mental 6 months have received regular medicine health services were referred support from CMC-Nepal. and treated locally therefore less referral in Kathmandu for the specialised service centre. 2.3 Monitoring of the Information for reflection One event One monitoring visit was One monitoring visit was project activities and to revisit project conducted in Udaypaur and conducted separately from activities for required Morang district from the NCD International Program Officer changes and adaptation in and Mental Health Section of Tear Australia. Report has the project will be available been received and shared to the after the monitoring visit by project team. board members/senior members. 2.4 Research on the Gaps of the current program Research tools Conducted research in 4 In four districts (Rasuwa, effectiveness of project will be identified and those finalised. Data project districts to find out the Dadeldhura, Morang and

deliveries as service will be considered while collection, effectiveness of project Udayapur) this research was providers and developing new project analysed and deliveries as service providers conducted. beneficiaries level prepared report and beneficiaries’ level

Prepared research report and was submitted to Tear Australia with recommendation of program strategy and activity level in the next phase (Output) Result 3 Communities have improved awareness about mental health and psychosocial needs, and is reduced stigma in communities Activities to achieve the result

3.1 Mental health orientation/reinforcement workshop to a) People with mental 625 people with mental 25 events of Conducted 16 events of MHSW (Udayapur, Morang health problems and health problems and their interaction interaction workshops in and Dadeldhura) involved in their family members family members will workshops with mental health and disability the training activities of the receive information and use the people with with the people with mental government (Mahotari, their knowledge in creating mental health health problems and their Lamjung and Kanchanpur) and awareness to increase problems and family members in research work at Udayapur support towards mentally ill their family and Morang thus these patients. They further feel members activities under the result 3 has supported to form or not completed as per planned in continue self-help group to 625 patients and 410 people (281 female) with this reporting year. raise the voice for their their care takers mental health problems and rights to treatment and other their family members service provided by the participated in the interaction government program and received information on mental health care and support

b) School students and 2500 students receive 2500 students In 16 schools, 709 students 89 mentally ill cases were teachers mental health information from 25 schools (421 girls) participated in the referred to the health facilities and use their knowledge in orientation on the awareness in from students and teachers of creating awareness at family mental health. Dadeldhura, Udayapur, and community level and Morang and Rasuwa. referring the cases at health facilities. 3.2 Orient Female 700 members of mother 25 events of 4 events of mental health 802 members of mothers group Community Health groups/cooperative mental health orientation conducted where and women cooperative Volunteer, traditional members and youth clubs orientation to 21 FCHVs received received basic information of healers, mother groups in receive mental health members of information about mental mental health, mental illness mental health information and use their cooperative, health. and mental health promotion. knowledge in creating

awareness at local level and mother groups 30 events of orientation case referral at health and youth clubs conducted for mother groups. facilities

100 traditional healers will 5 events, 100 11 events of traditional healer have increased traditional healers orientation conducted where 82 understanding and refer the traditional healers received cases at health facilities basic information of mental and appropriately. further message of the referral when it is needed.

3.3 Process orientation 5 self-help group will be At least three Two events of meeting Four SHGs formed in this and formation of self- formed from the new events of meeting conducted during process of reporting period after the series help group in new project project locations during the process SHG formation where 153 of formal and informal locations of SHG formation mentally ill people and their discussions and meetings. in each group families' member were participated. 3.4 Form Self Help 3-day basic/refresher 75 members from 75 members from 11 SHGs We did not manage to conduct Group (SHG) and training (letter/proposal 25 self-help group received training about fund refresher training in develop their writing, leadership raising and mobilisation, Dadeldhura rather we organizational and development, resource networking, mental health and reinforced separately to the leadership capacity mobilization, lobby and psychosocial awareness raising groups. In Okhaldhunga, there networking, record keeping and referrals. is new group formed and and focussed at individual group communication/listening level. skills) After the training SHG seemed pro-active to conduct meeting independently, started to approach at local level for the fund allocation in mental health issues.

4 regular group sessions in 4 sessions in each 4 group sessions conducted in One session with the SHG was each group key issues of 25 SHGs (total 8 SHGs, where 207 SHGs focussed in suicide prevention mental health, psychosocial, 100 sessions) members received opportunity at the time of world suicide behavior change aspect, to share their feeling and prevention day. mental health and received tips to manage their psychosocial care etc. owns stresses, emotions etc. SHG members have continued home visit for the mentally ill cases. They could able to talk with others and feel supported to reduce their own fear and anxiety. 10 members of SHGs have 10 members Provided livelihood support to Three client of Rasuwa, two of been empowered the 7 people with mental health Okhadhunda, one in economically (at least earn problems and they have started Dadeldhura and one of Morang Rs 2000-3000 per month) livelihood activities received livelihood support. from the supported provided them.

Three district level self- Three district Not progressed After the practice of federal help group/networks will level self-group structure, we dropped the idea be formed in the project network to form district level network. districts and the network We are planning for form start to act as a leading (rural) municipality level SHG. district level users’ . organization in the field of mental health

1500 people receive mental 1500 people 13 SHGs celebrated the world health awareness By 25 SHGs mental health day in information during the collaboration with the local world mental health day level and support of CMC- celebration conducted by 25 Nepal, where more than 700 SHGs peoples received information

on the health risks to the adolescents and young people. 3.5 Production and 26 episodes of radio 26 episodes of 16 episode of radio program broadcasting of radio program will be produced radio program material developed and programme from district and aired through 5FM broadcasted from 5 FM Radio FM radio stations radio stations stations.

Service seeking behaviour and referral increases

75 media persons receive 5 events, 75 3-events of mental health 24 journalists of three districts knowledge, skills and journalists orientation conducted for received knowledge and skills techniques on writing news journalists in Rasuwa, on writing the news for mental in mental health and as a Okhaldhunga and Udayapur. health issue. National and local result qualitative level media have started to news/article will be bring the issue of mental health published in their respective newspapers. 3.6 Develop CMC's wall CMC-Nepal's wall calendar 1 wall calendar Produced and printed a wall calendar and bulletin and bulletin are made 1 bulletin calendar and bulletin and available, increasing the distributed to the relevant visibility of CMC-Nepal at organizations and individuals national and community as usual level

Use of mental health and psychosocial awareness materials by the trained health staff and SHGs at the local level

(Output) Result 4 CMC-Nepal has an active network of organizations working in mental health and development for mainstreaming mental health and psychosocial disabilities / problems at policy levels. Activities to achieve the result 4 4.1 Continue advocacy Regular meetings at central At least two 1 event review meeting CMC-Nepal contributed in and lobby at central level level to share CMC's meeting at central conducted in central level with organisation of international for integration of mental experience and learning level with the MoHP and Department of mental health conference. health service into the government and Health Services where we existing health system Functional National Mental likeminded briefed achievement, learning Health Network for organizations and difficulties to the advocacy and lobby mental concerned central level health issues stakeholders.

Revised list of free Attended regular meetings in The NCD and Mental Health psychotropic medicine and Non-Communicable Division Section worked together with availability at health (NCD) and Mental Health Logistic Division and supplied facilities Section under the the psychotropic medicine to Epidemiology and Disease the health facilities where the Control Division and program is being implemented. contributed in drafting guideline of rehabilitation service, annual plan and budget of the next fiscal year 2019/2020

4.3 Rights-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 5038 2853 7891 17,412

*Total for the F M How did they participate? reporting period includes: A. Girls 1171 Girls participate in the group activities in mental health orientation, self-care and prevention fainting (mass fainting). 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 3590 In Self Help Group around 70% are women and out of them 15% are dalit. C. Persons with 33 36 The people with physical disability and blind is disabilities also participating in project activities. The project is trying to bring people with mental health problems and physical and other forms of disability together and they are coming out to visible and raising their voice to promote mental health and disability movement. They have become able to organize meeting and approach with reason to local level 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. E. Indigenous 1522 1061 Around 20 – 25% persons with mental health peoples and problems who are in Self Help Groups are from ethnic minorities the indigenous and ethnic minorities. They are participating in awareness-raising and advocacy at local level. F. Dalit 633 383 13% beneficiaries are from the dalit communities G. Other (Brahmin, 2606 1686 Cheetri and Others):

5. Project management

5.1 Roles and responsibilities There was no change in the project management structure and overall program is managed as per the project organogram presented with the project plan. CMC-Nepal was the main implementer of this project. Mental health coordinator and psychosocial coordinator were made responsible for overall implementation, monitoring, supervision, coordination and reporting of the project through the mobilisation of MHSW. There was one MHSW for Rasuwa and Okhaldhunga, one for Morang and Udayapur and ½ in . MHSW was made responsible for the local level coordination, empowering SHGs, providing psychosocial support activities and reporting of the project activities of the districts. The mental health and psychosocial coordinator was responsible for training and supervision of the prescribers and non-prescribers and building capacity of MHSW in mental health, psychosocial approach and social mobilization. Monthly team meetings, quarterly review meeting and half-yearly review meeting was inbuilt in the project which helped to discuss plan, share progress and review the achievement of the project activities.

There is only coordination role of Health Office located in the districts and CMC-Nepal has mainly engaged to the local level in review and planning and monitoring of the project activities. The health coordinator of the respective (rural) municipalities is involved in such activities. The representatives of SHGs have been also involved in planning of group activities and engaged in awareness campaigns, seeking mutual support with the DPOs to promote mental health and lobby with the local level for addressing mental health and psychosocial needs of the people with the mental health problems.

5.2 Cooperation and coordination with other organisations / institutions in the area

CMC-Nepal contributed largely to organize international mental health conference, which was conducted in February 2018 and child and adolescent’s mental health conference in November 2018. The main organisations and institutions working in mental health and psychosocial field were activity involved in organizing such events in the leadership with Ministry of Health and Population.

6. Finance Report The total expenditure of the project was NPR 11,227,898 in this reporting year. CMC-Nepal has received the funds on time in quarterly basis and the total funds received in this year was NPR 10,156,854 (including 150,837 for the research project). The self-financing from CMC-Nepal was NPR 82,377, which was used to partly cover the rental cost of central office. CMC-Nepal has utilized almost available budget (99% of total budget available) and the closing balance of the year 2018 is only NPR 14,170.

Tear Australia is a single funding agency to support in this project. CMC-Nepal has implemented same nature of the project in other four districts in funding support of Felm.

Some of the project activities i.e. mental health orientations at schools, follow-up with Self-Help Groups in the forms of the meeting and mental health training to the paramedics were cancelled due to the not availability of sufficient funds to manage those activities. There was no investment in purchasing of capital from the funding received from Tear Australia. The updated List of Staff showing the names, titles and Tear Australia's sharing of funding of the total personnel cost of each person is given in annex- 1.

7. Updated Risk Assessment

Type of risk A. B. Total What are the risks? Describe. Likeliho Impact (AxB) od Also, comment on the numbers given. 1-not 1-no likely impact, 2-low, 2-low, 3- 3- medium, mediu 4- m, considera 4- ble conside 5-high rable 5-high A. Project Internal Risks: Project 2 2 4 The transfer of the prescribers and non- implementation and prescribers in this reporting year was risk quality of work3 to the continuation of the service to the right-holders. Due to not enough qualification and practical experiences of trained health workers of in dealing with people with health problems affected in provided quality service. And there was no further health worker to train and develop.

There was a risk of not attending regular meeting by the representatives of the district level network of SHG of Dadeldhura due to not able to cover the travel and accommodation cost by themselves. CMC-Nepal supported to organize two such events and remaining events could not happen in their own expenses. Project management 2 2 4 Planning, implementation, monitoring and 4 reporting is followed as per plan. No significant risk has been observed. Organizational 1 1 1 A pre and post project activity preparation administration and and debriefing meeting was continued in culture5 the project.

3Incl. sustainability of results, targeting the vulnerable, participation, equality of opportunity, relevance, skills and expertise, not increasing workload of beneficiaries, not causing dependency, coordination etc. 4Incl. planning, monitoring, evaluating, learning, meeting deadlines etc. 5Incl. decision-making, transparency, participation, equality, learning organization, making adjustments to plans, cultural and conflict sensitivity resolving conflicts etc.

Sharing and reporting of events in line with communication protocol is in place.

MHSW are based in project district and they are invited in the six-monthly review and planning meeting. Even, CMC-Nepal provided opportunity to the MHSW to participate in international mental health and international child and adolescent’s mental health conference. There is system established in CMC to listening staff’s emotions and difficulties Financial 2 2 4 There is improvement in collecting administration6 supporting documents from the field staff than the previous years. The supervisor and finance team members were in regular contact with the field staff and reinforced to collect such documents.

An internal audit and external audit is place and that has helped to improve the internal control system. Resources7 1 1 1 Project staffs are comparatively well equipped with necessary materials, including computer and travel gears. There is no specific risks and impact observed. Action to prevent or mitigate future risks? (Must be filled for all issues that amount up 6 or more in total risk level): B. Project External Risks: Political situation, 2 1 2 There was no significant risk observed working with (rural) municipalities. Status of the civil 1 1 1 There is no significant risk and impact society / church observed. organizations Changes in 2 2 4 The administration legislation, or office asked the recommendation letter for requirements of the renewal of CMC from all the working registration, (rural) municipalities. It took more time permits etc. however CMC succeeded to collect the letters and renewed CMC as usual. Financial /Global 2 1 2 There was no risk observed in the fiscal situation implementation of project in year 2018. We received committed fund from TEAR Australia. Physical 1 1 1 There was not significant impact observed environment and at project beneficiaries and project climate implementation due to the effects of

6Incl. transparency, accuracy, documentation, segregation of duties etc. 7Incl. all financial support, staffing levels, equipment and assets, time, facilities etc.

natural calamities and climate change effect. Other related actors 1 1 1 The rights holders and duty bearers both and stakeholders accepted the CMC-Nepal working strategy of right based social mobilization approach and building access of mental health and psychosocial service. So, there was no risk observed working with the rights holders and duty bearers. Action to prevent or mitigate future risks? (Must be filled for all issues that amount up to 6 or more in total risk level):

8. Sustainability

Areas of sustainability How is it ensured in the project? What are the main challenges? What should be done differently to overcome these challenges? What changed during the reporting year? Economic/financial This program promotes mental health wellbeing and contribute to prevent mental health problems through closely working with families, communities’ groups, service providers and direct rights holders. Around 65% of total diagnosed mental health problems have been treated and recovered from the mental illness. Economic burden caused by mental health problems has been reduced and the family members have been gained opportunity to continue household and economic empowerment activities. Apart from this, 75% of total recovered people have been engaged in income-generating activities and contributing for families. The involvement of family members and recovered people having mental health problems indicates the regain of economic performance and thereby contributes for the economic sustainability at individual and family level.

Through the close coordination and regular sensitization of the elected representatives and government officials of the local level, 75% of the (rural) municipalities have supplied the psychotropic medicine up to 45% of total demand and they have agreed to increase the budget in mental health. CMC-Nepal is constantly working with people with mental health. The increasing trends of the supply of the psychotropic medicine from the local level has reduced the burden of purchasing of the medicine by the people with mental health problems and their family members. Institutional Government health workers working in project health facilities have been capacitated through training, regular clinical backstopping and distance coaching. At least two health workers have been developed as a prescriber and one health worker as non-prescribers in each project health facilities. The trained health workers working previously in project health facilities, have been transferred at local level as a health coordinator. Their placement at local level has contributed to allocate the (rural) municipalities level budget in mental health for awareness campaigns and psychotropic medicines. As explained above, there is increase trends of allocating budget in psychotropic medicine and awareness campaigns. The Chaundagadi Municipality of Udayapur, Belbari Municipality of Morang and Amargadhi Municipality of Dadeldhura allocated budget first time for the mental health training for prescribers and used it through sending health workers in the training. Socio-cultural The regular engagement of CMC-Nepal in creating awareness has brought positive attitude and change in behaviour of community people towards people with mental health problems. The change in attitude and supporting behaviour has gradually reduced social stigma, domestic violence and isolation of the people with mental health problems. People with the mental health problems and their families have attended regular meeting of the SHG, group sessions and other programs and there is culture established to respect each other human rights.

Trained health workers, FCHVs, mother groups, teacher, students and stable mental health survivors have increasingly involved in promotion of mental health well-being and prevention of mental health problems in the community. There is a significant change in service seeking attitude of community people. Almost 50% people with mental health problems have been referred in this year from FCHVs, SHGs, CPSWs, teachers and students.

The social mobilisation approach has helped to the people with mental health problems and their families and community to stand in solidarity to raise the voice for the rights and inclusion of persons with mental health problem and their treatment. This has further helped in finding local resource for psychotropic drugs for treatment and creating awareness at local level for de-stigmatization. The social mobilization approach has included social and cultural values to work with local communities to establish the ownership and sense of responsibilities in sustaining mental health services and community-based rehabilitation of person with mental and psychosocial disabilities. . Environmental This program does not directly address the environmental issues but closely works with the health workers and SHGs to create positive environment in family and communities. Political/legal The regular interaction and involvement of elected representatives and health coordinators of the local level in the project monitoring has created positive vibe in project implementation and sustain mental health work implemented. The level of understanding on the need of (rural) municipality wise action plan on mental health and psychosocial field is increased. They seemed committed to prepare such action plan and include it in the overall (rural) municipality plan and budget.

9. Challenges in Project Implementation

As explained above in outcome chapter, 75% of the (rural) municipalities have supplied psychotropic medicines and this covers only 45% of total demand of psychotropic medicine in a year. Likhu rural municipality (Okhaldhunga) and three municipalities of Rasuwa did not supply the medicine despite hard efforts made from series of meetings and interactions. Their reluctancy to supply the medicine might be due to the first year of the practice of federal system and not direct budget heading available in mental health. Even other municipalities have started to supply the medicines, it was not sufficient for all patients for whole year. CMC-Nepal has to further lobby with the elected representatives and increase the supply of the medicine in the next year.

CMC-Nepal conducted bilateral meeting along between the DPOs and SHG and joint meeting among them with the duty bearers i.e. (rural) municipality and health service providers. These meetings supported the SHG to recognize as psychosocial disability group. DPOs has provided space to them and showed commitment to support the SHG in raising mental health and psychosocial awareness and work together in promote mental health through sharing available budget they have received from (rural) municipalities in disability chapter. DPOs further helped SHG to make their disability card but because of blindness, hearing problem (deaf), it was difficult to listen their general issue and emotional difficulties in group while had group meeting. This challenge was managed somehow in few places with support of translator. However, this needs to be consideration in future and addressed so that all the participants included the people with physical and other forms of disability equally participate and contribute in the meetings.

There is increased burden of mental illness and loss of functioning in every day because of mental illness. There is progress in daily functioning after the treatment of mental illness and economic burden has been gradually reduced after the involvement in income generating activities. CMC- Nepal should focus its activity in creating awareness on the effects of mental health problems in the work performance and economic burden, increase referrals and encompass the mental health care and support from the family members and community people.

There was time line for 'effectiveness of program' research which we had planned before October. This year there was heavy raining and landslide in our project district. However, we had accomplished the planned activities but because big flood in river and landslide in the project site, it was difficult to reach in destination. There was also high risk to across the river and landslide fortunately nothing happened.

In new structure of local government, some rural (municipality) have already drafted and finalised the guideline in regard to enlist local community-based organisations like SHG, whereas some rural (municipality) are in process to draft it. It was easy to enlist or register the SHG in rural (municipality) where guideline is finalised but it was difficult to register where guideline line is not yet finalised. However, the concerned official of these municipality assured that once after finalise the guideline they will register the SHG and support them accordingly.

Section C. Monitoring and Evaluation

10. Project Monitoring Project monitoring was conducted at three different levels i.e. activity, outcome and impact level. Activity level monitoring was conducted in quarterly basis whereas outcome level monitoring was conducted semi-annual and annual basis and impact level monitoring was conducted in annual basis. A joint monitoring for outcome and impact monitoring was conducted with representation from the NCD and Mental Health Section of Department of Health Service, local level duty bearers, concerned right holders and CMC-Nepal. International Program Officer from Tear Australia was also involved in project monitoring visit in this year.

CMC-Nepal conducted 2-3 events of mental health clinical and psychosocial supervision in all health facilities in this reporting year, following supervision protocol and guideline on the basis of project logframe. The knowledge and skills of trained health workers was monitored through case supervision (paper case and real case) and observation of the case documentation.

Monitoring report from team/person involved was collected and organized debriefing meeting. Based on the feedback, the concerned project team members and senior management has taken necessary actions to address the issues highlighted by monitoring team.

Data regarding persons who received mental health and psychosocial service is collected in every three months by MHSW in technical guidance of the mental health and psychosocial coordinator Register is provided to each health facilities to record the clients who received mental health and psychosocial service. Data is disaggregated as age, gender, ethnicity and diagnoses. Data information was documented and compiled then stored in excel for retrieval of data as required.

Semi-annual plan of action was prepared based on the logframe presented in the project document and planning meeting organised in January and July 2018. Based on the activity plan, two coordinators monitored the progress from analysing the quarterly report submitted by MHSW. There was practice of organising quarterly review meeting at project level, where we monitored the progress and financial situation of the project and documented the progress and prepare further plan if targets by that were not achieved. The financial report is prepared in quarterly basis and submitted to the financial partner. Likewise, CMC-Nepal also prepare progress report in semi- annual and annual basis and submits to financial partners.

The information from the monitoring is used to evaluate the effectiveness of project activities and its impact at duty-bearers and right-holders. The learning from the project monitoring is capitalized in revision of project planning, strategy and overall project management to make the program more effective.

11. Reviews and Evaluations In consultation with and after the approval from Tear Australia, CMC-Nepal conducted evaluation research to find out the effectiveness of the project deliveries i.e. training, supervision, awareness activities and SHG initiatives, instead of carrying out the evaluation of the project.

It was the cross sectional study following comparative methods where data were collected from different clusters of project beneficiaries such as health workers trained in mental health and psychosocial support (n=43), mental patient received treatment from project implemented health facilities and control sample were selected from the health worker who have no training in mental health and psychosocial support (n=25) , mental patient visited first time in health facilities for treatment and patient having general health problems and are receiving treatment from the health facilities but not mental health service. Mental health and psychosocial training pre and post-test questionnaire were used with health workers to assess mental health knowledge and competency modified CIDT, WHO-DAS and service satisfaction forms were used in FGD with mental health self-help group and control sample of community member KII used with the HFOMC members and municipality leader and district health officer. Research tools used in the evaluation research have been adopted in Nepalese population already (CIDT, WHO-DAS, service satisfaction form, KII and FGD questionnaire) in other research studies thus have shown adequate validity.

The finding of the research revealed that the trained health workers have been actively engaged in delivery of mental health services. Training contents in mental health is reliable and relevant as there is statistically significant mean difference observed in pre-test to post test score and post- test to evaluation test score among the trained health workers than control sample. The difference was highly significant between two groups. and it further indicates the effectiveness and relevance of training content in mental health. Similar result observed in psychosocial support training in pre and post training score while it was a rather decline trend observed in the evaluation test score though it was not significant. Item analysis of psychosocial support pre-post questionnaire revealed less effective in measuring psychosocial knowledge and skill competency, thus recommended to revise the test tool for future. The competency in detecting mental health problems and provide treatment in trained health workers were compared with psychiatrist diagnosis and treatment. The findings of the competency of health workers has revealed that they are better skilful in detecting the common mental health problems such as psychosis, depression, anxiety and epilepsy but not effective in the case where there were comorbid condition such as anxiety and depression symptoms, depression and psychosis symptoms. They were rather entertaining symptom-based diagnosis which was later corrected by psychiatrist during clinical supervision time. Health workers were able to prescribe right medicine but not able to adjust dose as per the progress observed in the client. It is mainly due to either inadequate clinical supervision or lack of confidence to adjust dose of drug considering clinical progress in the patient.

There was increased level of awareness on mental health service availability in intervention group (42.9%) than control (26.9%). It has direct impact in service seeking attitudes because higher amount of mental patient in control group still depends on traditional healers' treatment than mental patient of intervention group (14.8% vs 3.3%). Daily life functioning level of mental patient measured from WHO-DAS and result showed less significantly impairment in the daily life functioning of patient in intervention than the control group patient. Mental patient in intervention group received support for treatment mainly from family and self-help group members. There is increased burden of diseases due to loss of functioning ability in every day in the control group mental patient than treated one (intervention). This shows the relevancy and effectiveness of the activities of CMPHPSP at community and higher level. CMHPSP activities resulted increased awareness on common mental health problems in community as result showed

much higher level of awareness in intervention population than control group. This include case detection based on symptoms, impact of mental illness in the daily life of patient, treatment need and support in treatment. So, community people are demonstrating supportive attitude to mental patient, encouraging family for treatment in health facilities which was observed much less in control population. The detail report of this research has already been shared to the Tear Australia.

The recommendation from the research was taken consideration in development of next phase especially in strengthening capacities of health professionals through increasing involvement of the psychiatrist in order to support them in management of the cases with comorbid symptoms as explained above. Further consideration is given to increase awareness in child and adolescent’s mental health issues and address treatment in order to prevent and promote mental health well- being of the children and adolescents. Activities will be designed to support in building resiliency of the vulnerable group such as children, people living with physical disability, women and old age people (refer the detail report, which was submitted in November 2018).

Section D. Lessons learned & future plans

11. Lessons learned The main lesson learning during the reporting year was as follows.

• The right based social mobilization approach has been effective to protect, increase respect and fulfill the human rights of the people with the mental problems. The mobilization of SHG in creating awareness and refer the cases at health facilities seems effective approach to increase patients flow in health facilities. The involvement of SHG members in review meeting with the (rural) municipalities and joint meeting with service providers has created pressure to allocate the budget and recognized the need of mental health in local level. The joint meeting with DPOs and collaboration at local level has brought positive impact at local to promote mental health.

• The regular involvement of the psychiatrist is needed to build the confidence of health workers for proper diagnosis and treatment. The health workers have been motivated from the regular field level clinical supervision organized at health facility level. The flow of the patient has been increased after the regular involvement of psychiatrist at health facility level.

• Media orientation is necessary to give pressure to the local elected bodies to include mental health activities in their plan.

• The regular interaction and advocacy at local level is important to sensitize local government and politicians in mental health and psychosocial issues. With ongoing contact and collaboration with (rural) municipality, it was possible to sensitize them in mental health and psychosocial issues. The previously trained health workers have been transferred to the (rural) municipalities after the new federal structure practice in Nepal. It has been easy to work with them due to the previous background of working as a prescriber in the project health facilities. The past experience working as prescribers has incredibly supported to approach at local level to allocate the budget from the local level plan for mental health awareness campaigns, psychotropic medicine and livelihood support. It has been easier working with local level on mental health & psychosocial field than the district level structure of the public health system.

• The level of confidence has been increased from the regular counseling service provided by MHSW and constant coaching from the psychosocial and mental health coordinator. The involvement of MHSW in providing psychosocial counselling service jointly with the trained ANMs has also increased motivation of trained ANMs. It has been also cost effective to develop the MHSW as a psychosocial counsellor and involve them in order to provide support to the ANMs in delivering psychosocial counselling service. The group sessions provided by the MHSW at community level and individual psychosocial counselling service through home visits seems effective community- based model of providing psychosocial counseling service.

12. Future plans CMC-Nepal has developed another three years proposal to continue mental health and psychosocial work in Nepal and this has been approved by the Tear Australia. It will continue program activities in Udayapur and Okhaldhunga districts and expand the program in Surkhet and Jajarkot districts. There will not be such big change at program strategy and activity level; however, there will be some changes at the activities level based on needs of local level. CMC- Nepal has added the component of suicide prevention based local needs and this will be only focussed in Surkhet and Jajarkot districts. CMC-Nepal will sign Memorandum of Understanding directly with the (rural) municipalities and will be made them responsible to contribute the budget in program implementation. CMC-Nepal will focus its activities at local and provincial level and conduct regular advocacy and lobby for mainstreaming mental health into the existing health care delivery system.

It will further focus on capacity building of Self-Help Group for their independent functioning in the (rural) municipality, make (rural) municipality level network of SHG and enlist them in the concerned (rural) municipality, an important step towards sustainability of mental health and psychosocial service, rights and inclusion of persons with mental and psychosocial disabilities. CMC-Nepal will be in contact to the SHG of the exit districts (Rasuwa, Morang and Dadeldhura) and trained health workers and will support from the distance. It will further explore the possibility of bi-lateral MoU between (rural) municipality and CMC-Nepal in those districts to strengthen mental health and psychosocial service and capacity of SHG and conduct activities accordingly with not having budgetary implication in the existing project.

Section E. Project Highlights

This program has been successful in creating mental health and psychosocial awareness and increasing access of mental health and psychosocial service in the project areas. Twenty-two health facilities have been performed well through integrating mental health and psychosocial service into the existing health care delivery system. There is at least two prescribers and one non- prescriber available in each project health facility and they are providing mental health and psychosocial service. The level of understanding of the concerned (rural) municipality on the need of mental health and psychosocial service has been increased; started to allocate the budget for the psychotropic medicine, mental health camps and awareness raising.

The existence of SHG has been visibly accepted by the (rural) municipalities and health service providers. Eight SHG is better functioning and remaining others needs minimal support from the CMC-Nepal in their organisational development and strengthen advocacy capacity for their rights. The collaboration with DPOs is really encouraging in most of the (rural) municipalities and journey in mental health movement in collaboration makes really meaningful to protect, respect and fulfil the rights of the people with psychosocial disabilities.

Signature:

Name: Ram Lal Shrestha

Position: Executive Director

Date: 8th March 2019

Annex – 1 CMC-Nepal Staff List (Updated on 31st December 2018)

Project Name: Community Mental Health and Psychosocial Support Programme S.No Staff Name Sex Designation Employed in % of salary CMC shared by Tear Australia 1 Ram Lal Shrestha M Executive 18/08/2003 30% Director 2 Bishnu Prasad Prajapati M Mental Health 14/08/2007 60% Coordinator 3 Rajesh Kumar Jha M Psychosocial 01/06/2010 60% Coordinator 4 Indira Pathak F Admin/Finance 04/02/2005 30% Officer

5 Srijana Shrestha F Administrative 16/07/2012 50% Assistant 6 *Shree Krishna M Driver cum 18/08/2003 25% Shrestha Assistant

**Rup Sunder Shrestha M Driver cum 05/04/2018 25% Assistant 7 Ram Chandra Maharjan M Office Assistant 18/08/2003 50% 8 Dharma Kumar Rai M Security Guard 17/10/2004 50% 9 Alsoda Rai F Social Mobilizer 01/02/2014 100% 10 Ramita Shrestha F Social Mobilizer 01/01/2014 100% 11 Anat Chaudhary M Social Mobilizer 01/02/2014 50% 12 ***Bishnu Rai F Office Helper 01/01/2016 50%

* Shree Krishna Shrestha was retired on 31st March 2018 ** Rup Sunder Shrestha was employed in place of Shree Krishna Shrestha in CMC effective from 5th April, 2018 *** 50% salary of Bishnu Rai was charged until June 2018.

Total: Tear Australia's Share: Male 7 (58%) Male 3.25 (50%) Female 5 (42%) Female 3.30 (50%)

38 Annex – 2

Success Stories

Counselling through home visits brought happiness in the life of Rama

Rama (name changed) is a 30 years old woman, living in Rasuwa, one of the Himalyan district of Nepal. Since last six months, the family members observed abnormal symptoms and behaviour of Rama. She used to cry, feeling lonely, no eagerness to do household chores, not showing interest to talk with anyone, irritation, didn't care about self-hygiene and around the house and feeling weakness. She seemed more stressful due to the weak financial situation and daily hand to mouth problems. She showed her stresses and anger with her children.

3 years ago, she was living happily with her family members (husband and two daughters) though she had to engage in labour work to earn money. In 2015, the mega earthquake collapsed their house. Fortunately, there was no physical damage of the lives of the people. After the earthquake, their life became more harder than the before to survive. Her husband also had to work hard and used to leave home early morning for labour work. He met another woman at work place and they each other fell in love. When Rama knew love affairs of her husband with another woman, there was family dispute and even quarrel between husband & wife. After this incident, Rama left the home and went to her mother's home to live. The woman to whom her husband was in love affairs was also married and it was not possible for them to marry again. So, they both committed suicides together. Rama did not cope this incident and gradually symptoms of mental health problems developed in Rama's health.

One day, MHSW of CMC-Nepal got chance to meet Rama with the help of SHG members, while doing home visit. MHSW assessed her mental health situation and talked with her relatives about her treatment. MHSW informed to Rama about the monthly clinical supervision of the psychiatrist in nearby health facility (Jibjibe PHC). She was eager for her medication and met psychiatrist in PHC for her treatment. Psychiatrist diagnosed her depression and medicine was provided. The psychiatrist further recommended for the psychosocial counselling. MHSW provided also five counselling sessions through home visits. During the counselling sessions, MHSW provided life skills, encouraged her to think positive, being an important member of this community and motivated her to bring willingness to do something for the society. All these tips during the sessions helped her to bring the courage back and live life happily. After the regular follow with the psychiatrist, regular medication & counselling, her depressive symptoms minimized. She also involved in the SHG, attended meeting and group sessions. At present, she is working as an active member of the SHG.

Rama built a small house from the earthquake relief fund. She is now happily living with her children and doing her household chores & looking after her children and farming.

39 Untreated 15 years of mental illness cured at local health facilities

A resident of Ajaymeru-3 VDC, Dadeldhura district, named Hira Lal Shah (name changed) with the age of 35 years old lives with 65 years old mother & 67 years old father. When he was at age of 20, he started sitting alone & showed aggressive behaviour. However, the family members ignored his behaviour and did not pay any attention why he is showing such behaviour.

He gradually showed aggressive behaviour to other as well and even started to beat others whatever he gets nearby. He ignored his self- hygiene, wandering here & there and murmuring. After this, his family went to traditional healer for the assessment and treatment of that illness but the problem didn't decrease at all, instead it increased further more. His family brought him to Bareli, India (The residents of west Nepal often visits Bareli for the treatment) for the treatment. The psychiatrist diagnosed him psychotic and provided medication. Due to poor economic condition, his family did not able to bring him in the follow-up and even they discontinued medication. Hira Lal’s mental health wellbeing did not improve and he remained untreated in the past 14 years.

While visiting the orientation program in Chamada School, Tej Bahadur Ayer who was the local teacher and working in the field of disability, visited Hira Lal’s house and suggested his parent to bring in the Chamada health post for the assessment and treatment of mental health problems. The trained health took detail assessment on his mental health situation, diagnosed mental illness and started medicine. The family members become surprised that the treatment of such illness can be done in their PHC. At beginning, the family members were reluctant to take medicine. The trained health worker explained that many people have received treatment from that PHC and are living their life happily. Afterwards they agreed to take medicine and provide better care during the treatment period. After the caring behaviour of 15 days, & regular medication, there was improvement in his mental health wellbeing. The improvement in Hira Lal’s mental health situation motivated their parent for the regular medication and realised the need of regular medication in treatment of mental illness. MHSW of CMC-Nepal visited regularly to their parent and Hira Lal and provided psycho-education in each home visits.

Nowadays, Hira Lal has gradually started to engage in household activities and he support his parents to graze goats nearby forest. He also providing support in farming and other household activities. He has started to care his self-hygiene. After one year of regular medication, his 65 years old mother shared her happiness that such illness cured in one-year time. Hira Lal is now helping in farming, cattle grazing and other activities. Her mother further added that he takes medicine regularly by himself and take care of his own hygiene. Hira Lal is now joined SHG and attend SHG meetings regularly.

These stories were translated by CMC-Nepal’s staff.

40

Annex-3 Highlights of 3 years project intervention and outcome Intervention/Outcome Year Year Year 2018 Total Remarks 2016 2017 2016-2018 No of health workers trained in 14 49 21 84 45 HWs are mental health (prescribers) still available No of medical received mental 12 47 44 103 7 MO are still health training/continued providing medical education service No of paramedics and nurses 14 - 65 79 received continued medical education No of health workers trained in 14 20 11 47 33 are psychosocial counselling health available at (non-prescribers) present to provide service No of SHG members received 12 86 - 98 basic mental health and psychosocial support training No of people received mental 1136 1854 1840 4830 health service (new) No of people received mental 1298 1189 2270 4757 health service (old) No of people direct mental 376 710 1304 2390 health service from psychiatrist during mental health clinical supervision No of people received 253 (193 288 (244 256 797 psychosocial counselling Female) female) service (new) No of people received 31 (22 74 (68 95 200 psychosocial counselling Female) female) service (old) No of people received direct 68 52 70 190 psychosocial counselling service during supervision No of health facility operation 378 42 263 883 management committee (HFOMC), local government officials and stakeholders sensitized in mental health issues People with mental health 483 304 410 1197 problems and their families (316 female) (181 female) (281 female) (778 female) received mental health information No of students received mental 1151 1334 709 3194 health orientation (682 girls) (706 girls) (421 girls) (1809 girls) No of FCHVs received mental 170 146 21 337 health orientation No of members of mother 688 498 802 1988 groups/cooperative received mental health orientation

41 No of traditional healers - 24 82 106 received mental health orientation No of SHG formed 11 4 4 19 3 SHG were formed before 2016 No of people with mental health 120 62 153 335 problems and their families in (85 female) (34 female) (106 female) (225 female) SHG No of people with mental health 2 7 7 16 90% have been problems received livelihood engaged in support income generating activities Percentage of Local 15% (30% 45% (40% 75% (45% level/district health office of total of total of total supplied psychotropic medicine demand) demand) demand)

42 PHOTOGRAPH

Mental health clinical supervision Home visit

CME for Medical Officers Meeting/Orientation with HFOMC

Mental Health Training Self Help Group Meeting

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