UNITED NATIONS HIGH COMMISSIONER FOR REFUGEES EVALUATION AND POLICY ANALYSIS UNIT
Refugee health in Nepal
Joint UNHCR-WHO evaluation of health and health programmes in Bhutanese refugee camps in Nepal
Muireann Brennan, Oleg Bilukha Marleen Bosmans, B.R Dahal, EPAU/2005/04 Kandarpa Chandra Jha April 2005 Evaluation and Policy Analysis Unit
UNHCR’s Evaluation and Policy Analysis Unit (EPAU) is committed to the systematic examination and assessment of UNHCR projects, programmes, policies and practices. EPAU also promotes rigorous research on issues related to the work of UNHCR and encourages an active exchange of ideas and information between humanitarian practitioners, policymakers and the academic community. All of these activities are undertaken with the purpose of enhancing UNHCR’s capacity to fulfill its mandate on behalf of refugees and other people of concern to the organization. The work of the unit is guided by the principles of transparency, independence, consultation, relevance and integrity.
Evaluation and Policy Analysis Unit United Nations High Commissioner for Refugees Case Postale 2500 1211 Geneva 2 Switzerland
Tel: (41 22) 739 8949 Fax: (41 22) 739 7344
e-mail: [email protected]
internet: www.unhcr.org/epau
All EPAU evaluation reports are placed in the public domain. Electronic versions are posted on the UNHCR website and hard copies can be obtained by contacting EPAU. They may be quoted, cited and copied, provided that the source is acknowledged. The views expressed in EPAU publications are not necessarily those of UNHCR. The designations and maps used do not imply the expression of any opinion or recognition on the part of UNHCR concerning the legal status of a territory or of its authorities.
This evaluation report is one of a series of three health evaluations conducted in late 2003 among refugee populations. The purpose of these evaluations is not only to improve health service delivery to those populations, but also to act as pilot evaluations for a broader "Inter-agency Health Services Evaluation in Humanitarian Crises" initiative. This initiative was launched by a group of non-governmental organizations, UN agencies, and academic institutions, and was stimulated by the lack of coherent, routine evaluations of the health of affected populations in crises. It has received funds from the US Bureau for Population, Refugees, and Migration. The experience of these evaluations will inform the development of a standardized health evaluation framework for use in responding to humanitarian crises.
Table of Content
Executive Summary and Recommendations...... 1 Main observations...... 1 Major recommendations ...... 2 Introduction...... 3 External Context...... 3 Internal Context...... 3 Methodology ...... 5 Evaluation Team Composition...... 5 Camp Selection ...... 5 Quantitative Methods - Health...... 5 Quantitative Methods - Nutrition...... 6 Qualitative Research - Sexual and Reproductive Health...... 6 Qualitative Methods - Nutrition ...... 7 Findings and Recommendations ...... 9 Demographic Data...... 9 Crude and Under-five Mortality Rates ...... 10 Other Selected Mortality Rates...... 11 Verification of mortality reporting in Beldangi I...... 12 Morbidity...... 14 Quality of Health Service Delivery...... 16 Basic Health Units ...... 16 Primary Health Care Centres (PHCC)...... 18 Specific Health Programmes and Cross Cutting Issues ...... 19 Communicable Disease Control...... 19 Extended Programme on Immunisation (EPI)...... 20 Mental health ...... 20 Essential Drugs and Supplies ...... 20 Health Education...... 20 Chronic Diseases ...... 21 The Health Information System (HIS)...... 21 Nutrition...... 21 Annual Nutrition Surveys - Major Trends...... 21 Methodological Issues with Nutrition Surveys...... 22 Growth Monitoring ...... 23 Mass Nutrition Screening ...... 24 Supplementary Feeding Programmes...... 25 Therapeutic Feeding Programmes (TFP)...... 28 Distribution of General Rations and Food Basket Monitoring ...... 28 Micronutrient Deficiencies...... 29 Eating Habits and Attitudes towards Foods...... 31 Feeding of Infants and Young Children...... 32 Reproductive Health ...... 33
Overall Programme...... 33 KAP Survey...... 34 Reproductive Health Unit (RHU) ...... 34 Lack of Privacy, Confidentiality and the Proportion of Female Staff ...... 35 Family Planning...... 36 Antenatal Care, Deliveries, Abortion and Post-abortion Care...... 37 STI/HIV/AIDS Knowledge and Awareness ...... 39 Counselling and Treatment ...... 40 Sexual and Gender-based Violence ...... 41 Referral System and SGBV Prevention Programmes ...... 41 Information and Communication ...... 43 Attitudes toward Victims of SGBV ...... 44 Recognition of Polygamy and Domestic Violence...... 45 Early Marriage, Early Pregnancy and School Dropout...... 46 Sexual Education and SRH Provisions...... 47 Youth Programmes ...... 48 Interaction with MoH Services...... 48 List of all Recommendations...... 51
Conclusions and Major Recommendations...... 61 Major Recommendations ...... 61 Annexes ...... 63 Annex 1 Focus Group Instruments...... 63 Annex 2 Mission Timeline ...... 85 Annex 3 Proposed ToR for Consultants ...... 87 Annex 4 Nepal Evaluation Questionnaire Regarding Follow Up to Recommendations. 93 Annex 5: List of Acronyms
Executive Summary and Recommendations
UNHCR, together with its implementing partners (IPs), has been supporting health, nutrition, water and sanitation activities for approximately 100,000 Bhutanese refugees in the districts of Jhapa and Morang in south-eastern Nepal since late 1990. UNHCR is to be congratulated in its commitment to the delivery of services to these refugees in an increasingly difficult environment. The joint evaluation team would like to thank UNHCR, the IPs, UN agencies, particularly WFP, Ministry of Health (MoH) staff and the refugee community for the assistance received in conducting this mission.
Currently, crude and under-five mortality rates among Bhutanese refugees are considerably lower than those of the surrounding population. In general, access to curative health services is better for the refugee as compared with the host population. However, despite distribution of an adequate general ration, nutrition indices for the refugees are not markedly different to those reported in the DHS (Demographic and Health Survey) of 2001 for the local population.
The joint evaluation identified some health and nutrition practices in the camps that are not in accordance with international norms and standards. These practices pose a threat to the health of the refugee community, and may also negatively affect the health of the local community. If the eventual aim is to integrate refugees who remain within the national health system, these practices must be corrected before any handover takes place.
Main Observations
The level of qualification of staff at the pre-hospital level is low. There are no standardized case management protocols (such as the Integrated Management of Childhood Illness – IMCI). Sexually transmitted infections (STIs) are being incorrectly managed. There have been mass discharges of children from the supplementary feeding programme (SFP) at lower than recommended weight-for- height. The therapeutic feeding programme (TFP) is inappropriate, and there is no nutrition counseling for mothers of growth faltering children. Despite the recent focus on sexual and gender-based violence (SGBV), there is no programmatic approach to this issue. There is confusion between the need to assure confidentiality for the victims of SGBV and the need to base interventions on an in-depth understanding of the underlying problems. In general, although different health and nutrition activities are being implemented in the camps, there is an absence of integrated programmatic approaches.
The joint evaluation team considers that these problems have arisen despite the desire of both UNHCR and its implementing partners to provide the best service possible to the refugees. The factors that have contributed to the current problems are: a lack of financial resources on the part of UNHCR Nepal; the handover of health and nutrition services, in January 2001, to a local NGO with little experience in public health programming; and the lack of oversight, on the part of UNHCR, by an experienced public health coordinator.
1 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Major Recommendations
1. UNHCR should replace the implementing partner with a more experienced NGO. 2. If it is not possible to replace the current IP with one with more public health experience, the IP's capacity must be improved in three key areas: a) IMCI; b) nutrition; and c) reproductive health/SGBV. This should be done through three consecutive consultancies of no less than two months each, in each of the three areas. A key activity of these consultants would be to work alongside the main IP and UNHCR field staff in order to build capacity. The consultants should also begin looking at the integration of MoH and refugee health services and work closely with other IPs such as WFP, as well as involving other potential partners such as the MoH, WHO, UNICEF and UNFPA. 3. In time, following the above interventions, UNHCR could consider handing over these more efficient clinics to the MoH. 4. UNHCR should engage a health coordinator with experience in overseeing public health programmes in refugee situations. 5. UNHCR should consider the possibility of collaborating with UNFPA or another partner for the development of a comprehensive reproductive health programme. 6. UNHCR should have a designated focal point for reproductive health within the Community Services Unit (CSU). 7. UNHCR should ensure that a well functioning community mental health programme is in place prior to withdrawal. 8. The remaining funds in the evaluation budget should be used to reassess the situation before June 2004. The joint evaluation mission urges UNHCR to take advantage of this difficult situation and to make the handover of services for the refugees to the MoH a model for other situations and countries.
2
Introduction
External Context
1. This evaluation was conducted as part of a three-year inter-agency initiative, the Interagency Health Evaluations in Humanitarian Crises Initiative (IHE-HCI), with the aim to institutionalize health programme evaluations in humanitarian situations by developing a set of guidelines for carrying out future interagency health evaluations. United Nations agencies and organisations (WHO, UNHCR, UNICEF, and UNFPA), NGOs (Epicentre, ICRC, IFRC, IRC, Merlin and Oxfam) and academic institutions (Columbia University and the London School of Tropical Medicine) working in the humanitarian health and nutrition sector joined together to develop this initiative. Three pilot countries were chosen in which to begin the initiative, Nepal, Pakistan and Zambia. The Nepal evaluation was the first to take place from 12 September – 15 October 2003 in the Bhutanese refugee camps in Nepal.
2. In March 2004 the report was first made available in pre-publication to serve as a basis for discussion during an Inter-agency Health Services Evaluation Workshop hosted by UNHCR. In July 2004, a Project Coordinator was appointed to manage IHE-HCI activities, including following up on the outcomes of the three pilot evaluations.1
Internal Context
3. The influx of Bhutanese refugees into Nepal began in late 1991 reportedly due to strict enforcement of citizenship and immigration laws by the Bhutanese authorities. As of January 2003, 102,558 refugees living in seven camps have relied on donor assistance for basic needs because of limited opportunities for integration and restricted movement.
4. In January 2001, responsibility for health and nutrition services was handed over to a new implementing partner, a local NGO. In 2002, reports from Nepal indicated that the quality of primary health care (PHC) services had possibly declined. Funding constraints were implicated. Monitoring was scaled down and as the number of qualified UNHCR staff in the country fell, those left could not effectively monitor all refugee camps. Moreover, reduced funding levels for health care, water, sanitation and community services were alleged to have had a negative impact on services.
5. During 2002, problems with sexual- and gender-based violence (SGBV) were uncovered in the camps. As a result, several evaluation missions both from within UNHCR and from outside the organization visited the camps to investigate the issue. For this reason, the joint evaluation team was asked to pay particular attention to reproductive health, including SGBV, and an SGBV expert was specifically recruited.
6. The team was also asked specifically to examine referral practices in the camps. In light of an expected upcoming statement by the High Commissioner on the
1 Further details about the actions undertaken as a result of this evaluation can be found in Annex 4 Nepal evaluation questionnaire regarding follow up to recommendations.
3 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL planned disengagement of UNHCR from the refugee camps, the team was asked to look at the opportunities for, and implications of, integration of a substantial proportion of refugees into the existing government health system. The TOR for the mission is attached as Annex 3.
7. At the time of the evaluation, the existing health information system (HIS) reported a relatively stable population with acceptable health indicators for a community living in a developing country. Crude and under-five mortality averaged 0.34 and 0.6 per 1,000 refugees per month, respectively. Measles vaccination coverage was reported to be 98%, and there were on average 3.95 to 5.34 annual OPD consultations per refugee. Global acute malnutrition (GAM) ranged from 5 to 10%, and the food ration was 2,100 Kcal per refugee per day. Per capita water supply was reported to be 20 litres per day.
4
Methodology
Evaluation Team Composition
8. The evaluation team consisted of two consultants, Dr. Muireann Brennan and Dr. Oleg Bilukha, recruited by UNHCR from the Centers for Disease Control and Prevention who focused on health and nutrition; a consultant, Ms. Marleen Bosman, recruited by UNHCR from Ghent University, who focused on reproductive health and SGBV; Dr. B.R. Dahal, a member of WHO's Nepal country office and UNHCR's medical coordinator, who focused on MoH services; and Dr. Kandarpa Chandra Jha, from the UNHCR field office in Damak, Nepal.
Camp Selection
9. The team visited all but one of the seven Nepalese refugee camps. Khudnabari camp (population 12,876) was not visited owing to increased security concerns at the time of the evaluation. Beldangi I camp was selected for the most in-depth examination of health and nutrition programmes. The rationale for choosing Beldangi I was that it was easily accessible from a security standpoint; it had a reasonably large population (17,700), and that it was expected to be fairly similar to the adjacent camps of Beldangi I and Beldangi II extension. The total population of the three Beldangi camps was about 50,700, or approximately 49% of the total refugee population in Nepal. Basic health information was also collected from an additional five camps and meetings were held with camp health committees.
Quantitative Methods - Health
10. Detailed monthly health and nutrition reports generated by the Asian Medical Doctors Association's (AMDA) health information system, between January and August 2003 were reviewed. These were compared with results from the 2001 DHS for Nepal and 2002 data from UNICEF's State of the World’s Children. Data were compared with UNHCR indicators as well as SPHERE guidelines. General trends in mortality over time from UNHCR and AMDA yearly reports were also reviewed.
11. The evaluation team attempted to verify mortality data in Beldangi I for the time period January-September 2003. Line lists of deaths with data on name, age, sex, cause of death, and date and location, were obtained from the following sources and cross-referenced for discrepancies: AMDA (in Primary Health Centre), Lutheran World Federation (LWF), Refugee Coordination Unit (RCU), Nepali Red Cross Society (NRCS).
12. A survey of essential drugs, basic equipment, and staff qualifications and training was carried out in five Basic Health Units (BHUs): Beldangi I (2); Beldangi II (2); and Goldhab (1). Two government sub-health posts (equivalent to a BHU) were also surveyed. Surveys were also carried out in four camp health posts (equivalent to health centres) and one government health centre.
13. Exit interviews were conducted with twenty mothers of children under five years of age.
5 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
A community based survey was conducted in Beldangi I using systematic sampling. However, results are not yet available.
Quantitative Methods - Nutrition
14. The team consulted reports of annual nutrition surveys conducted yearly in the camps over the previous three years, these included the Nepal Micronutrient Status Survey of 1998 (NMSS); the Demographic and Health Survey of 2001 (DHS); a nutrition survey conducted in 1998 in Bhutanese refugee camps by the National Institute of Nutrition (NIN); Rome, Italy and the Catholic University of Louvain, Brussels, Belgium, and an anthropometric survey conducted by CDC in 1999.
15. Nutrition data from the HIS for the period January-September 2003 were reviewed in detail. Activities and supplementary feeding programmes in Beldangi I, Beldangi II and Beldangi extension were observed. Staff were interviewed and daily registered were also reviewed. Food distributions were observed in Beldangi I and II.
Qualitative Research - Sexual and Reproductive Health
16. Qualitative research methods were used primarily in the areas of sexual and reproductive health. Two semi-structured techniques were used: key informant interviews and focus groups. Key informant interviews on sexual and reproductive health were held with the following UNHCR staff members: Protection Officer; UNHCR Branch Office in Kathmandu; UNHCR Associate Protection Officer, Damak; UNHCR Community Service Officer, Damak; UNHCR Community Service Assistant, Damak; UNHCR SGBV Specialist, Damak; Several field assistants UNHCR, Damak.
17. Government: Department of Health Services; Deputy Director of the Refugee Coordination Unit (RCU); RCU Supervisor at Beldangi II; RCU Supervisor at Beldangi I. 18. International Organizations: UNFPA Deputy Representative. 19. Implementing Partners: Director and Deputy Director, Asian Medical Doctors Association (AMDA), Kathmandu; AMDA Local Medical Coordinator; Director, Metchi Zonal Hospital (referral centre for refugees). 20. Camp Workers and Beneficiaries: School teachers, Sanischare camp and Beldangi I; Bhutanese Refugee Women’s Forum, Beldangi I; Women’s Focal Point, Beldangi I; Bhutanese Refugee Children’s Forum, Beldangi I; MCH staff nurse and auxiliary nurse midwife, Beldangi I; Reproductive Health Unit Assistant, Beldangi I; Camp Management Committee, Beldangi I.
21. Eight focus groups were held in quiet locations in Beldangi I. (two focus groups each, with adult women, adult men, adolescent girls and adolescent boys).
22. Four adult focus groups (each with 6-8 participants) were selected by the Bhutanese Refugee Women’s’ Forum (BRWF) according to the following criteria:
• Adult men and women of reproductive age (15-49 years); • Families with living children;
6 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
• Representing different wealth groups and caste groups; • Residing in different sectors in the camp; • People involved in camp committees, as well as people that are not;
23. Four adolescent focus groups were selected by the Bhutanese Refugees Children’s Forum according to the following criteria:
• Adolescents males and females (15-19 years); • Residing in different sectors of the camp; • School-going as well as non-school going children and adolescents; • Representing different wealth groups (poor and better off, low caste and high caste).
Qualitative Methods - Nutrition
24. Key informant interviews concerning nutrition were held with Implementing Partners: AMDA local health coordinator; Nepalese Red Cross Society (NRCS) representative, Beldangi I.
25. Workers involved in Nutrition Programmes in the Camps: In charge of nutrition unit, Beldangi II and Extension camps; In charge of nutrition unit, Beldangi I camp; Food basket monitor in Beldangi I camp; MCH staff nurse and auxiliary nurse midwife, Beldangi I; Auxiliary nurse midwife, Sanischare camp.
26. Four focus groups concerning nutrition were held in Beldangi I. Two groups focused on nutrition in pregnancy and lactation, supplementary food rations, and breastfeeding and infant feeding. The other two focus groups discussed food ration distribution, food habits in the family, and attitudes and beliefs towards foods. The meeting-place was organized in such a way as to guarantee privacy. The four focus groups participants were selected by the BRWF and refugee schoolteachers according to the criteria below.
27. Group one - Infant feeding:
• Pregnant women or young mothers (15-35 years) with children under five years old: • Different caste groups; • Different wealth status.
28. Group two - Infant feeding:
• Young mothers only (15-35 years) with children under 5 years old; • Different cast groups; • Different wealth status.
7 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
29. Group one - General nutrition:
• Adult women with children (25-40 years); • Different caste groups; • Different wealth groups; • Persons actively involved in camp committees and persons who were not.
30. Group two - General nutrition:
• Adult men (4) and women (4) with children (20-50 years); • Low or middle caste; • Low wealth status.
8
Findings and recommendations
Demographic Data
31. Implementing partners generally appeared to have excellent demographic data. However, there was little external confirmation of population numbers. Although a verification exercise was completed in one camp, this was done over an extended period, which could have allowed refugees living elsewhere in Nepal to have returned to the camp. During the Joint Assessment Mission (JAM), it was noted that some households appeared to have fewer sleeping materials than would be expected given the reported household size.
Recommendation
Since population data are a key element in calculating health indices, UNHCR should conduct a standard rapid verification exercise in at least one camp. If substantial discrepancies are found, the exercise should be conducted in all camps. The results of the community survey in Beldangi I should be reviewed for evidence of population over, or underestimation.
Table 1: Age distribution of Bhutanese refugee camp population, as compared with urban and rural populations in Nepal: August 2003 Age group (years) Camp No. (%) Nepal Urban % Nepal Rural % 0-4 7,704 (7) 10 16 5-17 35,786 (35) NA NA 18-59 53,318 (52) NA NA >60 6,084 (6) 6 7
32. The age distribution of the camp population appears more similar to urban than rural Nepal. There was no significant difference by age group in the proportion of males compared with females between the camps and national data for Nepal. At present it is impossible to carry out age group comparisons with national data, as the age groups are different. Family size appears higher in the camps compared with either urban or rural Nepal.
Table 2: Family size and the proportion of female-headed households of Bhutanese refugee camp population as compared with urban and rural populations in Nepal: August 2003 Camps Nepal Urban Nepal Rural Family size 6.8 5.0 5.3 % female headed households 16.7 16.1
33. Camp populations are not evenly distributed. However, this is not reflected in the distribution of Basic Health Units (BHUs). For example Beldangi I (population 17,802) has two BHUs, the same number as Beldangi II, which also serves the population of Beldangi II extension (total population 33,038).
9 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Figure 1: Population distribution by camp, Bhutanese refugees in Nepal: August 2003
20000 15000 10000 5000 0 I i I re a gi I i Ext m bari angi an ldhap Ti a d d scha o ang ni G Bel ld Bel e Sa B Khudun
Camp
Crude and Under-five Mortality Rates
34. Between January 2000 and September 2004 reported crude mortality rates per 1,000 refugees per year were well below the rate for Nepal. The crude mortality rate (annualized) for all camps combined for 2003 was 3.4 (Figure 2) compared with the national rate for Nepal which was ten per 1,000 per year for the same year. Mortality rates for one camp (Beldangi I) were verified. An additional seven deaths were identified for the period January-October 2003. However, the revised annualized crude mortality rate for this camp still remained low (4.5 per 1,000 per year).
35. There is no convenient comparison figure for under-five mortality. However, the 2001 DHS does give a figure for the under-five mortality risk (the risk that a child born alive will die before reaching his/her fifth birthday). Given several major assumptions it is possible to convert the DHS infant mortality ratio and the child mortality risk to an average rate for a five-year period. Under-five mortality rates for the camps for the period January 2000 to September 2003 were considerably lower than the rate reported in the 2001 DHS for the Terai region of Nepal.
Figure 2: Crude and under-five mortality rates among Bhutanese refugees, January 2000-September 2003, compared with selected national data.
Figure 2: Crude and under-five mortality rates among Bhutanese refugees, January 2000- September 2003, compared with selected national data.
21 U5MR Terai (DHS 2001) h r yea /
0 16 0 mont 0 , r 1 / e s h p eat 0 11
: D CMR Nepal 2001 0 R 0 M C d 1, r
an Verified CMR for Beldangi I e R 6 U5 MR camps M p <5 s CMR camps
eath 1
D 2000 2001 2002 2003 2000 2001 2002 2003 Months
Year
10 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
36. These data suggest that even if the population data from the camps were overestimated Bhutanese refugees would still have lower mortality rates than the host population. This is not surprising given the adequate general ration and other services provided by UNHCR and its IPs to the refugee population over the past 12 years. In emergency situations, the under-five mortality rate is generally around twice the crude mortality rate. This is not the case amongst the Bhutanese refugees, reflecting the fact that they are in a stable post-emergency situation.
37. The small number of deaths each month also results in unstable rates, making it difficult to track mortality on a monthly basis in this population. It is even more difficult to draw conclusions at camp level owing to small numbers.
Recommendation
In addition to calculating separate monthly mortality rates for all camps, cumulative mortality should also be calculated, as this figure will be more stable.
Other Selected Mortality Rates.
38. The current HIS does not provide useful data on cause-specific mortality, as most mortality comes under the category of “other” (Figure 3). The current system focuses on infectious diseases and in this population (as in many post-emergency populations) most mortality is attributable to chronic diseases.
Recommendation
The HIS mortality reporting system should be expanded to include the four or five most common chronic disease categories (as has been done for morbidity). This might help track needs for certain medications.
Figure 3: Cause Speci fic Mortality Among Bhutanese Refugees in Nep al: January-September 2003
Pneumonia Meningitis Neonatal
Other
N=220
11 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Table 3: Infant, maternal and neonatal mortality rates for all Bhutanese refugee camps for January-September 2003, compared with national data from the 2001 DHS.
Indicator Expressed as Camps Terai Infant Mortality Rate Deaths in under ones/1,000 live births 18.6* 80.8
Maternal Mortality Maternal deaths/100,000 live births 0** 540 Rate Neonatal Mortality Deaths in <28 days/1,000 live births 12.3 49.7 Rate *For 2002 only. **No maternal deaths were reported so far in 2003. In 2002, two maternal deaths were reported giving a rate of 110 per 100,000 live births.
39. Mortality rates for the Bhutanese refugees are lower compared with the host population. However, the reported camp maternal mortality rate is very unstable owing to the small population. In 2002, the rate was derived from just two deaths.
Recommendation
IPs should not place too much emphasis on the yearly maternal mortality ratio as this is very unstable.
Verification of Mortality Reporting in Beldangi I
40. As mortality is an important indicator, an attempt was made to validate reported figures in one camp. Deaths in the camps were recorded by the following IPs: AMDA, Lutheran World Federation (LWF), Refugee Coordination Unit (RCU), and Nepali Red Cross Society (NRCS).
41. AMDA compiled information on deaths and provided data on a monthly basis to UNHCR and RCU. AMDA also provided shrouds to families of the bereaved in which to bury a dead relative. The RCU passes this information to NRCS, which then adjusted the number of food rations accordingly. The families of a deceased person received an additional two-week ration to provide for the funeral ceremony. NRCS headquarters also reported mortality data to UNHCR. LWF provided bamboo poles to carry the deceased, mortality levels could be inferred from the applications for bamboo poles.
Table 4: A comparison of death registers from four different sources: January-September 2003
AMDA: 50 LWF: 36 (including three deaths not in AMDA records) RCU: 52 (including seven deaths in neither AMDA nor LWF records) NRCS: 33 (missing 19 from RCU) Total: 60 Source Deaths registered January-September 2003
12 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
42. Assuming that the additional seven deaths recorded by the RCU occurred in 2003, the total number of known deaths from all sources in the camp was 60 (50+3+7). If the population of the camp was 17,800 (the figure reported in the HIS) the adjusted CMR for the first nine months of 2003 was 0.37 deaths per 1,000 per month. This rate is close to the rate obtained if the lower AMDA figure of 50 deaths is used (0.31 deaths per 10,000 per year).
43. Seven of 60 deaths occurred in children under five years of age. Assuming the total under-five population in Beldangi I to be 1,800, the true U5MR for the first nine months of 2003 is 0.43 deaths per 1,000 children under five per month. This is higher than the reported under five-mortality rate for Beldangi I, but still well below the emergency cutoff level as defined in the 2001 DHS.
44. Fifty deaths were recorded in the AMDA register for the first nine months of 2003. LWF had records of 36 deaths for 2003, only three of which were not recorded in the AMDA register. There were many discrepancies between RCU and AMDA records. In the vast majority of cases, the date of death specified in the RCU records was later than that specified in AMDA records. Discrepancies as large as 7-8 months were not uncommon. The age and spelling of the name of the deceased also differed in many cases. In the RCU register for 2003, there were an additional seven deaths, which were not recorded by either AMDA or LWF. Because the date of death in the RCU records is usually months later than that recorded by AMDA or LWF, it is possible that some of the extra seven deaths found in RCU register may have in fact occurred in 2002 rather than in 2003.
45. The records found with NRCS mostly repeat the records available from RCU, which is not surprising given that NRCS gets its mortality data from RCU. However, of the total 52 deaths entered into RCU register in 2003, only 33 were recorded by NRCS. Most of the deaths found in the RCU register but missing in NRCS register have been recorded by RCU in April 2003. This discrepancy is surprising and deserves further investigation, because recording of deaths in NRCS register has implications for the amount of rations distributed.
46. AMDA, which distributes shrouds and LWF, which provides bamboo poles for funerals, appeared to have the timeliest records of deaths. However, the discrepancies between AMDA and RCU death records, it was felt that RCU may be receiving death reports from some other sources such as sector heads or camp refugee committees.
Recommendation
Every effort must be made to ensure that the HIS accurately captured all deaths. All three registers in all camps should be checked regularly and closely monitored. In addition, the records should be reviewed monthly with LWF and sector heads in each camp to check whether there were additional deaths that were not recorded by AMDA. AMDA records should be the primary source for mortality recording in the RCU, and the data should be transferred without delay on a monthly basis from AMDA to RCU to NRCS.
47. The age of the deceased was known in the cases of 57 reported deaths. Of these, 33 deaths (58%) occurred amongst persons aged 60 years or older. Twelve deaths (21%) occurred in the age group 30-59 years; five deaths (5%) in the age group 5-29 years; and seven deaths (12.3%) in the age group 0-4 years.
13 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
48. Cause and place of death were recorded for 50 of 60 deaths (those from the AMDA register). Thirty-one deaths (62%) occurred due to chronic conditions (such as cancer, chronic obstructive pulmonary disease, hypertension, diabetes, or chronic tuberculosis.) Three deaths (6%) were due to pneumonia or “severe chest infection,” two of whom were children aged nine and four years respectively. Two deaths were the result of suicide (4%); both were males aged 18 and 69 years, respectively. There were no recorded deaths due to diarrhea or severe dehydration.
49. Thirty deaths (60%) occurred at home, 13 (26%) in AMDA hospital, five (10%) in Biratnagar hospital, and two (4%) elsewhere. A four year-old child died at home rather than in the hospital.
Recommendation
50. Suicide should be added to the HIS as a cause of death. Some of the more common chronic disease categories such as COPD (Chronic Obstructive Pulmonary Disease), hypertension, diabetes and CCF should also be added. All deaths among children occurring at home should be investigated to see if preventive actions could have been taken.
Morbidity
51. Between January and September 2003, the HIS recorded a total of 322,903 new OPD visits by refugees. This means that in this time period each refugee visited the OPD three times. If these figures were extrapolated for the entire year, the number of new visits per refugee would be 4.7. The benchmark for a post-emergency situation is between 0.5-1.0 new visits per refugee per year. The eventual number may be higher, as the number of visits, appear to be increasing each month. These figures are not accounted for by duplicate reporting.
Recommendation
Reasons for such over-use of health services should be investigated. Such information should be used to design a community education programme around the overuse of out-patient department (OPD) services. Offering the services of a community health care worker as the first point of contact for some cases, particularly for adults, should be considered.
Figure 4 New OPD consultations per month, January-September 2003
100000
80000 60000
40000 20000 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Month
14 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
52. In the flood of general consultations, several potentially serious diseases are being overlooked. Although these diseases represent a small proportion of all illnesses, because of either their epidemic potential, associated morbidity, or indicator of underlying problems in the community, they need to be addressed. For example, between January and September 2003, 7,589 cases of bloody diarroea were reported. This is a serious condition and could be either dysentery or amoebiasis.
Recommendation
Laboratory confirmation must be obtained on several stool specimens to identify the organism. Treatment protocols for the specific disease must be put in place. The role of water, sanitation and hygienic practices should be investigated and appropriate action taken.
53. Between January and September 2003, 748 new cases of tuberculosis were reported through the HIS, which is an extremely high number. All suspected new TB cases should have the name of the patient and hut location recorded. The AMDA health coordinator must follow up these cases.
Recommendation:
AMDA must confirm whether or not the above cases were adequately investigated and if they were confirmed. All new cases of suspected TB should be reported to the health coordinator, so that they can be followed up.
54. A total of 5,388 cases of injury were reported between January and September 2003. This is quite a high figure and needs to be further examined.
Recommendation
The HIS should record injury at least as being intentional or unintentional. If cases of attempted suicide are occurring they should be tallied separately.
55. A total of 601 new cases of mental health illness were reported between January and September 2003. This is quite a high figure and suggests that there may be a need for a community based mental health programme.
Recommendation
The current mental health programme needs improvement. An investigation should be conducted as to what types of mental illness are being reported and what are the underlying causes.
56. A total of 734 new cases of STI were reported between January and September 2003. Only 0.2% of cases were reported among men. This suggests that STIs in men are not being diagnosed and treated. This will lead to the development of drug resistant STIs, which might then spread to the local community.
15 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Recommendation
Protocols for the management of STIs must be put in place as soon as possible. Organisms should be tested for drug sensitivity. Partner tracing should be strictly adhered to. A community education programme aimed at men may be needed.
57. A large proportion of the morbidity being reported such as diarrhoeal diseases, and scabies is often associated with lack of access to sufficient water. In the initial community survey, many people reported using river water.
Recommendation
The actual amount of water being collected per family should be determined, perhaps through the UNHCR community assistants. The actual amount may either be below 20 litres per person per day, or that amount may not be sufficient for this population.
58. At present, only persons with suspected malaria who have a history of travel to India have a blood slide taken to identify whether the patient has falciparum malaria because it is assumed that there is no indigenous transmission of plasmodium falciparum. This is not a safe assumption.
Recommendation
At least a proportion of suspected malaria cases among locals and non-travelled refugees should have blood slides taken.
Quality of Health Service Delivery
Basic Health Units
59. There are a total of ten Basic Health Units (BHUs) and four Primary Health Care (PHC) centres that serve the camp. These do not correspond to national health structures. A BHU is below the level of a health post in the government and the PHCC is between the level of health post and PHCC. Doctors visit the camps once a month and see patients that staff at the PHCC cannot manage. Emergency cases are referred to the AMDA hospital in Damak, or one of the government zonal hospitals.
60. There are on average 0.5 BHUs per 5,000 population, which is adequate. However, these are unequally distributed. For example two BHUs in Beldangi II and extension serve a total population of 33,000 (0.30 per 5,000 population). Five of the ten refugee BHUs were visited and facility checklists completed. These included two BHUs in Beldangi I, the two BHUs in Beldangi II and one BHU in Goldhab. Two government sub-health posts were also visited for comparison.
61. There were an average of 160 consultations per BHU per day for Beldangi I, and 109 and 150 respectively for the two BHUs in Beldangi II. On the days of the surveys, it was observed that only one health worker was seeing patients. This meant that these health workers were seeing over 100 patients per day (the SPHERE benchmark is 50 per day). There was little time to examine and advise individual patients. In contrast, the number of patients seen daily at the two government sub-health posts (SHPs) was between 10 and 20. This suggests that if refugees were to revert to the
16 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL responsibility of existing government structures, these structures would be unable to cope with the higher numbers.
62. BHU staff that see patients were mostly male. They received initial training from Save the Children Foundation (SCF) but most had received no refresher training in the last five years. There were no case definitions or treatment protocols available in the BHUs. Of the five items of basic equipment on the checklist (stethoscope, BP monitor, thermometer, weighing scale and gloves) two BHUs had items listed and three had three items. The two government SHPs had one item and four items respectively. One government of the two SHPs had both case definitions and protocols available.
Recommendations
It is key that UNHCR send an experienced consultant for at least two months to work with the implementing partner to improve the delivery of primary health care. The consultant should conduct IMCI training for all clinicians, use or adapt MoH develop treatment protocols and institute use of standard case definitions. Part of the TOR should be to work with the MoH and other possible health partners such as WHO and UNICEF.
63. Pharmacy stock registers were very well kept in the BHUs and all were up to date. However, amoxicillin was not available at the level of the BHU despite being as an essential drug for a government SHP. Chloroquine was also not available at the BHU, as it was provided at the level of the PHCC. Oral dehydration salts (ORS) was in stock in all BHUs except Goldhab, which reported a two-month shortage. Two of the five BHUs had no condoms and three had no oral contraceptives. (One had been without stocks for one year, the other for thee months.) A review of records at Beldangi I found that each prescription contained an average of two drugs and 37% of all patients received an oral antibiotic. This suggests inappropriate prescribing practices. Well maintained latrines and water were available in the five BHUs visited.
64. In general the level of drugs and services available in the BHU approximates to that of a government SHP rather than a health post. This may lead to increased referrals to the next level.
Recommendations
Drugs and services at the BHUs should be upgraded to match what should be theoretically available in a government health post. Staff should be given training in IMCI to which MoH staff form surrounding clinics should also be included. Nepal National Recommended Case Definitions (available from the MoH's Epidemiology and Disease Control Division) should be available and used. The number of BHU workers who see patients should be increased so that even allowing for sickness or leave, each clinician sees no more that 50 patients per day. Treatment protocols should be available and used. Adding another BHU to Beldangi II extension should be considered. WHO Nepal should be asked to conduct an appropriate prescribing practice workshop for all health workers.
65. Recommendation for integration: A dialogue should begin as soon as possible with the MoH on how the BHUs might be incorporated into the government system. Before the handover process, UNHCR should ensure that the BHUs are using the
17 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL same case definitions and protocols and giving the same services as recommended for government health posts.
Primary Health Care Centres (PHCC)
66. Four of the six PHCCs serving the refugee population were visited: Beldangi I; Beldangi II; Goldhab and Timai. One government PHCC was also visited.
67. UNHCR guidelines recommend one PHCC per 30,000 population. Therefore, six PHCCs would seem to be far too many for the current refugee population. The staff of PHCCs was also unevenly distributed. Beldangi II and extension with a population of 33,000 still has just one PHCC and the same staffing level as the other PHCCs. Although they are called PHCCs, the centres in the camps provide drugs and services comparable to those recommended for government health posts. For example, there are no in-patient beds in the camp PHCCs, whereas government PHCCs usually do have in-patient beds. This means that patients requiring admission or overnight observation must be sent to a referral hospital, which drives up the number of referrals.
68. The Health Programme Officer (HPO), who is Nepalese, carries out most of the work along with those he supervises. Although these health workers are experienced, most have not received refresher training for over five years. They are also overwhelmed by the large number of consultations. These factors have led to lack of confidence of the population in the services provided at the PHCC, which has in turn resulted in refugees insisting on being referred to either the AMDA hospital or Mechi Zonal Hospital. This normally happened at night, when only refugee staff was on duty. These health workers may be more easily pressured into giving inappropriate referrals.
69. While in theory each camp has a visit from a qualified doctor once a week to see serious cases, in practice, most of the doctors recruited were newly-qualified, one-year postgraduates from the AMDA hospital. Doctors visit the camps on their day, which follows a 24-hour shift in the hospital. As travelling two and from the camps takes time, the doctors typically spend about two hours each week actually seeing patients. Most refuse to see more than 50 patients per visit, which would give an average of two and a half minutes per patient. Patients were seen according to the length of time they had been waiting to see the doctor, rather than by the urgency of the case.
70. For the months of August and September 2003, approximately 7,000 prescriptions were issued at Beldangi I PHCC. If each prescription (many were for 2-3 drugs) was given to a different person, 40% of the camp population received some kind of medication in the two-week period. Almost half (49%) of all prescriptions contained at least one antibiotic, and about 5% were psychiatric drugs such as diazepam.
71. The system as a whole does not appear to be the most cost effective. The cost of improving the level of services at the PHCC might be offset by a decrease in the number of referrals. Improved staff training in appropriate case management and prescribing practices might reduce drug costs. A community education campaign on rational use of health services and drugs may be needed, once services have been improved.
18 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
72. The visiting physicians system is not useful. Originally, Bhutanese doctors were employed in the camps. These were experienced doctors and generally well-liked by the population. However, these doctors had found jobs elsewhere, and were not willing to work for the lower salaries offered by the IP.
Recommendations
Increase the overall number of PHCC staff in Beldangi II PHCC that sees patients. In Beldangi I and Beldangi II, services and drugs should be upgraded to match what should be theoretically available in a government PHCC. This alone will improve in- camp services to a third of the refugee population. IMCI training should be conducted for PHCC staff. Standard case definitions should be used. Treatment protocols should be available in all PHCCs. These health workers should also attend a WHO workshop on appropriate prescribing practices.
73. Recommendation for integration: The PHCCs in Beldangi I and Beldangi II should remain after handover to the Government of Nepal by UNHCR. Services and staffing and protocols should be uniform with the MoH PHCCs. The government PHCC at Mangalbare (which is excellent) is a good model to follow.
74. Only one of the four PHCCs visited had private settings for OPD consultations, this is necessary if patients are to be encouraged to report socially-sensitive conditions such as STIs in men. Only three of the five items of basic equipment were available in all four PHCCs. There was no evidence of re-use of disposable syringes at any of the PHCCs, which is excellent. However, although all had a working sterilizer, none had a color monitor to indicate reaching the appropriate sterilizing temperature. All four had privacy for MCH consultations and an MCH examination cot. Depo-Provera was available in all PHCCs as was post abortion care. In two of the PHCCs both ARI and CDD protocols were available and in two, case definitions were available.
Specific Health Programmes and Cross-Cutting Issues
Communicable Disease Control
75. In general, communicable disease control focuses more on specific activities that are mainly curative, than on a programmatic approach. For example, control of STIs should include good case identification with appropriate use of laboratory methods, good case management, partner tracing, community education based on an examination of attitudes and beliefs around STIs and cross linkages with youth education and other programmes aimed at adolescents. This is particularly important as UNHCR begins to disengage from refugee programmes, since the camp residents will have more responsibility for the health of their community.
Recommendation
AMDA should move from focusing on individual activities to a more programmatic approach.
19 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Extended Programme on Immunisation (EPI)
76. EPI coverage was extremely high as a result of an extremely good tracking system, and the fact that community health workers follow up on mothers of children who are due to be vaccinated. EPI cards were also examined prior to food distribution. The system does not have to rely on mothers’ knowledge and desire to have children immunized. After disengagement, the health service may need to rely more on the mothers’ active participation.
Recommendation
AMDA should make sure that mothers are well educated about the benefits of vaccination.
Mental Health
77. Mental health was reported to be a serious issue in the camps. Patients were presenting to the health system with complaints such as anxiety and peptic ulcer disease, which may have roots in psychological problems. Services available in Beldangi I were visited. There was only one mental health counselor for the entire camp, who had received very little training over five years ago. There was no private spot in the consultation area where such patients could be seen. The mental health counselor only saw those patients who had been prescribed medication. Alcohol abuse was mentioned frequently by the community, implementing partners and UNHCR as a significant problem in the camps. However, this issue has not been assessed.
Recommendation
Good quality community based mental health services should be made available, especially since such services might play an important role in dealing with the psychological consequences of SGBV.
Essential Drugs and Supplies
78. Many doctors prescribe name-based rather than essential drugs. This was expensive for UNHCR. It also aroused dissatisfaction in patients, as it could take weeks to locate the medication.
Recommendation
Doctors prescribing a name-based drug should be obliged to complete a form justifying the need to do so. Drugs at camp health facilities should include all drugs on the recommended government lists. Staff should be trained in prescribing them, in order to help to reduce referrals to hospitals.
Health Education
79. Methods and materials observed for health education in reproductive health and HIV were not suitable.
20 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Recommendation
All health education materials should be reviewed. Someone from UNHCR or another partner with this expertise (WHO, UNICEF, UNFPA) should attend health education sample sessions given by the implementing partner.
Chronic Diseases
80. The implementing partner was providing an exceptional level of service to the refugee population compared with that available to the local population, particularly with regard to drug treatment. However, after UNHCR’s disengagement only drugs on the government list of essential drugs will be available.
Recommendation
Every effort should be made to stabilise patients on a drug on the essential list rather than a name-based drug.
The Health Information System (HIS)
81. The HIS put out a large amount of impressive-looking data each month. However, there were several major problems: data quality was poor in terms of which diseases or conditions were actually reported and which truly exist; data were not being analysed to see what action needs to be taken; and UNHCR was not reviewing the data adequately.
Recommendation
Since SGBV has been identified as a significant problem in the camps, the HIS should collect information on domestic violence and self-inflicted injury. Camp data should be shared with local and regional government public health staff.
Nutrition
Annual Nutrition Surveys - Major Trends
82. Annual nutrition surveys were conducted in the Bhutanese refugee camps. The primary target group is children under five years of age. The prevalence of acute malnutrition (wasting) in previous years was reported using weight-for-height (WH) as a percentage of the median. Data on the prevalence of acute malnutrition using WH Z scores are available from nutrition surveys conducted in 1999, 2000, 2002 and 2003.
Table 5: Prevalence of Acute Malnutrition in Bhutanese refugee children aged 0-59 months 92 93 94 95 96 97 98 99 00 01 02 03 WH<80% 17.0 5.1 1.5 5.7 5.8 4.5 4.3 4.0 3.6 5.5 3.5 4.8 WHZ<- 9.9 9.8 7.9 8.4 2SD
21 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
83. Representative data on acute malnutrition prevalence in Nepal (expressed using Z scores) are available from two large national surveys: the Nepal Micronutrient Status Survey of 1998 (NMSS) and the Demographic and Health Survey of 2001 (DHS). The NMSS reported a prevalence of acute malnutrition of 6.8% in Eastern Terai and 6.7% nationally; The DHS reported a prevalence of acute malnutrition of 10.8% in Eastern Terai and 9.6% nationally. These data were comparable to the rates reported in Bhutanese refugee population, which has not changed substantially during recent years. Despite the post-emergency context, in which refugees were provided with sufficient food and health services, childhood malnutrition continues to pose a public health problem.
84. The prevalence of chronic malnutrition (stunting) in refugee children, measured by height-for-age, and expressed in Z scores, is presented in Table 6.
Table 6: The prevalence of Chronic Malnutrition in Bhutanese Refugee Children aged 0-59 months 1999 2000 2001 2002 2003 HAZ<-2SD 31.7 33.0 33.2 29.8 28.9 HAZ<-3SD 7.0 6.6 5.7 5.7 8.0
85. NMSS reported a prevalence of chronic malnutrition of 44.4% in Eastern Terai and 47.1% nationally; DHS reported a prevalence of chronic malnutrition of 41.4% in Eastern Terai and 50.5% nationally. The prevalence of stunting in refugee children while low compared to regional and national data, remains high by international standards.
Recommendation
In future nutrition surveys the prevalence of stunting should be disaggregated according to age (e.g., 0-11 months, 12-23 months, and 24-59 months). The prevalence of stunting should also be measured in 6-10 year old schoolchildren.
86. A nutrition survey conducted in 1998 in Bhutanese refugee camps by the National Institute of Nutrition, Rome, Italy and the Catholic University of Leuven, Belgium, showed that the prevalence of stunting is higher with increasing age and can be as high as 75% in the age group 6–10 years. Similarly, an anthropometric survey conducted by CDC in 1999 showed a low average height among adolescents in this population. A similar trend of higher prevalence of stunting with increasing age of children was seen in the national data (NMSS, DHS).
87. In protracted post-emergency refugee situations where wasting was maintained at relatively low levels by emergency standards (under 10%) and food supply was sufficient and consistent, stunting may be an indicator of concern. High levels of stunting may indicate that a high proportion of young children may have recurrent episodes of infectious disease and/or repeated bouts of under-nutrition (especially micronutrient deficiencies) that are insufficiently addressed by the healthcare system.
Methodological Issues with Nutrition Surveys
88. Nutrition surveys are conducted every year in June (the beginning of the monsoon season). Although it is not known how the nutritional status of refugee
22 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL population changes depending on the season, conducting the survey in the same month every year allows the assessment of trends in nutrition indicators.
89. In 2003, there was a great improvement in the quality of the nutrition survey report, which was, in part, attributable to the training workshop on EPI Info organized by WFP in 2002.
Recommendation
To further improve the quality of nutrition survey reporting, 95% confidence intervals (or values for standard deviation) should be reported with all major prevalence indicators. Also, tests for significance of association should be reported when bi- variate (e.g. 2*2 tables) or multi-variate analyses are presented. Acute malnutrition prevalence should be expressed in Z scores, since this permits comparison with other national and international data where acute malnutrition prevalence is reported using Z scores.
90. The number of households to be included in the survey was based on the assumption that, on average, there was only one child aged under-five per household. However, in reality there were fewer than 0.5 children aged under-five per household in this refugee population.
Recommendation
The following method for calculating the required number of households should be used. If the required sample size of 396 children has been determined assuming simple random sampling and expected prevalence of wasting of about 10% with required precision of 3%, then, the required number of households to be included in the survey is determined as follows: number of children divided by average household size and by proportion of children aged under five in the total population. For example, if average household size is 6.0 and proportion of children under 5 in the total population is 0.08 (8%), then the required number of households is determined as follows: 396/(6*0.48)=825.
91. If only children under 5 are of interest in the survey, then those of 825 selected households that have no such children can be skipped. It is not necessary to go to neighbouring households until a child aged under five is found. As usual, all children under the age of five found in selected households should be measured.
Growth Monitoring
92. Previously, the weight and height of all children aged less than twelve months was measured monthly. The WH percentage of the median was recorded and weight for age was plotted on the graph in each child’s Road to Health card. The recommendation made by the WFP/UNHCR Joint Assessment Mission in 2002 has meant that, as of January 2003, monthly monitoring was expanded to include all children aged under two. This year’s WFP/UNHCR Joint Assessment Mission further recommended expanding monthly growth monitoring to all children under three years of age.
93. Compliance of children under the age of one is ensured by the fact that their mothers collect supplementary feeding rations on a weekly basis, and thus defaulters
23 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL can easily be followed up. However, ensuring monthly compliance from children older than one is fraught with logistical difficulties. The data for 2003 from Beldangi I camp show 100% compliance of children under the age of one, whereas in the cohort aged one to two years about 30% of children do not present themselves for monthly growth monitoring. Expanding growth monitoring and promotion to include children aged two to three years may face a similar problem of non-compliance.
Recommendations
Provisions should be made to ensure effective monthly growth monitoring of children over one year of age, if such monitoring is deemed essential and beneficial. Possible solutions could include a system of small incentives for monthly visits, more proactive follow-up of no-show cases by community health workers, measuring children in their homes, etc.
94. If the shortage of staff and/or other logistical problems make it difficult to ensure compliance in cohorts older than one year, an alternative monitoring strategy may be advised: include only children in monthly screenings under one year of age and children under five years of age who had borderline low (85% WHM or lower) nutrition status at the annual nutrition screening. The latter cohort (under-five with borderline low WH scores) should be included in monthly nutrition screening for at least six months or until the child has WHM score over 85% on three consecutive monthly measurements.
95. Staff in the nutrition units have little, if any, expertise and/or time for counselling mothers whose children show decline in their growth pattern. The only objective of this comprehensive monitoring effort is detection of malnourished children for admission into selective feeding programmes.
Recommendation
Efforts must be undertaken urgently to enhance expertise of nutrition staff in the area of counselling and follow-up. Specific field guidelines on counselling regarding infant feeding and growth promotion should be adapted from existing sources, such as IMCI guidelines, and implemented in all camps. The staff capacity of nutrition units should be increased as appropriate to meet new workload demands.
Mass Nutrition Screening
96. Previously, all under-five children were screened every six months using mid- upper arm circumference (MUAC). As per the recommendation from the 2002 WFP/UNHCR Joint Assessment Mission, mass screening is now being conducted using weight and height measurements. The latest mass screening, using weight and height measures, was carried out in June 2003. In Beldangi I, 550 of 1455 children aged one to five years (over 30%) were not measured.
Recommendation
Additional provisions should be made to ensure that growth monitoring is conducted by full coverage by mass screening of children under-five years of age.
24 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
97. The IP has decided to conduct mass screening once a year (in December), six months from the time of the annual nutrition survey. Once-a-year screening will detect children who become malnourished after the screening is conducted.
Recommendation
Invite for monthly follow-up those children whose median WH percentage lies just above the cut-off point (e.g., children with 80-85% of median WH score) should be invited for monthly follow-up. This may be especially important for children between the ages of two and five who are not usually targeted for monthly growth monitoring. Determine whether there are pronounced seasonal patterns or cycles of malnutrition in children under-five, and if such patterns exist, to conduct a mass screening during the “worst” season to detect the maximum number of cases of malnutrition.
Supplementary Feeding Programmes
98. Supplementary feeding is implemented in all camps. Categories of beneficiaries and their proportion of the total number (as of December 2002 and of June 2003) are provided in Table 7.
Table 7. Supplementary Feeding Programme: the categories of beneficiaries and their proportion in total number of beneficiaries in December 2002 and in June 2003
December 2002 June 2003 Malnourished children 119 (4.6%) 236 (8.0%) Pregnant women 639 (24.6%) 830 (28.1%) Lactating mothers, 0-6 months after delivery 997 (38.4%) 750 (25.4%) Children aged 6-11 months 755 (29.1%) 1071 (36.2%) TB patients in active treatment, elderly sick 86 (3.3%) 71 (2.4%) Total 2596 2958
99. All categories of beneficiaries are provided with a daily ration of 80g of UNILITO (fortified wheat-soya blend produced locally in Biratnagar city), 15g of sugar and 10g of vegetable oil. This provides about 450kcal as well as 14g of protein and 15g of fat per day. Malnourished children additionally receive 40g of dried skim milk (DSM), which brings the calorie content of the ration to about 590kcal and protein content to about 29g.
100. As can be seen from Table 3, malnourished children comprise less than 10% of the total number of beneficiaries in this operation. It must be remembered, however, that malnourished children are normally the primary SFP target group. Only after the needs of this group are fully met and additional resources are available should the programme include additional categories of beneficiaries.
101. The revised SPHERE minimum standard benchmarks for the SFP programme are as follows: of all exits, recoveries > 75%, deaths <3%, defaulters <15%. From the monthly reports for 2002 and 2003 that were available to the mission, it seems that indicators of SFP for Bhutanese refugees are well within the specified benchmarks. From data gathered over 11 months in 2002 (all reports except for the month of November were available); there were 648 exits, of those only four deaths (0.6%) and three defaults (0.5%). The rest of the exits were discharges, which presumes that those discharged have recovered. By international standards, children should be discharged
25 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL from SFP only after they reach 85% of the median WH on at least two consecutive measurements (normally measurements are done at 2 week intervals).
102. However, closer review of the registers revealed several issues, which make meaningful interpretation of the above data from monthly reports impossible. First, according to the records the majority of children are being discharged before reaching 85% WH median. Furthermore, many children are being discharged before reaching even 80% WH median.
103. For example, of 92 children under 5 years of age who were in the SFP in Beldangi II camp by mid-July 2002, 61 (66%) were discharged at the end of that month. Only 9 of those 61 discharged had reached 85% median WH at least once. The remaining 52 discharged children did not reach 85% median WH. Of those, 28 did not reach 80% median WH, and 11 did not even reach 75%. Among those discharged were children with WH median as low as 70-71%.
104. The following pattern was seen in Beldangi Extension camp: of 36 children under five years of age who were in the SFP by mid-July 2002, 27 (75%) were discharged at the end of that month. Only three of the children who were discharged had reached the 85% median WH at least once. None of the remaining 24 discharged children had reached the 85% median WH; 16 had not reached the 80% median WH, and 10 had not reached 75%. At the same time (end of July 2002) all children over 5 years of age participating in the SFP in Beldangi II and Beldangi SFP beneficiaries in extension camp were also discharged, the vast majority of whom had not reached the internationally-accepted discharge criteria. A similar, albeit less striking, picture was observed in Beldangi I camp: of the 92 children who were discharged in 2002, only 35 reached 85% median WH.
105. The discharge of children in Beldangi II and Extension camps was reportedly undertaken on direct orders from the camp public health officer following instructions from the implementing partner’s headquarters. The justification offered was reportedly “to see whether the children who failed to gain weight with supplementary food would recover better with the family food available at home.”
Recommendations
The practices of discharge observed in the SFP in Bhutanese refugee camps are unacceptable and demonstrate a lack of expertise and supervision. These practices must be reversed as soon as possible. Clear and uniform guidelines of discharge must be communicated to the staff of nutrition units in all camps, and strict adherence to these guidelines must be closely monitored.
106. These discharge practices mean that the exit statistics provided in monthly report are largely meaningless, and cannot be used in any objective evaluation of programme performance.
107. If the current IP is to administer SFP for Bhutanese refugees in the future, urgent technical assistance should be provided to correct irregularities and ensure that the programmes are administered according to internationally-accepted guidelines. Constant monitoring and follow-up on the part of UNHCR is advisable.
26 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
108. At this time, it is not recommended or advisable to decrease or eliminate the SFP for malnourished children or other categories of beneficiaries. Only if economic conditions of refugees, access to jobs and access to alternative food sources beyond those currently distributed in the general ration meaningfully change to the better, should the exit strategies for SFP be considered involving all partners concerned.
109. Another serious problem with the SFP in this operation is the widespread failure of children to gain sufficient weight, resulting in lengthy stays in the programme. The IP must report the average length of stay in monthly reports as is required.
110. By international standards, children should be able to achieve the 85% WH benchmark within 4-6 weeks, and be discharged within 6-10 weeks (after they achieve 85% WH median on 2 consecutive measurements). However, children have tended to stay much longer in the SFP. For example, of those discharged in Beldangi I camp in 2003, the median length of stay was six months; of the 25 discharged in 2003, ten were discharged before reaching 85% WH median. In Beldangi II and Extension camps, for the whole of 2003 (up to the end of September) there were only nine exits from the programme, three of which were deaths. Of the total of 104 children currently in the programme in these two camps, 36 children have actually decreased their WH median score since they were admitted.
111. Nutrition units staff in the camps are overwhelmed by the amount of work required (e.g., mixing and distributing supplementary rations, measuring and weighing children, etc.) These staff members (usually refugees the majority of whom have been working in these positions for several years) have also little or no expertise in counselling the mothers on optimal infant and young child feeding practices or in following up the long-term cases of malnutrition.
Recommendations
Additional training should be given to nutrition unit staff and this should include: internationally-accepted guidelines on supplementary feeding for young children; methods of preparation of the supplementary ration, guidelines on the type; amount and frequency of feeding for children of different ages, including breastfeeding; appropriate ages at which complementary foods should be introduced; and counselling techniques.
112. A full course of counselling for mothers should be mandatory on admission to SFP and TFP The number of staff in nutrition units should be increased, to meet increased workloads. Close monitoring and follow-up of long-term cases of malnutrition should be instituted, and children with chronic medical problems should be referred for further treatment as appropriate. Clear and comprehensive guidelines for monitoring and follow-up of children who fail to improve their WH scores should be instituted. The average length of stay is a crucial indicator to evaluate the effectiveness of the SFP in controlling malnutrition, and should be calculated on a regular basis and included in monthly reports.
113. According to international standards, measurement of children in SFP should be conducted at least every two weeks. Records in Beldangi II and Extension camps showed that such measurements were only being carried out once a month, and sometime even more infrequently. In the first nine months of 2003, children were
27 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL measured six times – in February, March, May, July, August, and September, instead of 18 times according to international norms.
Recommendation
Measurement of malnourished children should be done at least every 2 weeks. All staff of nutrition units should adhere to these standards, and implementing partners should ensure appropriate monitoring of measurement practices.
Therapeutic Feeding Programmes (TFPs)
114. According to international standards, TFPs are established to treat severely malnourished children (WH <70% median). These children are at high risk of dying, and must be treated and fed in a day care or clinical setting, under the close supervision of trained staff. Therapeutic foods must be given at two-hour intervals throughout the day and the trained staff must closely monitor actual intake.
115. In Bhutanese refugee camps, the mothers of severely malnourished children are given a pre-mix for preparation of high energy milk as well as bananas and eggs, and instructed how to prepare and administer therapeutic feeding to their children at home. Little if any daily supervision by trained staff is done to ensure that the food is prepared correctly and the children are fed at specified schedule and in necessary amount.
Recommendation
Urgent measures should be taken to ensure proper care and feeding for severely malnourished children. Because of the small number of cases it is not cost-effective to have day care setting for therapeutic feeding in each camp. An alternative solution might be to have the TFP in the closest referral hospital (e.g., AMDA hospital) where children from all camps could be referred. Care should be in strict compliance with international guidelines and norms.
Distribution of General Rations and Food Basket Monitoring
116. The general ration which consists of 410g parboiled rice, 60g lentils, 25g vegetable oil, 20g sugar, 7.5g salt, and 20g chick peas per person per day is distributed to all registered refugees irrespective of age, on a fortnightly basis. The World Food Programme provides this ration. In addition, UNHCR provides fresh vegetables on a weekly basis. The total amount of food distributed is believed to provide about 2000- 2100 kcal per day.
Recommendation
The amount or quality of foods distributed as a general ration should be maintained. A decrease be considered involving all partners concerned should only be considered if economic conditions of refugees and access to alternative food sources improve. If the amount of supplementary vegetable ration provided by UNHCR is to be decreased or such distribution is to be stopped altogether, close monitoring of micronutrient status of the refugee population is strongly advised.
28 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
117. There seem to be common concerns among refugees about the quality of food supplied, particularly rice, lentils and vegetables. Further analysis of this issue is beyond the scope of this mission.
118. With regard to the frequency of the distribution of general ration, the prevailing opinion among refugees and camp officials seems to be that the current frequency should be continued, and not changed to once-a-month distribution. Several reasons were given, including the difficulty of transporting large amounts of food, lack of storage facilities, problems with petty theft of food from the households, difficulties in rationing food evenly for an extended time, and the notion that certain members of the household may sell the food to buy alcohol and/or other items.
119. There seems to be confusion as to the exact amount of ration entitlement, especially among people who are illiterate, have only basic reading and writing skills, or who are from low castes. Posters specifying the ration entitlement for families of different sizes are not currently posted at the distribution site. Such information is available in a table form from the food basket monitor who reported conducting some “awareness-raising” activities. How such activities are conducted and how many people are reached is not clear.
Recommendation
To ensure transparency and uniform access to information regarding the amount of food entitlement, posters should be placed at each distribution site. Posters must be in the native language, using simple words and pictures that can be understood by the least educated members of refugee community. They should include exact amount of food entitlement for all food types being distributed, and should contain aggregate amounts for families of different sizes.
120. A dedicated refugee staff member attached to the nutrition unit currently conducts food basket monitoring. Because the records of food monitoring activities are readily accessible to the camp officials and refugee committee members, it is difficult, if not impossible, to ensure impartial and independent monitoring.
Recommendation
To ensure impartial and independent monitoring, a system of random surprise checks by outside staff (preferably WFP or UNHCR) should be instituted. Monitoring may need to specifically target poor and less educated members of refugee community.
Micronutrient Deficiencies
121. Since an outbreak of angular stomatitis (possibly attributed to Vitamin B2 [riboflavin] deficiency) was detected in refugee camps early in 1999, measurement of this condition has now been included in the annual nutrition surveys. Trends in the prevalence of the signs of Vitamin B2 deficiency since 1999 are presented in Table 8 (overleaf).
29 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Table 8. Prevalence of clinical signs of Vitamin B2 deficiency in Bhutanese refugee population, 1999-2003 (in per cent)
1999 2000 2001 2002 2003 Percentage of all families with at least one member with the signs of 40 19 16.1 10 Vitamin B2 deficiency Percentage of children aged under five with signs of Vitamin B2 39.6 10 7.8 6.5 3.9 deficiency
122. The steady fall in the prevalence of clinical signs of Vitamin B2 deficiency has been attributed to UNHCR's distribution of fresh vegetables, home gardening practices, awareness-raising campaigns, and the availability of Vitamin B complex pills in health facilities in the camps. At present, the situation appears to be improving steadily, although 863 and 521 new cases of angular stomatitis were reported in May and June of 2003, respectively. Further diversification of general diet may have a beneficial effect on the prevalence of this and other micronutrient deficiencies.
123. The mission noted a high reported incidence of morbidity from “mild beriberi” (mild vitamin B1 deficiency) reported in the monthly reports. For example, 459 new cases were reported in May 2003, and 454 new cases in June 2003. On the other hand, no cases of “severe beriberi” were reported in May 2003, and five cases were reported in June 2003. The symptoms of mild beriberi are not very specific and include loss of appetite, malaise, a slight increase in pulse rate, as well as sensation of “pins and needles.” Most of the symptoms are difficult to ascertain during physical examination, and thus the diagnosis is open to wide interpretation.
Recommendation
The case definition of beriberi should be formalized and the information communicated to camp health facilities. A more discriminate approach to diagnosis and reporting of beriberi cases is recommended.
124. Among other micronutrient deficiencies reportable monthly are pellagra (no cases in May and June 2003), scurvy (91 and 55 cases), and Vitamin A deficiency (66 and 37 cases). At the time of the mission, camp health facilities had no written case definitions or diagnosis guidelines for any micronutrient deficiencies. It is surprising that no further inquiry has been conducted into the fact that dozens of new cases of scurvy or vitamin A deficiency are being routinely reported on a monthly basis.
Recommendation
Case definitions for all micronutrient deficiencies prevalent in the camps should be developed, and staff should be trained accordingly. Severity of the cases should be routinely ascertained. The correctness of diagnosis may need to be confirmed by
30 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL medical staff with higher qualifications and experience in diagnosing and treatment of such conditions. If reported incidence of scurvy and Vitamin A deficiency is correct, further nutrition investigation is warranted and additional preventive interventions may be required depending on the outcome of such studies.
125. Every six months Vitamin A supplements are distributed to all children under five years of age (200,000 IU for children of twelve months or younger, 400,000 IU for children aged 1-5 years). One dose of 400,000 IU is routinely given to all mothers immediately after delivery. The coverage of children under the age of five by routine Vitamin A supplementation seems to be relatively high: 95.3% in 2002 and 98.4% in 2003 as reported in annual nutrition surveys.
126. The iron/folate (Fe fumarate 60 mg, folic acid 0.5 mg) daily supplements are routinely distributed to all pregnant women from the time of registration in MCH unit until 45 days post-delivery. The Hemoglobin (Hb) measurement is taken to determine the dosage of the supplement. There seems to be some lack of uniformity in the dosage prescribed: in Beldangi I mothers are given one pill a day in Hb is >10g/dl, 2 pills a day if HB is 8-10 g/dl, and 4 pills a day if Hb is <8 g/dl. In Sanischare, the guidelines are 1 pill a day if Hb >8g/dl, and 2 pills if Hb <8 g/dl.
Recommendation
The recommended iron dosage should be standardized among camps according to the latest international guidelines, and written instructions should be available in each MCH unit. The uniformity and adherence to instructions should be closely monitored.
Eating Habits and Attitudes towards Foods
127. Food that is distributed is the food that is most commonly eaten in the camps. The usual dishes are steamed or fried rice, daal (lentils prepared as a type of gravy and eaten with rice), and mixed vegetables, fried or prepared as a curry.
128. Meat is considered very expensive and most families do not eat it more than once a month. Milk and milk products (including yoghurt, butter, and ghee) are also considered a luxury.
129. These same products (meat, milk and milk products) seem to be also perceived as especially healthy and essential for child development. Fruits and green leafy vegetables are also considered as healthy. There are some cast differences in food consumption. For example, higher caste families (Brahmin, Chhetri) are less likely to eat meat, especially pork or buffalo meat. They tend to be more likely to adhere to vegetarian diet. More research is needed to further elicit cultural beliefs and practices towards foods in this population.
130. Pregnant and lactating women like to eat the supplementary food they receive, as it is “nutritious, tastes good and easy to prepare.” Some husbands make extra efforts to buy more fruits and vegetables for pregnant and lactating women. It seems to be generally accepted that a woman has to eat diverse and sufficient food to have a healthy baby and produce enough milk.
31 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Feeding of Infants and Young Children.
131. Breastfeeding seems to be a universal practice and some mothers’ breastfeed their children for as long as five years. On the other hand, it seems that many mothers tend to introduce UNILITO mix and cow’s milk very early (in the first 1-2 months of life). UNILITO and milk are regarded as especially nutritious and easy to digest foods for the baby, and “not having enough breast milk” is a reason commonly given for introducing these foods as early as 2-3 weeks of life. UNILITO is prepared as a paste and fed to the child by the mother using her fingers. Milk may be given with a spoon or in a bottle with the nipple. Cows’ milk is never diluted, even for the smallest babies, as dilution is thought to decrease the nutritional value of milk. Rice with daal seems to be introduced later in life, at about 6-8 months. Some mothers tend to introduce solid and semi-solid foods very late (as late as 2-2.5 years). Both early and late introduction of complementary foods may seriously affect the health and nutrition of young children.
132. According to international guidelines, exclusive breastfeeding is recommended until six months of life, when the introduction of semi-solid and solid foods (like UNILITO, rice, etc.) should take place. Animal milk must be diluted with water if given to children under the age of one. The early introduction of supplementary foods may interfere with breastmilk production and increase incidence of gastrointestinal infections, among other effects. The late (at one year and later) introduction of complementary foods may lead to macro and micronutrient deficiencies in children, and negatively affect growth. From annual nutrition surveys it is clear that the highest prevalence of acute malnutrition occurs in children aged 12- 23 years. These children are most vulnerable because breastmilk cannot fully satisfy their nutritional needs, and they require small, nutrient dense meals, fed by a caregiver at least five to six times a day.
Recommendation
More attention should be paid to counselling nutrition practices to pregnant women, breastfeeding mothers and caregivers of young children and toddlers. Special emphasis should be given to the timing of the introduction of complementary foods; appropriate ways of preparation; frequency of feeding; and the amount of nutrient dense food given. Comprehensive guides to assist the staff in counselling should be developed, and the staff of both nutrition units and MCH units should be required to counsel caregivers of infants and young children IMCI materials may be instrumental in developing such counselling guidelines. External technical assistance may be required because the IP does not seem to have the necessary technical expertise and experience. Special care should be taken to address the concerns of mothers who feel they “do not having enough milk,” and to counsel them on appropriate infant and young child feeding practices. Health workers should advise against the early introduction of other foods, especially UNILITO and cows milk, which seem to be commonly given in such situations.
133. Further quantitative data on infant feeding practices and mother’s beliefs concerning the appropriate age of introduction of various foods will be available from the survey.
32 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Recommendation
The IP needs technical assistance in interpreting these data. UNHCR should review these data critically each month and ask pertinent questions. A meeting should be held at least every two months between the IP and MoH public health personnel.
Reproductive Health
134. The 1994 ICPD and 1995 Beijing Platforms of Action constituted important landmarks in the defense and promotion of the sexual and reproductive rights of refugees. UNHCR along with other agencies (UNFPA, WHO, international NGOs etc.) committed themselves to the development and improvement of guidelines, manuals and other tools to enhance the provision of comprehensive sexual and reproductive health (SRH) services for refugees and displaced populations, which go far beyond the mere provision of mother and child health services. SRH services should not only provide for quality medical and counseling services on key issues of SRH (such as family planning, safe motherhood, STI/HIV/AIDS and SGBV, and harmful traditional practices). SRH services should also pay due attention to issues such as male involvement in SRH programmes, the empowerment of women and adolescents, psychosocial support and legal aid where required in order to enable the refugee population to claim their sexual and reproductive rights.
Overall Programme
135. SRH services in the camps were initially mainly focused on care of the mother and child. However, services were gradually expanded over time to include other SRH issues. UNHCR delegated SRH services to its health-implementing partner, AMDA, which began Its SRH activities in April 2002. These included awareness- raising as well as clinical activities.
136. Awareness-raising activities are mainly focused on peer education through trained Community Health Volunteers on RH, STI/HIV/AIDS and Sexual and Gender-Based Violence (SGBV). There are also activities such as mass sensitization through training, meetings and mass celebrations. Clinical activities within the context of the RH programmes include laboratory services, e.g., syphilis testing (for ANC mothers) and STI case management (monthly STI clinic, case management training for health staff). The curriculum for peer education training is based on a knowledge attitudes and Practice (KAP) survey carried out in April 2002. So far 96 community health volunteers (CHVs) have been trained (48 male, 48 female), and, as of June 2003, 2,680 peer-sharing activities were reported. The target age group for peer educating activities is between 10 to 24 years.
137. The implementation of the RH programme is still ongoing. However some observations can be made on the basis of activities reviewed, and those observed in Beldangi I.
33 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
KAP Survey
138. The quality, reliability and accuracy of the KAP survey are questionable.
139. Target age group: the age group 10-24 years interviewed was too broad be covered by the same questionnaire. For example, what is the relevance of asking 10- year old boys or girls if using condoms affects pleasure, or who chooses the methods of family planning in the family?
140. The number of possible answers to many questions: For example the question “What is sexual contact in your view?” had multiple answers “kissing”, “touching”, “vaginal sex”, “anal sex” and “others”, but according to the analysis only one answer had been taken into account.
141. Faulty questions: For example, in the case of the question “Have you ever had sexual contact?” no definition was given for sexual contact.
142. Incomplete analysis: The results failed to differentiate between age, school- going status, marital status and sex.
Reproductive Health Unit (RHU)
143. The programme began in Beldangi I on March 1, 2003 with the assignment of a RHU assistant. This person attended a five-day workshop on HIV/AIDS and peer education and a four-day training on VCT. She received no specific training in STI/STDs; neither did she receive any in-depth training on SGBV. The CHV received one-day refresher training on RH, SGBV and HIV/AIDS.
144. So far the RHU assistant has been encouraging the CHVs to engage in peer education and hand in monthly forms with the name, the age and the address of the persons they approached and the topics covered. These forms are compiled by the RHU Assistant and handed over in the Monthly Report Format to the RH Supervisor. This format does not only include data on the number of peer education activities, but also gives an overview of the STI cases treated at the STI clinic and the number of condoms that have been supplied. These data are copied from the STI clinic and the MCH registers. The RHU Assistant is also in charge of the organization of the yearly National Condom Day, which is organized in collaboration with all the refugee organizations in the camp. So far she has not able to use her knowledge on VCT.
145. The CHVs in charge of the peer education programme for young people in the age groups 10-24 years, are themselves aged between 21 and 40 years old. According to AMDA it is difficult to find peer educators in the age group of 10 to 20. Consequently this particular age group is hard to reach through the peer education programme. Also, when looking at the forms, the main focus of the peer education seems to be on HIV/AIDS, and does not cover other aspects of SRH.
146. According to the RHU Assistant the RHU does not have any leaflets or other documents to give to those who have been approached through the peer education programme. According to AMDA, however, handouts should be available at the RHU. AMDA assumes that the manual, which was developed for training of the CHVs and school students, can also be used as handouts. It is not clear why the same manual is used for both students and CHVs, or why the manual (which comprises
34 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL written text only) can be considered a suitable hand out for peer education activities targeting the entire age group 10-to 24 years and for those who are literate and less literate.
147. The RH Unit is supposed to support the MCH in each camp. To this end both services are provided in the same compound. However, as of now, it is not clear, to either the RHU assistant, or to Maternal and Child Health (MCH) staff, what are specific tasks of the RHU assistant in the MCH? The RHU assistant reported that for the first few months of her assignment she could not work because of the lack of supervision by the AMDA RH Supervisor. She also reported that four men had dropped out of the CHVs programme — the programme originally had seven men and seven women, i.e. one man and one woman per sector. She reported this problem to the RH Supervisor in the July 2003 report, but as of 30 September 2003, she had not received a response.
148. It is not clear why the RHU should be part of the MCH and not the other way around. The RHU assistant stated that she would like to do more counselling and awareness-raising. MCH staff have asked that the RHU Assistant be better trained so that she could in turn train them. At present, apart from monthly reporting to the RH Supervisor, the RH Assistant assists the MCH with filling in the Family Planning (FP) register and calling in the patients for the STI clinic, which is open once a month.
Lack of privacy, confidentiality and the proportion of female staff
149. At present, both women and men with SRH problems are referred by the BHU to the MCH (women) or the PHCC center (men). Both the BHU and the PHC are very public areas with no guarantees of confidentiality whatsoever. In a society where talking about sexuality and SRH is still a taboo, both men and women may feel very inhibited in raising SRH issues with health workers knowing that everybody present in the compound may hear them. Another major problem is the lack of female health staff. Of the staff at the PHCC, 70% are male. Women may be severely inhibited in explaining their SRH problems to a predominantly male staff.
Recommendations
AMDA, the RH implementing partner of UNHCR in the camps, is a clinically- oriented NGO whose major expertise is provision of medical care. This means they may not have the required expertise for the implementation SRH awareness-raising and education programmes.
150. In spite of international efforts to promote SRH in refugee settings, the SRH programme in the camps is lagging behind and does not conform to minimum standards. There is a huge need for programme development and adequate supervision and monitoring of SRH services.
151. The decision of UNHCR to create a Community Services Unit in the Damak sub- office (which will be charged with supervision of SRH programmes), and to increase the number of field assistants, is a first and important step in the promotion of SRH in the camps. However, it needs to be said that these measures were primarily inspired by the need for to develop an adequate response to SGBV in the camps, rather than by a real concern about the overall SRH status of the refugee population.
35 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
152. In order to promote a comprehensive approach of the sexual and reproductive rights of the refugee population and to improve the quality of SRH services in the camp, a SRH coordinator should be assigned at the level of the UNHCR Sub-office.
153. The SRH coordinator should be charged with the development of an appropriate and comprehensive SRH programme according to international UN guidelines. The SRH programme should respond to the specific SRH needs and problems of the refugee population and set priorities for SRH needs to be addressed in close collaboration with all the stakeholders involved, including IPs as well as the refugee population, and more specifically men and women of reproductive age and adolescents. This programme should also comprise quantitative as well as qualitative indicators that will enable UNHCR to supervise and monitor the programme adequately.
154. Serious efforts should be made to increase the number of female health staff in the camp health services and to improve confidentiality and privacy at all health facilities in the camps.
Family Planning
155. Modern contraceptives such as the oral contraceptives (OCs), condoms and Depo-Provera are freely available at health facilities in the camp. Family planning (FP) counseling is widely provided by the traditional birth attendants (TBAs), at the BHU and MCH. OCs and condoms are provided at the level of the BHU and Depo-Provera at the MCH clinic. Women can also go to the hospital for IUD placement or Norplant. Information on family planning education is also provided by the Community Health Volunteers in peer education activities.
156. The MoH supplies contraceptives, but for the past two months there has been a shortage and they are no longer regularly available. Men will use condoms when the woman has problems with using other kinds of modern contraceptives or when other contraceptives are lacking.
157. The contraceptive prevalence rate (CPR) in the camps is 30% (2002) which is low compared with the national average of 40%and the national target (of the national Tenth Five Year Plan (2002/2003 – 2006/2007) of 47%. Compared to the CPR in Jhapa district (61%) and in Morang district (78%) the CPR is extremely low. 2
158. Data on the total fertility rate of the refugee population are not readily available. The average family size in the camps is 6.8 and this figure may be an indication that fertility in the camps is still very high. This is also high in comparison with Nepali figures. National family planning policy aims to reduce the total fertility rate from 4.1 per woman in 2001 to 3.5 by the end of 2007. In contrast, refugees report a serious problem of infertility in the camps but this was difficult to verify, as infertility is not included in the HIS.
159. Usually it is women who take the initiative to raise the issue of using FP. Apparently men and women decide together on the number of children they want to have. However, some women expressed their concern that their husband may take a
2 Annual Report. Department of Health Services. 2058/59 (2001/2002), His Majesty’s Government of Nepal. Ministry of Health, Department of Health Services, Kathmandu.
36 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL second wife if they “do not give him” a second child or the daughter or son he wishes to have.
160. When asked about their child-bearing wishes women say they prefer to have two to three children. Men desire even fewer children, one or at most two. At the MCH mothers who already have three children or are at risk of unsafe pregnancies are counseled in family planning.
161. Both women and men prefer to space birth with 4 to 6 years in between “for the blood to become well” and in order to be able to give their children all they need. Men however, are too shy to go for condoms themselves. The main reason is the lack of confidentiality and privacy at the BHU. They would rather go outside the camp to buy condoms or ask their wives to get condoms at the MCH.
162. Men do not seem to be unwilling to use FP and show genuine interest in the SRH of their wives, but it is not clear to which extent counseling programmes are also targeting them.
Recommendation
Family Planning (FP) services in the camps seem to be widely accepted and known by the population in the camp, both for limiting the number of children and for birth spacing. Use of FP services, however, is still rather low and could be increased. Measures should also be taken to guarantee a regular and reliable supply of modern contraceptives.
163. The problem of infertility in the camps should be investigated to see if there is a relationship between infertility and neglect of STI cases and treatment on the one hand, and SGBV on the other.
164. Men should be involved in FP programmes as a first step of involving them in other SRH issues such as the prevention of STI/HIV/AIDS or SGBV. Contraceptive use by men enables them to approach FP with their wives. Activities may include couple counseling, condom promotion (not only for the prevention of STI/HIV/AIDS but also for FP), and peer group sessions.
165. Confidentiality and privacy at the BHU for both men and women should be improved, particularly when counseling is needed regarding sexual issues. For FP counseling and supply women prefer to go to the MCH where they are also attended by female health staff. Men, however, have no alternatives.
Antenatal Care, Deliveries, Abortion and Post-abortion Care
166. Women have an antenatal consultation (ANC) as soon as they know that they are pregnant, i.e. at about 4-5 months gestation. The first ANC is given at the BHU, for further consultation the women can go directly to the MCH. The father is invited to come to the first ANC at the MCH together with his wife where they will receive counseling about care during pregnancy, risk pregnancies and immunization. They are also given a safe delivery kit3 for home delivery. On average, women have ten ANC visits, which is high compared to the national target that considers four ANC
3 The safe delivery kit contains: a plastic, soap, a blade to cut the chord and a plastic coin.
37 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL visits standard to complete antenatal care, which is only achieved in 37.9% of the cases nationwide. ANC coverage in the camps is said to be 100%.
167. TBAs or trained staff conducted 99% of deliveries in 2002. Sixty-nine percent of deliveries take place at home with the attendance of a trained TBA (traditional birth attendants). Risk pregnancies are referred to the MCH (30% of total referrals), where the mothers will be attended by a staff nurse who has received a three-year training, including midwifery, or to the hospital (70% of total referrals) where a caesarean section can be performed.
168. All TBAs have received three months of training and yearly refresher training. They are monitored and supervised by the Auxiliary Nurse Midwife (ANM). There are 2,500 TBAs in the camps but most are no longer in active service. For instance in Beldangi I only 19 of 42 TBAs were still active or less than 50%. It is not clear if the TBAs really are “traditional” birth attendants since many have never worked as TBAs in Bhutan but were trained as TBAs in the camps. TBAs receive an incentive of 40 rupees per delivery and attend an average of 5-8 deliveries per month.
169. Home deliveries in Sanischare have been subject to controversy as the local midwife, who recently graduated, has not been able to carry out a single delivery in the past four months. In Beldangi I, only two deliveries had taken place the previous month at the MCH by the end of September 2003. This is far fewer than the number of deliveries attended by TBAs at home.
170. The main reasons stated by women to give birth at home is “because of shyness” and “at home they can have food and hot water.” For example, the delivery room at the MCH in Beldangi I does not guarantee much privacy as it is next to the counseling room with only a curtain covering the door opening. Moreover deliveries can only be carried out at the MCH on working days during working hours of 8.00 am to 4.30 pm.
171. Another important factor is that men seem to be very concerned about their wife when she has to deliver but feel a little excluded, as they are often not allowed to stay with her, by the TBA or by the midwife.
172. There are no data available on induced abortions in the camp. However, focus group discussions indicated that abortions in the camp were not uncommon. Women could go to private clinics, “take medicine” or perform an unsafe abortion at home, in the forest or at a secret location in the camp, such as the toilet. Abortion is legal in Nepal but abortion services have not been provided by the AMDA hospital since 2002.
Recommendation
The policy of home deliveries attended by TBAs should be reconsidered. There are skilled midwives in the camps who are unable to gain experience and consequently face a real risk of losing their skills because of lack of practice. Moreover, revision of the home delivery policy would also conform to the decision of the MoH to no longer promote home deliveries attended by TBAs.
173. Men should be encouraged and enabled to stay with their spouses during labour and delivery, if this is what they wish.
38 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
174. The practice of unsafe abortions in the camp should not be neglected. Appropriate provisions should be taken to inform refugees, including adolescents, about the risks of unsafe abortions and that safe abortions are performed under the conditions as stated by the law.
STI/HIV/AIDS Knowledge and Awareness
175. So far 13 cases of HIV/AIDS have been detected in the camps, but from the focus group discussions it appears that refugees know very little about STI/HIV/AIDS. In the women’s focus groups none of the participants, even the TBA who was participating had never heard about an STI, an STD, or “diseases you can get from sexual intercourse… from sexual contact… from sex.”
176. Knowledge about HIV/AIDS was limited to the fact that it is a deadly disease. The TBA who participated in the focus group discussions and who had been attending pregnant women since 1994 had no idea what an STI/STD could be. The RH CHV who participated in the focus group discussions could name the most frequent STDs and symptoms but also did not have further information.
177. The men in the focus groups had “heard about diseases you can get from sexual relationship”, “they use to listen but that they don’t know”, meaning that the health workers had “talked to them about it but that they do not know.” They also knew that “you can get it from sexual relationship outside the camp… and that you should use a condom”, but thought that “you cannot get it from sexual relationship within the camp.” When asked which people are particularly at risk of being infected with HIV/AIDS, the answer was that “the person who is 16-24 age, most of them they get HIV/AIDS.”
178. The boys and girls who participated in the focus group discussions — most of them were school going children — showed more accurate knowledge about STI/HIV/AIDS. Most of the information they had came from the radio and not from programmes set up in the camps or from the teachers at school.
39 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Counselling and Treatment
179. Health data on STI cases for the months of January, May and June 2003) showed an alarming difference between the number of female cases (98.6%) and male cases (1.4%) that were treated. Data mentioning four cases of men with vaginal discharge may indicate poor English language skills and understanding of HIS terminology.
180. Access to STI counseling and treatment for women is easier as women can go for STI consultation to the MCH. However, for STI treatment they need to be referred by the BHU to the MCH first. The mainly male staff at the BHU will attend them in a public environment where confidentiality is out of question and where they feel too shy to explain that they have “a female problem”. They will just show very vaguely where they feel pain and “say little things to the doctor who will refer me to the MCH” (RH CHV). Men with STI problems are supposed to be referred by the BHU to the PCH where confidentiality is an equally big problem and proper medical examination is difficult to perform.
181. Women with an STI will be treated at the MCH, but it is not clear if they are properly physically examined. Infected women will also been given medicine for their husbands. If there is no improvement after the third treatment, the MCH will ask her to come back with her husband. Considering the fact that men do not feel comfortable going to the MCH, one may wonder about the efficiency of this approach. It is also important to highlight that health staff at the MCH explicitly asked for STI training because they do not feel very comfortable dealing with STI cases.
182. Serious cases are referred to the STI clinic which is held once a month at the MCH and thus not very easily accessible for men. There are occasional changes in the doctors that are present and they can be from either gender. AMDA fully agreed that it is mainly women living in the camp that are treated for STI and explained that men seeking treatment of very severe STI cases would go to a doctor outside the camp. Apparently. The low number of men seeking treatment did not alarm them.
Recommendations
Refugee’s knowledge about STI/HIV/AIDS needs to be improved. STI services are deficient, particularly for men, and need to be improved. Moreover, health workers need to be trained on the management of STI/HIV/AIDS cases.
183. There is a clear need for a coherent, comprehensive and high quality STI/HIV/AIDS programme in the camps for both adults and adolescents. This programme should focus on prevention and awareness raising, training of health staff, the establishment of a confidential environment for treatment and counseling and regular supervision and monitoring. The employment of female staff at all levels of the health services should be encouraged.
184. Attention should be given to helping refugees and health workers feel more comfortable discussing all aspects related to sexuality and SRH in a language that people understand.
185. The programme should also specifically target the male population. Partner notification, counseling and treatment should be taken up more seriously.
40 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Sexual and Gender-based Violence
Referral System and SGBV Prevention Programmes
186. In September 2002, UNHCR discovered that there was a serious problem of sexual- and gender-based violence (SGBV) in the camps including rape, attempted rape, gang rape, and trafficking and domestic violence. These acts of SGBV were (allegedly) perpetrated by men of both the refugee and the local population, and also by medical staff, teachers and aid workers. It appeared that these cases were not properly dealt with and were not duly reported to the legal authorities. Over the past months the prevalence of SGBV in the camps has been thoroughly investigated by both internal and external missions. The mission report of Human Rights Watch (HRW)4 gives a complete overview of the real scope of the problem and also identifies the strengths and gaps in the efforts to develop proper responses.
187. Alarmed by the prevalence of SGBV in the camps, UNHCR assumed responsibility and has been actively dealing with the incidents since September 2002. UNHCR developed a set of “Standards of Conduct Securing the Protection from Sexual Exploitation and Abuse” which are binding on all employees in the humanitarian aid programme. UNHCR has also committed itself to follow-up on all cases that have been reported. UNHCR has equally invested a lot in the development of a referral system for victims/survivors of SGBV together with all its implementing partners and the Camp Management Committees (CMC)5 of all seven camps. This process resulted in the final first version of the “Manual of Interagency Procedures and Practices: Support to Refugee Communities for Prevention & Response to Sexual and Gender-based Violence in Jhapa and Morang Districts, Nepal.” This manual underwent a final review by December 15, 2003.
188. The referral system does not only provide for proper medical aid, but also for legal assistance and psychosocial support and defines the specific responsibilities of each of the implementing partners. The referral system also pays due attention to the active involvement of the refugees in the reporting of the cases. UNHCR’s findings are that as a result of the steps that have been taken to protect the refugees against SGBV there is a growing confidence among the refugees for reporting cases to the proper referral points.
189. UNHCR has also come to an agreement with the National Bar Association/Jhapa Unit (NBA) for the legal follow-up of the cases. The NBA constituted a panel of 12 lawyers specialized in SGBV and will be in charge of the organization of legal literacy awareness programmes in the camps. The idea is to organize 207 classes on the legal aspects of SGBV for the Comics in all seven camps. These plans are still at a proposal stage. Several cases have already been brought to court successfully.
4 “Trapped by Inequality. Bhutanese Refugee Women in Nepal.” Human Rights Watch, Volume 15, N°8 (C), New York, September 2003. 5 The Camp Management Committee is the refugee-run administration in the camps. It is headed by a Camp Secretary and made up by representatives of the different sectors and sub-sectors. The Camp Secretary as well as the Sector and Sub-sector Heads are elected on a yearly basis. The CMC is in charge of death and birth registration, food distribution, SGBV reporting and health programming. A Counselling Board is elected from the CMC members and serves as a community justice mechanism for the settlement of internal disputes in the camps such as problems between neighbours, domestic violence and divorces.
41 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
190. UNHCR’s IP for health services in the camps, AMDA, developed a “Protocol for Health Workers when Dealing with Cases of SGBV” and a “Protocol on Clinical Examination of Rape Survivors” based upon the WHO guidelines for “Clinical Management of Survivors of Rape” (WHO/UNHCR, Geneva, 2002). AMDA also organized training for its health staff in the treatment of SGBV cases. Rape survivors are also screened for STI/HIV/AIDS. Emergency contraception is not available, but normal contraceptives are used as such.
191. The decision of UNHCR to increase its field-level staff in the camps, the recent employment of a Community Services Officer in September 2003 as well as the assignment of a Community Services Assistant, a SGBV Specialist and a Health Coordinator are clear indications of UNHCR’s commitment to the importance of enhancing social services programmes in the camps in order to better protect the refugees from SGBV. A member of the Bhutanese Health Association has also been selected for a four-month course in Katmandu with CVICT, a well-known Nepali NGO with expertise in psychosocial support of survivors of severe cases of SGBV. Unfortunately, of the two final candidates, one male and one female, the man was selected.
192. Awareness-raising campaigns on SGBV programmes in the camps were very dispersed. All IPs agreed to include a SGBV component in their 2003 programmes, but the resources to deal properly with SGBV prevention and protection were limited and the quality of the SGBV awareness raising activities is still very low. The development and implementation of comprehensive social service programmes under the UNHCR supervision will no doubt contribute to the reinforcement of awareness-raising and prevention programmes in the camps. The mission acknowledges the efforts made by UNHCR and IPs to raise levels of legal protection and psychosocial support SGBV survivors and the organization of training, prevention and awareness-raising activities. However, in spite of all these efforts, there is still no programmatic approach towards raising awareness and preventing SGBV, a fact that is also reflected in the lack of quality and coherence of field activities.
193. The recent statement by the UN High Commissioner for Refugees regarding the the phasing out of the humanitarian aid programmes in the Bhutanese refugee camps, is a source of deep concern to the mission as reductions in funding levels of the Bhutanese refugee camps in Nepal will lead to cuts in social services programmes. In this respect the mission wishes to recall previous experiences referred to in the HRW report where it states that: “the programmatic choice to minimize UNHCR staffing in the camps contributed to grave problems in the administration of justice, especially in cases of gender-based violence” (p.22); and that “Bhutan, Nepal, UNHCR and international monitors have a responsibility to guarantee that gender-based violence programming is not abandoned, and that refugee women’s rights are fully respected in each step.”
Recommendations
UNHCR should develop a common and programmatic approach to SGBV that is adapted to the specific needs in the camps. There is an urgent need for constant monitoring and supervision by UNHCR of the quality of the programs that are being developed by its implementing partners. Implementing partners and the donor community should take up their full responsibility and provide financial and
42 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL logistical support for both technical and social aid programmes that are particularly aimed at the protection of women’s and children’s rights.
Information and Communication
194. One of the major obstacles in assessing the SGBV programme in the camps was the lack of timely access to documents and information that would have enabled the HAM mission to gain insight into the real scope of the problem and to have a better understanding of the kinds of SGBV cases were occurring (sexual abuse, rape, domestic violence, trafficking…), the age and nationality of the victims and of the alleged perpetrators, and the place where these incidents took place (inside or outside the camp).
195. “Secrecy” and “confidentiality” were mentioned as main reasons why this information could not be revealed, as well as shortage of time to classify the existing data. It was also mentioned there had been so many missions over the past year with the goal of investigating SGBV that people are becoming quite upset by it. “Secrecy” and “confidentiality” were also the main reason why SGBV was not discussed among the refugees. Considering the findings of the Human Rights Watch investigation it was also very surprising to find out that the women in the focus groups and even the Bhutanese Refugee Women’s Forum (BRWF) denied very explicitly that there were serious problems of SGBV in the camps. “(S)GBV should be treated confidentially and that is why we don’t know about it” (Women’s Focal Point/BRWF).
196. The Camp Management Committee and the RCU Camp Supervisor also complained about the lack of communication on the follow-up of the SGBV cases that have been reported to UNHCR. Some of the IPs also voiced their lack of understanding of UNHCR’s attitude not to share any information about SGBV in the camps.
197. The silence surrounding the SGBV cases it makes it difficult, if not impossible, for the refugee community to gain a real understanding of the seriousness of SGBV prevalence in the camps. Moreover, the refugee community has a right to information and is entitled to be duly informed about situations that may directly affect their physical, mental and social well-being. Access to information can be organized without violating the victims’ and (alleged) perpetrators’ rights. Reliable information will motivate the community to assume responsibility for the identification of SGBV cases in the camps. It will also contribute to more transparency and a higher level of accountability of stakeholders involved in the fight against SGBV. By providing public information UNHCR will also encourage effective participation of the refugee community with respect to the identification of needs and gaps related to the community’s responses and attitudes towards SGBV and the changes that are needed to meet these gaps.
Recommendations
While it is completely acceptable that cases of SGBV are considered as confidential in order to fully protect the rights of the victims and the alleged perpetrators, it is difficult to understand why the refugee community’s role should be limited to mere reporting and registration: it could play a major role in awareness-raising and sensitization in order to prevent and combat a further increase of SGBV in the camps.
43 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
198. The refugee community, and more particularly refugee women, should be involved in all aspects of the development and adminstration of programmes to combat SGBV in the camps. Their involvement should not be restricted to the mere reporting of SGBV incidents in the camp.
199. Systematized information and data-analysis on the types of aggression and frequency of SGBV is still needed to be able to identify and prioritize needs in the prevention of and protection from SGBV and to develop appropriate programmes. Data analysis and basic statistical information are also needed in order to identify indicators for the assessment of the effectiveness of the interventions that will be undertaken.
Attitudes toward Victims of SGBV
200. Apparently UNHCR and IP staff members had difficulties understanding why the HAM mission paid attention to SGBV, and how SGBV was related to the overall issue of sexual and reproductive health.
201. Reactions of the health-implementing partners when asked about the scope of the problem and the measures they had taken to deal with SGBV at the health level, ranged from reluctance to give clear information to diminishing the magnitude of the problem.
202. These attitudes not only showed the discomfort of IPs with the attention given by the international community to SGBV, and that were also clear indications of a lack of understanding among the —mainly male — health staff in dealing with SGBV victims. Services in the camp are still male-dominated both among IPs and refugee organizations. So far, efforts to reach equal representation of men and women in camps have only resulted in a merely numeric equity and not in tangible progress in empowering women, and fully respecting their participation in decision-making processes.
203. Another issue of major concern is the widespread stigmatization of victims of SGBV. When asked what would happen to the girl who had been a victim of rape, all men in the focus groups unanimously agreed that this girl would never get married and that even if somebody would be willing to marry her, “the marriage would be unhappy because the girl would be neglected by the community.” Because of fear of stigmatization and that “the whole community will know about it” the participants in the adult focus group discussions also indicated that they would turn first to one of the neighbour’s to consult him or her about what to do in case of SGBV. It appears that the refugees rely heavily upon neighbour’s advice to decide whether they should report the case or not.
Recommendations
There is a need for specialized gender-training and sensitisation of all stakeholders involved in the management of the camps, including the Refugee Coordination Unit (RCU) administrators, the police officers, the senior management and the staff of the aid agencies as well as the members of the CMC.
44 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
204. UNHCR should explicitly encourage its implementing partners to gender- mainstream their policies, and to develop strategies to actively promote the employment of female staff at all programme levels.
205. Comprehensive awareness-raising and sensitization programmes that do not exclusively deal with SGBV from a strictly medical/clinical or legal point of view should be developed. These programmes should highlight SGBV within the broader scope of SRH and also emphasize the long-term impact of SGBV on the mental and social well being of its victims and their families.
Recognition of Polygamy and Domestic Violence
206. The main focus of the SGBV related activities in the camp has been on sexual violence, and more particularly on rape, attempted rape, sexual abuse and trafficking, and much less on the impact of polygamy and domestic violence on the physical, mental and social well-being of women.
207. The interagency procedure manual uses the definitions of SGBV defined in the document on “Sexual and Gender-Based Violence against Refugees, Returnees and Internally Displaced Persons” (UNHCR, Geneva, May 2003), but apparently fails to adapt them to the specific context of the Bhutanese refugees. “Polygamy-related problems” are classified as “non-SGBV cases.” In the camps, however, polygamy6 is widespread, and is a main cause of distress and depression among women who have been affected by it. Nevertheless, most IPs do not regard it as a problem affecting women’s SRH status. In this respect the mission wishes bring attention to the HRW report which explicitly mentions Nepali legislation on polygamy and women’s custody over the children in case of divorce and remarriage as a main cause of discrimination against women and one of the leading causes of SGBV.
208. Insufficient attention is, likewise, paid to the prevalence of domestic violence as an expression of SGBV. Focus group discussions revealed that domestic violence is commonly regarded as a private problem that should be solved by the “quarrelling” partners (“It is up to themselves… no one can do anything” or “the quarrel disappears as it started… by themselves.”) They also revealed that there is a causal relationship between alcohol abuse and domestic violence. Social stigmatization and the lack of legal protection inhibit women from reporting domestic violence.
209. UNHCR recognizes that domestic violence is a major problem in the camps but at the same time admits that cases of domestic violence are mainly settled by the Sector or Sub-sector Head, and that appropriate services to prevent domestic violence are still lacking (lack of space, lack of training, lack of awareness raising and lack of psychosocial counseling).
6 HRW uses the term “polygyny” referring to men having more than one wife and “polygamy” referring to both men having more than one wife or women having more than one husband (“polyandry”). The HAM report will use “polygamy” to refer to men having more than one wife, as “polygamy” is most commonly used by both the refugees and the implementing partners when referring to men having more than one wife.
45 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Recommendations
UNHCR and its IPs should fully address the problems of polygamy and domestic violence in the camp and recognise these very explicitly as SGBV in the interagency procedure manual.
210. UNHCR should cooperate with other UN agencies and NGOs to advocate for legislative changes in Nepal to protect women and children’s rights.
Early Marriage, Early Pregnancy and School Drop-out
211. Marriage customs have changed profoundly since the refugees arrived at the camp. In Bhutan marriage was arranged between the parents of the boy and the girl. Although parents reportedly also asked for the consent of their children, it remains to be seen whether this consent was really free of pressure: “The girl was obliged to marry the boy who wanted her.”
212. Most women in the focus groups were married by a “love marriage”, or elopement whereby the boy takes the girl away for some days and after they return to the camp they will ask the parents to arrange the marriage. This kind of elopement is often practiced in cases of inter-caste marriages, as young people are fully aware that they will never get their parents’ consent to marry someone from a lower caste. Most girls who marry by elopement, marry at the age of 14 or 15. Girls who only reached grade 5 or 6 at school apparently ran a higher risk of elopement at a young age. After grade 6, a gradual increase in school dropout rates among girls was noticeable.
213. Until the end of 2002 pregnant girls were not allowed to finish school. While the rule changed in 2003, the attitude of the teachers did not, and pregnant girls were not encouraged to finish their schooling. Teachers at Beldangi I and Sanischari unanimously agreed that “the girl should stay with her child”, and that she should stay home as soon as she knows that she is pregnant. “Our society is not that advanced. These girls are shy and prefer to stay home.” “She should become a housewife” and “If she wishes, she should be given vocational training, non-formal education.” Young fathers, on the other hand, are expected to finish school at least till grade 10: “Well, he should finish his studies. You know, be a student at school and a father at home.”
214. Women seem to prefer the system of love marriage to arranged marriages. Most men and adolescent boys, however, preferred arranged marriages and waited to marry until they had finished school. Many young teachers also delayed marriage because they have no future to offer to their wives if they remained in the camps.
215. No doubt there is a link between low education and early marriage by elopement. According to Nepali law, girls are not allowed to marry before the age of 18 and boys before the age of 20 years. Only if the parents agree, girls may marry at the ages of 16 and boys at the age of 18. Early marriages are not registered in the camp. Thus in cases of marriage by elopement where the marriages are not legally registered, young girls become extremely vulnerable.
216. According to the TBA who participated in the focus group discussion, most girls are pregnant when they get married and according to the health data reports 9% and more of the women who come for their first antenatal consultation are younger than 19 years.
46 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
217. In the camps there are no services where young people can go for counseling, treatment and support for SRH related issues. Unmarried and pregnant girls run the risk of stigmatization and exclusion. “She will never get married.” “She can only get married to somebody from outside the camp.” “Her parents will chase her from the house.” “If the father does not want to marry her, they will pay another man and give him gold to marry the girl till she gives birth.”
218. Marriage “by elopement” is very common in the camps and is mainly practiced by young people between the ages of 13 and 18. In-school and out-school education programmes should be set up to raise awareness among the young and their parents, and even grandparents about the risks of early marriage, early pregnancy and the benefits of good education.
Recommendations
Considering the very young age at which girls elope (13-15 years) SRH awareness- raising programmes should be developed that target the age group between 10 to 15 years, and not to wait till they reach 9th or 10th grade at school.
219. Girls should be encouraged and supported to stay in school and complete their education. Steps should be taken to encourage pregnant girls to finish their education and to raise awareness among parents, schoolteachers (young and old) and the students themselves about the importance of women’s education not only for their own well-being, but also for their families.
Sexual Education and SRH Provisions
220. General knowledge about SRH related issues among school-going adolescents is fairly good, however this finding may be somehow biased by the fact that almost all participants in the adolescent focus group discussions were still going to school.
221. It also appeared that most of them were active members of the Bhutanese Children’s Forum. Consequently there is more than sufficient cause to assume that knowledge levels on SRH-related issues among school dropouts, and particularly among girls for the reasons stated above, may be far lower.
222. Reproductive health is also included in the curriculum of grades 9 and 10. Most of the teachers are very young and only received one day of teacher’s training after finishing grade 12, feel uncomfortable when they have to teach the subject. All (young) teachers insisted upon the need for training in SRH issues in order to be able to teach the subject properly. Girls also explained that they felt too shy to ask questions about SRH because they shared the classroom with boys.
223. The radio was mentioned as main source of information on SRH for young people.
Recommendations
Attention should be paid to the development of appropriate sexual education programmes for school-going and non-school-going-children and adolescents. These programmes should include quality peer education and pay due attention to the creation of a confidential environment where boys and girls can talk easily about
47 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
SRH-related issues. In the camps special SRH services for unmarried young people should be developed where they can go for counseling, treatment and psychosocial support.
Youth Programmes
224. Young people, who are undergoing rapid physical, emotional and mental development, are very much in need of opportunities to explore and develop their personality in all respects. Life for young people in the camps, however, is very monotonous. When they do not go to school, boys as well as girls work at home, weaving for extra income, or helping in the kitchen and with the laundry. Finishing school, moreover, does not offer them any perspective for the future, because, as refugees, they are not allowed to leave the camps and to look for a job.
225. Recreational and creative activities in the camp are very limited mainly due to a lack of resources. The Bhutanese Refugee Children Forum in Beldangi I organizes art classes but only has one pencil for three children; it also holds music classes but has only three instruments for 50 students. Teachers at school complain that there is no budget for sports or recreational activities and that the school magazine had to be closed down for the same reason.
226. Children in the camps have few dreams. When asked to make a wish, they could only think of returning to Bhutan, a country that most of them had never seen or could not even remember. They had no idea what life could be like if they had not become refugees. Many felt despised by Nepalese adolescents. The Children’s Forum in Belgdangi I included an exposure visit to Nepalese Youth Organizations in its 2003 programme, but later cancelled it due to lack of funds. “The first year it was because there was no budget. The second year because there was no budget. The third year because there was no budget. Last year it was because of security. This year also it was because of security… But what can we do? We have to accept.”
Recommendation
Priority should be given to supporting the Bhutanese Refugee Children’s Forum in the camps and to the development of appropriate life-skill training programmes that also pay due attention to the provision of recreational and creative opportunities for children and adolescents. Possibilities of exchange programmes with their local peers should be considered.
Interaction with MoH Services
227. With current plans for disengagement, it is important to involve the MoH as much as possible. Dr. B.D Chataut, Director-General of Health Services for the MoH attended the debriefing workshop in Kathmandu and expressed his interest in the MoH and UNHCR working closer together with other partners. The WHO Representative also expressed interest in supporting UNHCR and its implementing partners. At the debriefing workshop the following recommendations were made.
48 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Recommendations
UNHCR should support IMCI training, conducted by the MHO/WHO for all Bhutanese and implementing partner staff.
228. MoH staff working in health posts and clinics should also attend the training, to improve contact and coordination.
229. UNHCR should advocate with UNICEF and WHO that Jhapa and Morang districts be included as special focus districts for IMCI.
230. UNHCR should also support a WHO/MoH workshop on rational drug prescribing practices.
231. As part of the disengagement process, UNHCR should provide basic equipment to surrounding government facilities, especially if these facilities are expected to cope with an increased workload as a result.
232. Regular meetings on disease surveillance should be held between MoH public health staff, UNHCR and IP staff.
233. Government case definitions and protocols for case management should be made be made available in all camp facilities.
49
List of all Recommendations
234. Since population data are a key element in calculating health indices, UNHCR should conduct a standard rapid verification exercise in at least one camp. If substantial discrepancies are found, the exercise should be extended to all camps. The results of the community survey in Beldangi I should be reviewed to assess whether the evidence exists to show that population data has been over or underestimated.
235. In addition to calculating separate monthly mortality rates for all camps, cumulative mortality should also be calculated, as this figure will be more stable.
236. The HIS mortality reporting system should be expanded to include the four or five most common chronic disease categories (as has been done for morbidity). This might help track needs for certain medications.
237. Implenenting partners should not place too much emphasis on the yearly maternal mortality ratio as this is very unstable.
238. Every effort must be made to ensure that the HIS captures all deaths. All three registers in all camps should be checked regularly and closely monitored. In addition, the records should be reviewed monthly with LWF and sector heads in each camp to check whether there were additional deaths that were not recorded by AMDA. AMDA records should be the primary source for mortality recording in the Refugee Coordinating Unit (RCU), and the data should be transferred without delay on a monthly basis from AMDA to RCU to NRCS.
239. Suicide should be added to the HIS as a cause of death. Some of the more common chronic disease categories such as Chronic Obstructive Pulmonary Disease (COPD), hypertension, diabetes and CCF should also be added. All deaths among children occurring at home should be investigated to see if preventive actions could have been taken.
240. Reasons for such over-use of health services should be investigated. This information should be used to design a community education programme around the overuse of out-patient department (OPD) services. Offering the services of a community health care worker as the first point of contact for some cases, particularly for adults, should be considered.
241. Laboratory confirmation must be obtained on several stool specimens to identify the organism. Treatment protocols for the specific disease must be put in place. The role of water, sanitation and hygienic practices should be investigated and appropriate action taken.
242. AMDA must confirm whether or not the above cases were adequately investigated and if they were confirmed. All new cases of suspected TB should be reported to the health coordinator, so that they can be followed up.
243. The HIS should record injury at least as being intentional or unintentional. If cases of attempted suicide are occurring they should be tallied separately.
51 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
244. The current mental health programme needs improvement. An investigation should be conducted as to what types of mental illness are being reported and what are the underlying causes.
245. Protocols for the management of STIs must be put in place as soon as possible. Organisms should be tested for drug sensitivity. Partner tracing should be strictly adhered to. A community education programme aimed at men may be needed.
246. The actual amount of water being collected per family should be determined, perhaps through the UNHCR community assistants. The actual amount may either be below 20 litres per person per day, or that amount may not be sufficient for this population.
247. At least a proportion of suspected malaria cases among locals and non-traveled refugees should have blood slides taken.
248. It is crucial that UNHCR send an experienced consultant for at least two months to work with the implementing partner to improve the delivery of primary health care. The consultant should conduct IMCI training for all clinicians, use or adapt MoH develop treatment protocols and institute use of standard case definitions. Part of the TOR should be to work with the MoH and other possible health partners such as WHO and UNICEF.
249. Drugs and services at the BHUs should be upgraded to match what should be theoretically available in a government health post. Staff should be given training in IMCI to which MoH staff form surrounding clinics should also be included. Nepal National Recommended Case Definitions (available from the MoH EDCD) should be available and used. The number of BHU workers who see patients should be increased so that even allowing for sickness or leave, each clinician sees no more that 50 patients per day. Treatment protocols should be available and used. Adding another BHU to Beldangi II extension should be considered. WHO Nepal should be asked to conduct an appropriate prescribing practice workshop for all health workers.
250. A dialogue should begin as soon as possible with the MoH on how the BHUs might be incorporated into the government system. Before the handover process, UNHCR should ensure that the BHUs are using the same case definitions and protocols and giving the same services as recommended for government health posts.
251. Increase the overall number of PHCC staff in Beldangi II PHCC that sees patients. In Beldangi I and Beldangi II, services and drugs should be upgraded to match what should be theoretically available in a government PHCC. This alone will improve in-camp services for a third of the refugee population. IMCI training should be conducted for PHCC staff. Standard case definitions should be used. Treatment protocols should be available in all PHCCs. These health workers should also attend a WHO workshop on appropriate prescribing practices.
252. The PHCCs in Beldangi I and Beldangi II should remain after UNHCR’s handover to the Government of Nepal. Services and staffing and protocols should be uniform with the MoH PHCCs. The government PHCC at Mangalbare (which is excellent) is a good model to follow.
52 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
253. AMDA should move from focusing on individual activities to a more programmatic approach.
254. AMDA should make sure that mothers are sufficiently well educated to now about the benefits of vaccination.
255. Good quality community-based mental health services should be made available, especially since such services might play an important role in dealing with the psychological consequences of SGBV.
256. Doctors prescribing a name-based drug should be obliged to complete a form justifying the need to do so. Drugs at camp health facilities should include all drugs on the recommended government lists. Staff should be trained in prescribing them, in order to help to reduce referrals to hospitals.
257. All health education materials should be reviewed. Someone from UNHCR or another partner with this expertise (WHO, UNICEF, UNFPA) should attend health education sample sessions given by the implementing partner.
258. Every effort should be made to stabilize patients on a drug on the essential list rather than a name-based drug.
259. Since SGBV has been identified as a significant problem in the camps, the HIS should collect information on domestic violence and self-inflicted injury. Camp data should be shared with local and regional government public health staff.
260. In future nutrition surveys the prevalence of stunting should be disaggregated according to age (e.g., 0-11 months, 12-23 months, and 24-59 months). The prevalence of stunting should also be measured in 6-10 year-old schoolchildren.
261. To further improve the quality of nutrition survey reporting, 95% confidence intervals (or values for standard deviation) should be reported with all major prevalence indicators. Also, tests for significance of association should be reported when bi-variate (e.g. 2*2 tables) or multi-variate analyses are presented. Acute malnutrition prevalence should be expressed in Z scores, as this makes it possible to make a comparison with other national and international data where acute malnutrition prevalence is reported using Z scores.
262. The following method for calculating the required number of households should be used. If the required sample size of 396 children has been determined assuming simple random sampling and expected prevalence of wasting of about 10% with required precision of 3%, then, the required number of households to be included in the survey is determined as follows: number of children divided by average household size and by proportion of children aged under-five in the total population. For example, if average household size is 6.0 and proportion of children aged under-five in the total population is 0.08 (8%), then the required number of households is determined as follows: 396/(6*0.48)=825.
263. If only children aged under-five are of interest in the survey, then those of 825 selected households that have no such children can be skipped. It is not necessary to go to neighbouring households until a child aged under-five is found. As usual, all children aged under-five found in selected households should be measured.
53 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
264. Provisions should be made to ensure effective monthly growth monitoring of children aged over one year of age, if such monitoring is deemed essential and beneficial. Possible solutions could include a system of small incentives for monthly visits, more proactive follow-up of no-show cases by community health workers, measuring children in their homes, etc.
265. If the shortage of staff and/or other logistical problems make it difficult to ensure compliance in cohorts older than one year, an alternative monitoring strategy may be advised: to include in monthly screening only children under one year of age and children under five years of age who had borderline low (85% WHM or lower) nutrition status at the annual nutrition screening. The latter cohort (under-five with borderline low WH scores) should be included in monthly nutrition screening for at least six months or until the child has WHM score over 85% on three consecutive monthly measurements.
266. Efforts must be undertaken urgently to enhance the expertise of nutrition staff in the area of counselling and follow-up. Specific field guidelines on counselling on infant feeding and growth promotion should be adapted from existing sources, such as IMCI guidelines, and implemented in all camps. Staff capacity of nutrition units should be increased as appropriate to meet new workload demands.
267. Enhancing growth monitoring will mean that additional provisions should be made to ensure full coverage by mass screening of children under-five years of age.
268. Invite for monthly follow-up those children whose WH % of median score lies just above the cut-off point (e.g., children with 80-85% of median WH score) should be invited for monthly follow-up. This may be especially important for children aged between two to five years-old who are not usually targeted for monthly growth monitoring. Determine whether there are pronounced seasonal patterns or cycles of malnutrition in children under-five, and if such patterns exist, to conduct a mass screening during the “worst” season to detect the maximum number of cases of malnutrition.
269. The practices of SFP discharge observed in Bhutanese refugee camps are unacceptable and demonstrate a lack of expertise and supervision. These practices must be reversed as soon as possible. Clear and uniform guidelines of discharge must be communicated to the staff of nutrition units in all camps, and strict adherence to these guidelines must be closely monitored.
270. Under such discharge practices, the exit statistics provided in monthly report are largely meaningless and cannot be used for objective evaluation of programme performance.
271. If the current IP is to administer SFP for Bhutanese refugees in the future, urgent technical assistance should be provided to correct irregularities and ensure that programmes are administered according to internationally-accepted guidelines. Constant monitoring and follow-up on the part of UNHCR is advisable.
272. At this time, it is not recommended or advisable to decrease or eliminate the SFP for malnourished children or other categories of beneficiaries. Only if economic conditions of refugees, access to jobs and access to alternative food sources beyond
54 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL those currently distributed in the general ration meaningfully change to the better, should the exit strategies for SFP be considered involving all partners concerned.
273. Additional training should be given to nutrition units staff include internationally accepted guidelines on supplementary feeding for young children, methods of preparation of the supplementary ration, guidelines on the type, amount and frequency of feeding for children of different ages, including breastfeeding, appropriate ages at which complementary foods should be introduced, and counseling techniques.
274. A full course of counselling for mothers should be mandatory on admission to SFP and TFP. The number of staff in nutrition units should be increased, to meet increased workloads. Close monitoring and follow-up of long-term cases of malnutrition should be instituted, and children with chronic medical problems should be referred for further treatment as appropriate. Clear and comprehensive guidelines for monitoring and follow-up of children who fail to improve their WH scores should be instituted. The average length of stay is a crucial indicator to evaluate the effectiveness of the SFP in controlling malnutrition, and should be calculated on a regular basis and included in monthly reports.
275. Measurement of malnourished children should be carried out every two weeks, at the very least. All staff of nutrition units should adhere to these standards, and implementing partners should ensure appropriate monitoring of measurement practices.
276. Urgent measures should be taken to ensure proper care and feeding for severely malnourished children. Because of the small number of cases it is not cost- effective to have a day-care setting for therapeutic feeding in each camp. An alternative solution might be to have the TFP in the closest referral hospital (e.g., AMDA hospital) where children from all camps could be referred. Care should be in strict compliance with international guidelines and norms.
277. The amount or quality of foods distributed as a general ration should be maintained. Only if economic conditions of refugees and access to alternative food sources improve, should a decrease be considered involving all partners concerned. If the amount of supplementary vegetable ration provided by UNHCR is to be decreased or such distribution is to be stopped altogether, close monitoring of micronutrient status of the refugee population is strongly advised.
278. To ensure transparency and uniform access to information on the amount of food entitlement, posters should be placed at each distribution site. Posters must use a language that is commonly understood by the refugees, and should use simple words and pictures that can be understood by the least educated members of refugee community. They should include the exact amount of food entitlement for all food types being distributed, and should contain aggregate amounts for families of different sizes.
279. To ensure impartial and independent monitoring, a system of random checks by outside staff (preferably WFP or UNHCR) should be instituted. Monitoring may need to specifically target poor and less educated members of refugee community.
55 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
280. The case definition of beriberi should be formalized and such information communicated to health facilities in the camps. More discriminate approach to diagnosis and reporting of beriberi cases is recommended.
281. Case definitions for all micronutrient deficiencies prevalent in the camps should be developed, and staff trained accordingly. The severity of the cases should be routinely ascertained. The correctness of diagnosis may need to be confirmed by medical staff with higher qualifications and experience in diagnosing and treatment of such conditions. If reported incidence of scurvy and Vitamin A deficiency is correct, further nutrition investigation is warranted and additional preventive interventions may be required depending on the outcome of such studies.
282. The recommended iron dosage should be standardized among camps according to the latest international guidelines, and written instructions should be available in each MCH unit. The uniformity and adherence to instructions should be closely monitored.
283. More attention should be paid to nutrition counselling of pregnant women, breastfeeding mothers and caregivers of young children and toddlers. Special emphasis should be given to the timing of introduction of complementary foods, appropriate ways of preparation, frequency of feeding and amount of nutrient dense food provided. Comprehensive guides to assist the staff in counselling should be developed, and the staff of both nutrition units and MCH units should be required to provide advice to caregivers of infants and young children on IMCI materials. External technical assistance may be required because the implementing partner does not seem to have the necessary technical expertise and experience. Special care should be taken to assist the mothers who perceive that they “do not having enough milk,” to address their concerns, and to counsel them on appropriate infant and young child feeding practices. Health workers should advise against the early introduction of other foods, especially UNILITO and cow’s milk, which seem to be commonly given in such situations.
284. The IP needs technical assistance in interpreting these data. UNHCR should review these data critically each month and ask pertinent questions. A meeting at least every two months should be held between the implementing partner and MoH public health personnel.
285. AMDA, the reproductive health implementing partner in the camps, is a clinically-oriented NGO whose major expertise is provision of medical care. This means they may not have the required expertise for the implementation SRH awareness-raising and education programmes.
286. In spite of international efforts to promote SRH in refugee settings, the SRH programme in the camps is lagging behind and does not conform to minimum standards. There is a huge need for programme development and adequate supervision and monitoring of SRH services.
287. UNHCR’s decision to create a Community Services Unit in the Damak Sub- office, which would eventually be handed the responsibility of SRH programmes, as well as its decision to increase the number of field assistants, is a first and important step in the promotion of SRH in the camps. However, it needs to be said that these measures were inspired in the main by the need for to develop an adequate response
56 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL to SGBV in the camps, rather than by a real concern about the overall SRH status of the refugee population.
288. In order to promote a comprehensive approach of the sexual and reproductive health (SRH) of the refugee population and to improve the quality of SRH services in the camp, a SRH coordinator should be assigned at the level of the UNHCR Sub- office.
289. The SRH coordinator should be asked to develop an appropriate and comprehensive SRH programme in line with international UN guidelines. The SRH programme should respond to the specific SRH needs and problems of the refugee population and set priorities in the SRH needs to be addressed in close collaboration with all stakeholders involved, including IPs and the refugee population, and more specifically men and women of reproductive age and adolescents. This programme should also comprise quantitative, as well as qualitative indicators that will enable UNHCR to supervise and monitor the programme adequately.
290. Serious efforts should be made to increase the number of female health staff in the camp health services and to improve confidentiality and privacy at all health facilities in the camps.
291. Family Planning (FP) services in the camps seem to be widely accepted and familiar to the population in the camp, both for limiting the number of children and for birth spacing. The recourse to FP services, however, is still rather low and could be increased. Measures should also be taken to guarantee a regular and reliable supply of modern contraceptives.
292. The problem of infertility in the camps should be investigated to see if there is a relationship between infertility and neglect of STI cases and treatment on the one hand, or sexual-and gender-based violence (SGBV) on the other.
293. Men should be involved in FP programmes as a first step towards engaging them in other SRH issues such as the prevention of STI/HIV/AIDS or SGBV. Contraceptive use by men enables them to share the responsibility of FP with their wife. Activities may include couple counseling, condom promotion (not only for the prevention of STI/HIV/AIDS but also for FP reasons), and peer group sessions.
294. Confidentiality and privacy at the BHU for both men and women should be improved, particularly when counselling is needed regarding sexual issues. For FP counseling and supply women prefer to go to the MCH where they are also attended by female health staff. Men, however, have no alternatives.
295. The policy of home deliveries attended by TBAs should be reconsidered. There are skilled midwives in the camps who are unable to gain experience and who, consequently, face a real risk of losing their skills because of lack of practice. Moreover, revision of the home delivery policy would also conform to the decision of the MoH to no longer promote home deliveries attended by TBAs.
296. Men should be encouraged and enabled to stay with their spouses during the period of labour and delivery, if both wish them to do so.
297. The practice of unsafe abortions in the camp should not be neglected. Appropriate provisions should be taken to inform refugees, including adolescents,
57 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL about the risks of unsafe abortions and that safe abortions are performed under the conditions as stated by the law.
298. Refugees’ knowledge on STI/HIV/AIDS needs to be improved. STI services are deficient, particularly for men, and need to be improved. Moreover, health workers need to be trained on the management of STI/HIV/AIDS cases.
299. There is a clear need for a coherent, comprehensive and high quality STI/HIV/AIDS programme in the camps for both adults and adolescents. This programme should focus on prevention and awareness raising, training of health staff, the establishment of a confidential environment for treatment and counseling and regular supervision and monitoring. The employment of female staff at all levels of the health services should be encouraged.
300. Assistance should be provided to refugees and health workers to make them feel more comfortable discussing all aspects related to sexuality and SRH in an easily understandable language.
301. The programme should also specifically target the male population. Partner notification, counselling and treatment should be taken up more seriously.
302. UNHCR should develop a common and programmatic approach to SGBV that is adapted to the specific needs in the camps. There is an urgent need for constant monitoring and supervision by UNHCR of the quality of the programs that are being developed by its implementing partners. Implementing partners and the donor community should take up their full responsibility and provide financial and logistical support for both technical and social aid programmes that are particularly aimed at the protection of women’s and children’s rights.
303. While it is completely acceptable that cases of SGBV are being handled confidentially in order to fully protect the rights of the victims and the alleged perpetrators, it is difficult to understand why the refugee community’s role should be limited to mere reporting and registration; it could play a major role in awareness- raising and sensitization to prevent and combat a further increase in SGBV in the camps.
304. The refugee community, and more particularly refugee women, should be involved in all aspects of the development and maintenance of programmes to combat SGBV in the camps. Their involvement should not be restricted to the mere reporting of SGBV incidences in the camp.
305. Systematized information and data-analysis on the kind and frequency of SGBV is still needed in order to be able to identify and prioritize needs in the prevention of and protection from SGBV and to develop appropriate programmes. Data analysis and basic statistical information are also needed in order to identify indicators for the assessment of the effectiveness of the interventions that will be undertaken.
306. There is a need for specialized gender-training and sensitization of all stakeholders involved in the management of the camps, including the Refugee Coordination Unit (RCU) administrators, the police officers, the senior management and the staff of the aid agencies as well as the members of the CMC.
58 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
307. UNHCR should explicitly encourage its implementing partners to gender- mainstream their policies, and develop strategies to actively promote the employment of female staff at all programme levels.
308. Comprehensive awareness-raising and sensitization programmes need to be developed that do not exclusively deal with SGBV from a strictly medical/clinical or legal point of view. These programmes should highlight SGBV within the broader scope of SRH and also emphasize the long-term impact on the mental and social well-being of SGBV survivors and their families.
309. UNHCR and its implementing partners should fully address the problems of polygamy and domestic violence in the camp and recognize these very explicitly as SGBV in the interagency procedure manual.
310. UNHCR should cooperate with other UN agencies and NGOs to advocate for legislative changes in Nepal to protect women and children’s rights.
311. Considering the very young age at which girls elope (13-15 years) SRH awareness-raising programmes should be developed that target the 10-15 years-old age group, and not to wait till they reach ninth or tenth grade at school.
312. Girls should be encouraged and supported to stay in school and complete their educations. Steps should be taken to encourage pregnant girls to finish their education and to raise awareness among parents, schoolteachers (young and old) and the students themselves about the importance of women’s education not only for their own well-being, but also for their families.
313. Attention should be given to the development of appropriate sexual education programmes for school-going and non-school-going children and adolescents. These programmes should include quality peer education and pay due attention to the creation of a confidential environment where boys and girls can talk easily about SRH related issues. In the camps special SRH services for unmarried young people should be developed where they can go for counseling, treatment and psychosocial support.
314. Priority should be given to supporting the Bhutanese Refugee Children’s Forum in the camps and to the development of appropriate life-skill training programmes that also pay due attention to the provision of recreational and creative opportunities for children and adolescents. Possibilities of exchange programmes with their local peers should be considered.
315. UNHCR should support IMCI training, conducted by the MoH/WHO for all Bhutanese and implementing partner staff.
316. MoH staff working in health posts and clinics should also attend the training, to improve contact and coordination.
317. UNHCR should advocate with UNICEF and WHO that Jhapa and Morang districts be included as special focus districts for IMCI.
318. UNHCR should also support a WHO/MoH workshop on rational drug prescribing practices.
59 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
319. As part of the disengagement process, UNHCR should give support in terms of basic equipment to surrounding government facilities, especially if these facilities are expected to cope with an increased workload as a result.
320. Regular meetings should be held between MoH public health staff, UNHCR and implementing partner staff on disease surveillance.
321. Government case definitions and protocols for case management should be made used in all camp facilities.
60
Conclusions and Major Recommendations
322. Currently, crude and under-five mortality rates among Bhutanese refugees are considerably lower than those of the surrounding population. In general, access to curative health services is better for the refugee than is the case for the host population. However, despite distribution of an adequate general ration, nutrition indices for the refugees are not markedly different to those reported in the 2001 DHS for the local population.
323. The Joint Evaluation mission identified some health and nutrition practices in the camps that are not in accordance with international norms and standards. These practices pose a threat to the health of the refugee community, and may also negatively affect the health of the local community. If the eventual aim is to integrate refugees who remain within the national health system, these practices must be corrected before any handover takes place.
324. The level of qualification of staff at the pre-hospital level is low. There are no standardised case management protocols (such IMCI). Sexually transmitted infections are being incorrectly managed. There have been mass discharges of children from the SFP at lower than recommended weight for height. The TFP is inappropriate, and there is no nutrition counselling for mothers of growth faltering children. Despite the recent focus on sexual and gender-based violence (SGBV), there is no programmatic approach to this issue. There is confusion between the need to assure confidentiality for the victims of SGBV and the need to base interventions on an in-depth understanding of the underlying problems. In general, although different health and nutrition activities are being implemented in the camps, there is an absence of integrated programmatic approaches.
325. The joint evaluation team feels that the problems above have arisen despite the desire of both UNHCR and its IPs to provide the best service possible to the refugees. The factors that have contributed to the current problems are: a lack of financial resources on the part of UNHCR-Nepal; the handover of health and nutrition services in January 2001 to a local NGO with little experience in public health programming; and the lack of oversight on the part of UNHCR, of an experienced public health coordinator.
Major Recommendations
1. UNHCR should replace the IP with a more experienced NGO. 2. If it is not possible to replace the current IP with one with more public health experience, the capacity of the implementing partner must be improved in three key areas: a) IMCI; b) nutrition and c) reproductive health/SGBV. Three consecutive consultancies of no less than two months each in each of the three areas are needed to strengthen capacity in these areas. A key activity of these consultants would be to work alongside the main implementing partner and UNHCR field staff in order to build capacity. The consultants should also begin looking at the integration of MoH and refugee health services and work closely with other implementing partners such as
61 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
WFP as well as involving other potential partners such as the MoH, WHO, UNICEF and UNFPA. 3. In time, following the above interventions, UNHCR should consider handing over these more efficient clinics to the MoH. 4. UNHCR should engage a health coordinator with experience in overseeing public health programmes in refugee situations. 5. UNHCR should consider the possibility of collaborating with UNFPA or another partner for the development of a comprehensive RH programme. 6. UNHCR should have a designated focal point for reproductive health within the Community Services Unit. 7. UNHCR should ensure that a well-functioning community mental health programme is put in place prior to withdrawal. 8. The remaining funds in the evaluation budget should be used to reassess the situation before June 2004. The joint evaluation mission urges UNHCR to take advantage of this difficult situation and to ensure the handover of services for the refugees to the MoH a model for other situations and countries.
62 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Annexes
Annex 1 Focus Group Instruments
Reproductive Health Focus Group Instruments
ASSESSMENT OF SRH PROGRAMME FOR BUTHANESE REFUGEES FOCUS GROUP DISCUSSIONS FOR WOMEN/MEN IN THEIR REPRODUCTIVE AGE (15-49years). Guideline
Name of facilitator: …………………………………… Date: … /09 /2003
Camp: BELDANGI - I Number of participants: …………
Selection A group of between six to eight women/men will be selected by the RWF (Refugees Criteria for Women’s Forum) according to the following criteria: participation - Adult women/men in their reproductive age (15-49 years) in the focus - Four separate groups: two composed of men and two of women group - Each of these four groups will have between six and eight participants. - These participants are selected from different wealth groups in the camp (poor and more prosperous/from low castes as well as high castes). - Participants come from different sectors in the camp. - Participants should all have children. - Including people who have been actively involved in camp committees and people who have not.
Hello, my name is Marleen Bosmans. I am from Belgium and was invited by UNHCR to participate in an assessment of the health programmes in the camps.
I am particularly interested in learning about life in the camps and some of the sexual and reproductive health needs of people here. I would like your permission to ask you questions about issues such as pregnancy, delivery, use of family planning methods, sexual transmitted infections, etc…. I am fully aware of the fact that these are very sensitive and personal issues. So, if you prefer not to answer certain questions, please feel free to keep silent.
I hope that the results of these discussions with you will help the organizations that work with UNHCR to improve their services. I expect our discussion to last about one and a half to two hours.
It is important for you to understand that the information, which we gather in the discussions, will be treated with the utmost confidentiality. This means that your name will not appear in any document.
63 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
QUESTIONNAIRE
SOCIO- I’d like to ask some background questions about marriages and the relationship between CULTURAL men and women in the camp. ENVIRON- MENT Marriage Have there been changes in marriage customs since you have been living in the camps? What were the customs in Bhutan? What are they now? Do people prefer to marry with someone from the camp? Can boys and girl freely choose the person they want to marry? When a boy and a girl marry, is there a bride price/dowry to be paid? If so, who pays it? How do most people marry (in a civil ceremony, in the temple, other ways)? Are all marriages officially registered?
At what age do/did women generally marry? Do women usually wait until after marriage to have sex? What about men? Has this changed since you've been living in Nepal?
When a man and a woman marry, where do they go and live? (e.g., do they have a home of their own, with the husband’s parents, with the bride’s parents)?
Do you know men in the camp who have more than one wife? Is it normal for a man to have more than one wife? Do the spouses and their respective children live under the same roof? Are the wives and their children all treated equally? Gender Have the specific tasks and roles of men and women changed since you've relations been living in the camps? Do men and women take care of different tasks between than before they arrived at the camps? Who takes care of the children? husband and wife Is it easy for a husband and wife to talk about sexuality? Who decides how many children a couple has?
Can families in the camp rely on any extra income in addition to what they receive from UNHCR? Who provides this extra income? What is this income used for? Who takes the decisions about household expenses for the education of the children, health needs, etc.?
FAMILY I’d like to ask some questions about family size, family planning and child spacing. PLANNING Family Size How many children do most couples in the camp want? How many children do most couples have? Has this number changed over the years? At which age women normally have their first baby?
64 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Child What is preferable? Should women have their babies shortly one after Spacing another, or should births are much more spaced in time? Which reasons one can have for spacing childbirth?
Use of What do women and men do to prevent or postpone having babies? What contraceptive are the traditional ways? What are the modern ways (condoms, oral methods contraceptives, injectibles, IUD, POPs, diaphragm, female condom, female sterilization, vasectomy)? Which family planning method is the preferred one (the traditional or the modern way)? Which modern contraceptive do you prefer most? Why?
Who decides to use contraceptives (husband, wife, others)? Can women use family planning without the consent of their husband?
Are women in favour of using modern contraceptives? Are men? In this camp, where do people go to get their contraceptives? Do people have problems with getting contraceptives? Who normally goes to fetch contraceptives, women or men?
SAFE Now, I’d like to ask questions about women having babies in this camp. MOTHER- HOOD Pregnancy (FOR WOMEN ONLY) (FOR When women get pregnant, who do they tell first? Do women (and men) WOMEN feel happy about being pregnant? ONLY) At what age do women use to have their first baby? When you got pregnant for the first time, did you know how babies were made? Are women in the camp afraid of becoming pregnant? Do women prefer big or small babies?
Are women treated differently - better or worse - by their partners or others – during pregnancy? If yes, how (respect, family support, workload, nutrition)?
What do people in the community think about an unmarried woman/girl who has a baby? Who helps her?
What, if anything, do women do immediately after having unprotected sex to prevent a pregnancy? Where do they get help for this?
Sometimes women are pregnant but they don’t want to be because they do not have enough food to feed their children, or they are not married, or they got pregnant when they were raped. What do women do when they think or know they are pregnant but do not want to be?
65 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Antenatal (FOR WOMEN ONLY) Care (ANC) How do women in this camp take care of themselves when they are pregnant? Do health workers ever visit pregnant women in their homes? What kind of health workers (traditional healers, FCHW, CHW, doctor, nurse, midwife, TBA)?
Do women go to ANC consultations at the MCH during pregnancy? Do they go alone or does someone accompany them? Do women go immediately to the ANC consultation as soon as they know that they are pregnant? Do they go to the ANC consultation often? What services do they provide at ANC consultation (counselling, vitamins, additional food rations, nutritional supplements, and iron-folate supplements.
Do they also explain why pregnant women should take these supplements? What kind of nutritional supplements do they give you (UNILITO)? Do you take it? If not, why not? Did they explain you how to prepare it? How exactly do you prepare it (cooking it for a maximum of five minutes until it boils)?
Delivery (FOR WOMEN ONLY)
Where do women in the camp generally have their babies? Where do they prefer to give birth (at home, at the health centre, at the hospital, at a private clinic)? Why (habit, confidentiality, distance, male/female staff, complications)?
Who stays with the woman while she is in labour? How long does labour normally take? Do you know of women who died while having a baby? Or their babies died? Do you know why they died?
Who do women prefer to be attended by during delivery (mother, sister in law, mother in law, TBA, midwife, a doctor, a nurse, a gynaecologist)? If a woman has a problem when she is delivering the baby, who decides how to take care of her? Who is called? Where is she taken? What do they do for her?
Breastfeeding (FOR WOMEN ONLY)
Do most women here breastfeed their babies? Do they start breastfeeding immediately after the baby is born (“first milk”)? Who advises the mothers on breastfeeding? How long do mothers usually breastfeed in the camp (months, years)? All babies, from the first to the last-born? Do mothers use to breastfeed their babies more or less than since you arrived at the camp?
How many times did you breastfeed the baby in the first months after birth? According to a fixed schedule or whenever the baby wanted? How do you know when a baby wants to eat?
66 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
When you are/were breastfeeding, do/did you change the way you eat? In which way? Do they advise breastfeeding mothers in the camp to take UNILITO as well? Do/did you take it? Do you also give to the baby? If yes, from which month on? If no, why not? How many months/years do they usually breastfeed? When do you start giving the baby something in addition to breast milk? If yes, what do you feed them?
It may happen that some mothers do not have enough milk to breastfeed the baby. Do you know of methods to improve the mother’s production of milk? Can you turn to someone for advice? Who do you go to? Do you change food habits as well? How? How do people feed small babies if the mother does not have enough milk or cannot feed the baby?
Do people in the camps also use the “Rice Feeding Ceremony” (normally 5 months after birth for girls and 6 months after birth for boys)? Or do you have another kind of ceremony for the baby (Nwaran - 11 days after birth)? How is it called? Could you explain me about the ceremony?
STD/ Would you mind if we talked about Sexually Transmitted Infections/Diseases (STI/STD) HIV/AIDS and HIV/AIDS for a few minutes?
Prevention Have you heard about diseases you can get from having sex? Can you name some STDs (syphilis, gonorrhoea, herpes, HIV/AIDS? Do you think that there are a lot of STDs in the camp? Do you know what some of the symptoms of STDs are (e.g., urethral discharge, genital ulcers, vaginal discharge)?
Have you heard of HIV/AIDS? Are people in this camp worried about getting HIV/AIDS? Do people in the camp know how they can get HIV/AIDS (sex with an HIV infected person, sharing needles and razor blades with HIV infected persons, unsafe blood transfusion, mother to child transmission…)?
Do you know anyone with STD/HIV/AIDS? Do they do how to prevent STD/HIV/AIDS? Do you know who runs a high risk of being infected with STI/HIV/AIDS?
Are there men and women in the camp who have sex out of wedlock? Do people think this is wrong for men? For women? In your personal opinion, do you think that have sexual relationship before marriage? Does this only happen since you are living in the camp or did this also happen in your home country as well? Are there men who have sex with men in the camp?
Are condoms always available in the camp? Who uses condoms (married couples, single adults, adolescents, sick people, commercial sex workers, men having sex with men)?
Is there a drug problem in your community? Which drugs are used? Are any drugs injected?
67 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Care and What do you think people do when they think they have an STI or treatment HIV/AIDS? Do they go for treatment? Where? Can they get tests? Where? If people are tested positively, can they go somewhere for medical treatment?
If a man or a woman is tested positive, does he/she tell anybody? Should he/she tell his/her (sexual) partner(s)? Should the (se) (sexual) partner(s) go for treatment as well? What if she/or he does not?
Social Imagine that your partner is STI or HIV/AIDS positive, would you like support him/her to tell you that he/she has been tested positive? How would you react if your partner told you that she/he was tested positive?
Is there a reason why someone should not tell his/her partner that their test was positive?
SEXUAL I’d also like to ask some questions about violence in the camps, and more specifically about AND violence against women (sexual and domestic violence). GENDER BASED VIOLENCE Domestic How is life in the camp? When people are not working, how do they pass Violence their time? Do people in this camp like to drink alcohol? Can only men drink alcohol, or do women and children drink as well? Do you think that the use of alcohol in the camp is a problem? Why or why not?
What do you know about men in the camp who are violent with their wives (e.g. yelling, beating, cutting them)? Has this kind of violence increased or decreased in this camp over the years? What is your feeling about husbands who hit their wives? In your opinion, do you think that men who hit their wife are “bad” men? Why do you think they do this? Sexual Do women and young girls feel safe to walk alone in the camp? Do you Violence know of women in this camp who were forced to have sex when they did not want to? Do you know of women who have sex for money, protection, food or other things? With whom do these women have sex? What do you know and think about this kind of situation? Support and Do women look for help here when they have been beaten? Or raped? If Protection not, why not? Where would women go for help? What kind of support may they need?
I have heard that about a year ago a lot of cases of violence against women were detected and investigated. I was told that action has been taken to support the victims and to punish the perpetrators. Apparently, efforts were also made to protect women and to prevent these kinds of incidents from recurring in the future. Which services are available in the camps now (medical, social, legal)? Did the community participate in the design and the implementation of these measures? Do you think that the security situation for women has improved now?
68 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
HEALTH Treatment Is everyone in the camp treated in the same way at the camp health ACCESS facilities? If no, what may be the reason for this difference in treatment? Do you have the impression that poor people and rich people are treated differently? Could you explain?
How about the public health facilities of the government outside the camp? Are you satisfied with the treatment you get there? Do you have the impression that refugees are treated differently compared to Nepali people? Could you explain? CONCLU- One last question... SION Are there other health services that you would like to have in this camp? What are they? Which are the most important?
69 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
ASSESSMENT OF SRH PROGRAMME FOR BUTHANESE REFUGEES FOCUS GROUP DISCUSSIONS FOR ADOLESCENTS (15-19years). Guideline
Name of facilitator: …………………………………… Date: … /09 /2003
Camp: BELDANGI-I Number of participants: …………
Selection A group of between six to eight adolescents will be selected by the RCF (Refugees Children’s Criteria for Forum) according to the following criteria: the - Four separate groups: two composed of boys and two of girls compositio - Aged between 15 and 19 years. n of the - Each of these four groups will have between six and eight participants. focus - Participants come from different sectors in the camp. groups - They should be representatives of both school-going and non school-going groups. Mix of school going and non-school going. - These participants are selected from different wealth groups in the camp (poor and more prosperous/from low castes as well as high castes).). - The meeting place should guarantee privacy and confidentiality.
"Hello, my name is Marleen Bosmans. I am from Belgium and was invited by UNHCR to participate in an assessment of the health programmes in the camps.
I am particularly interested in learning about the life of young people in the camps and about the sexual and reproductive health needs of people here. I would like your permission to ask you a few questions about issues such as pregnancy, delivery, use of family planning methods, sexual transmitted infections, etc…. I am fully aware of the fact that these are very sensitive and personal issues. So, if you prefer not to answer certain questions, please feel free to keep silent.
I hope that the results of our talks will help the organizations that work with UNHCR to improve their services. I expect our discussion to last about one and a half to two hours.
It is important for you to understand that the information, which we gather in the discussions, will be treated with the utmost confidentiality. This means that your name will not appear in any document.
70 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
QUESTIONNAIRE
SOCIO- Maybe we could begin by you telling me a bit about life in the camp and how it is being a CULTURA boy or a girl growing up in a refugee camp. L Life skills How are things around here for young people? What do you do all day ENVIRON- when you are not at school? MENT Are there any special activities for young people in the camp (sports, theatre, games, the internet…). Is there a difference between girls and boy in terms of what they are allowed to do and the tasks they should take up at home?
Do know about young people using drugs in the camps? Which kind of drugs? What about alcohol, do people in the camp use to drink alcohol? Do young people? Don’t they get drunk? Boys? Girls? How do they behave when they are drunk? What do you think about people that are drunk?
Do you like living here? Do you ever have a chance of visiting the other camps? Do you have a lot of contact with Nepali people of your age? Do you have Nepali friends? What would you do if you were not living in a camp? What plans do you have for your life? Do you ever dream of returning to Bhutan?
Also, boys and girls they fall in love all over the world. Surely the same goes for you as well. In your opinion, is there an appropriate age for having a boyfriend/girlfriend?
What do you do when you fall in love? Can boys invite the girl to go out together? Can girls invite the boy? Should a boy and a girl get officially engaged before they can meet each other? Can they meet in private? Please, you let me know how things happen as I have no idea?
At what age do boys normally marry? And girls?
Sexuality As you grow up, your body starts changing. From a young child you are growing into a young woman/man. If you allow me, I should like to ask some questions about it. How do you feel about these changes in your body? Can you tell me, in your own words, what the most important changes are? Do you ever talk about these changes? To whom? Did someone inform you why and how these changes take place? With whom do you can talk about these things?
71 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
FOR GIRLS ONLY:
When you had your first menstruation, what was your reaction? Did you know what happened exactly? Had anybody explained to you that this would happen? Was there anyone you could go to? Who?
In your opinion, what does it mean if a girl has menstruation? Girls who have already menstruated, are they being treated differently?
FOR GIRLS AND BOYS:
Do you know of boys and girls of about your age who have already had sexual relations without being married? What do you think about it?
Do you know boys and girls of about your age who already have children? Would you already like to have children too? Why?
Do you know about girls who got pregnant before being married? What do you think about it? Should she get married? Should the boy accept to marry her? Have you heard of cases when the father of the baby refused to marry the girl? What happened then to the girl? Do you think that they should get married? At which age boys and girls in the camp normally get married?
If the girl is still going to school and gets pregnant, can she still attend school so that she can finish her education? And her boyfriend, the father of the baby, can he still go to school? Do you think these girls should be encouraged to finish school?
Do you know what the signs of pregnancy are? Which? Do you know how a girl can get pregnant? Would you mind explaining it in your own words?
FAMILY Knowledge Do you know how you can prevent pregnancy? How? Can you name some PLANNIN modern contraceptives? Who explained you how to prevent pregnancy? In G your opinion, if two young people are sexually active who should take care that the girl does not get pregnant (the boyfriend, the girlfriend, both)?
Access Do young people have access to contraceptives even when they are not married? Could you explain how and where they can get them? Would you, as a young and unmarried person go to one of the health facilities in the camp and ask for contraceptives? Do you think that they will give it to you? If not, why not?
72 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
STI/ Awareness Have you heard about diseases you can get from having sex? Can you name HIV/AIDS some STDs (syphilis, gonorrhoea, herpes, HIV/AIDS)? Could you name some symptoms of STDs? Would you go to the health centre if you thought that you had an STD? If not, why not? If yes, should you go alone or ask someone to accompany you?
Have you heard of HIV/AIDS? Where? What do you know about it? Are young people in this camp worried about getting HIV/AIDS? Do you know how you can get HIV/AIDS (sex with an HIV-infected person, sharing needles and razor blades with HIV infected persons, unsafe blood transfusion, mother to child transmission…)?
Do you know people with STD/HIV/AIDS? Do you know how to prevent STD/HIV/AIDS? Do you know which groups of people run a higher risk of being infected with STI/HIV/AIDS?
Do you know what a condom is? In the camp they use to have a “Condom Day”, what exactly do they do then? What do you think is the purpose of organizing such a day? Do young people also get free condoms? Could you tell me what condoms are used for, other than for family planning?
SEXUAL Awareness Do young girls feel safe to walk alone in the camp? Also when it is already AND dark? Do you know of young girls in this camp who were forced to have GENDER sex when they did not want to? How do you feel about them? What do BASED think about this kind of situations? VIOLENCE In case such a thing happened to you/your girlfriend, what would you do? How would you react? Do you think you/your girlfriend could defend yourself/herself? Do you know where you/she should seek help?
I have been told that around a year ago, there was a real problem of violence against women in the camp. Had these problems with violence been going on for a long time already, or was it quite a new phenomenon? How do you feel about it?
I have also been told that measures have been taken to protect women and look after those women who were victim of sexual violence. Do you think that the security situation has improved? Do you know what you would do if you had been sexually assaulted?
CONCLU- One last question... SION Are there other health services that you would like to have in this camp? What are they? Which are the most important?
Thank you for your time. I have learned quite a lot about life of young people in the camp and your health concerns. I hope it has also been interesting for you. Thank you very much, once again.
73 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Nutrition Focus Group Instruments
Guide 1
Supplementary Feeding Programme
Have you ever received additional food, which is often given to women when they are pregnant and breastfeeding, or to small babies (e.g., UNILITO or PITHO)? What did you get?
How did you prepare this food? Did you like it? Why or why not? How many members of your family ate this food? Did they like it? Who usually eats most of it?
Do you know why this food is given? What benefits, if any, does it have and how is it different from the other food you normally receive?
Did you give this food to a small baby? Did the baby like the food? How did you prepare this food for the baby? At what age do you think it is appropriate to start giving this food the small baby?
Did anybody tell you how this food should be prepared? Who told you? What did they tell?
Nutrition in Pregnancy and Lactation
When you were pregnant, did you change the way you eat? In general, did you eat more or less than normal? Why?
Did you eat any new foods that you did not eat before, or did you eat more of some foods compared to the time before pregnancy? Did you eat less of any food or stopped eating them during pregnancy? Why?
Are there any foods that could help pregnant woman to be stronger and to give birth to a healthy baby? Are there any special foods that would make your baby smart? What foods may cause stomach problems, vomiting, and constipation during pregnancy?
Some pregnant mothers may be worried that the baby would grow too big and they will have a difficult labour. Are there any special foods that could make your baby grow too big?
When you were breastfeeding, did you change the way you eat? In general, did you eat more or less than normal? Why?
Did you eat any new foods that you did not eat before, or did you eat more of some foods compared to the time before breastfeeding? Did you eat less of any food or stopped eating them during breastfeeding? Why?
Sometimes the woman may feel that she does not have enough milk to feed her baby. Are there any foods that could help you to produce more milk for your baby? What foods can make the milk better? Why?
Did anybody tell you what you should eat during pregnancy and breastfeeding? Did you ask anybody? What did they tell you?
74 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Breastfeeding
How long (months, years) do mothers usually breastfeed in this camp? Did it change from the time before you came to this country? How did it change?
Do mothers usually give their “first milk” to the baby? Why or why not?
How many times did you breastfeed your baby in the first months after birth? Did you have the schedule or did you breastfeed when baby wanted? How did you know that baby wants to eat?
What foods or drinks are usually given to the baby before “Rice Feeding Ceremony”? Why do you think these foods and drinks are given? How often do people give them to their babies? How do they prepare these foods?
How do people feed small babies if mother does not have milk or mother is away from the baby?
Complementary feeding
How old is the child when he has “Rice Feeding Ceremony”? Is this different for girls and boys? Do all people observe/celebrate “Rice Feeding Ceremony”? Who does and who does not?
What foods are given to the baby 6 months and older (or after the Ceremony)? Do you prepare special foods for the baby or give the foods prepared for the whole family?
Which foods do you start to give first? Which foods do you introduce later? What is the age of the baby when different foods should be introduced?
Why should foods be introduced in this order?
Which foods are easy for the baby to digest? Which are difficult to digest? Which foods if given to small baby can make him/her sick?
Are there any foods that could make your baby smarter (make him talk/walk early)? Are there any foods that could make the baby grow faster?
How much food do you give to the baby? How do you feed the baby (with spoon, cup, etc)? Do you prefer to give to the baby thick (dense) or thin (more liquid) foods? Do you add anything to the food (e.g., sugar, oil, butter, salt etc.)?
Do you prepare porridges with water or with milk?
Do people give tea to small babies? How early in life and how often?
When do people start giving cow’s (or other animals’) milk to their babies? Do they dilute it with water? Do they boil it? Add anything else? Is cows milk good for small babies?
Other issues (diarrhea, micronutrients, de-worming, growth monitoring, etc)
75 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
What foods do you give to the baby when he/she has diarrhea? Do you continue breastfeeding or stop? What foods should not be given during diarrhea?
Did you ask somebody what to give to the baby with diarrhea? What did they tell you?
Did your baby receive red vitamin A pill (show the pill)? How many times? How often is it given? How old was the baby when it received this pill for the first time? Did somebody tell you why this pill is needed? What do you think?
When you were pregnant, did you receive iron tablets? Did you like them? Did you have any problems with these tablets? (e.g., nausea, constipation, etc.) Did you take them as prescribed? Did somebody tell you why this pill is needed? What do you think?
We saw some people in the camp that have cracks or sores in the angles of their mouth. Why do you think it happens? Who (children or adults, males or females, poor or better-off people) have such things most often? What can be done to avoid such things? Can you treat them? How?
When your baby was small, did health workers in the Health Center weigh or measure him/her? How often? Did they measure him/her standing or lying down?
How did they record weight and height? Did they explain to you why they do it? If they tell you that your baby is not growing properly, did they also explain what you can do (what foods to give, etc) to make him/her grow better? What did they tell you?
Counselling on Healthy Eating
Who do you ask when you need to know what to eat (for example, when you or somebody in your family was sick, or you were pregnant or breastfeeding) or how to feed your baby?
Could you tell use specific examples when you asked somebody? What did they tell you? Did you follow their advice? Did it work well for you?
Would you ask for such advice health workers in the camp? Traditional birth attendants? Mother in law? Your friends?
Did health workers give you any advice on nutrition when you came for pregnancy checkups or for checkups with your small baby? How many times did they give you an advice? What did they tell you?
Did they tell you how to breastfeed your baby and how and when introduce other foods? What did they tell you?
Ranking Exercise:
List several categories of people (or media sources) where you can get information on nutrition (include primary health workers, traditional birth attendants, traditional healers, doctors, mothers-in law, family members, friends, radio, leaflets, other sources).
76 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Rank them in order from most commonly to least commonly used.
Rank them from most highly trusted to least trustworthy.
77 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Nutrition Guide 2
General Food Ration
Who decides on food issues in the family: what to prepare, how much food to use every day, etc.? Who in the family is responsible for cooking and feeding children?
Who in your family usually goes to collect the ration? Where and how often do you collect your ration?
Do you know how much food each member of your family (or the family as a whole) is entitled to?
How do you feel about the amount and the quality of the food you receive? How did it change during the recent 3-4 years?
Is there anything that should be done to improve the situation?
Would it be more convenient for you to collect your food once a month rather than 2 time a month as you doing now? Why or why not?
Have you ever seen your food distribution card? Do you keep you food distribution card in your house?
What do you do with the food you receive? What dishes do you prepare? Do you exchange your food for other food or other items (clothes, etc.)? If you need to use your food this way, are you still left with enough food to eat?
Do you have difficulty with distributing your food evenly during the two weeks until you get another distribution? Do you know of situations when people run out of food several days before they can get the new distribution? Why do you think this happens?
In addition to rice, beans and oil, do you also receive fresh fruits and vegetables? If yes, how often do you get them? What fruits or vegetables do you get? Are you happy with their condition/freshness? Are they enough for your family?
If for some reason the food you have is insufficient to feed the family as usual, what do you do?
If you need to decrease amount of food given to family members, how you decide how much food to give to each family member? Whose food portion would be affected most?
Foods Normally Eaten
What are the most common dishes you usually prepare every day? Which dishes do you like? Which dishes does your husband like? Does you mother-in law or your husband tell you what dishes to prepare? How often do they tell you?
What about your children – what foods do they like to eat?
Do you have enough dishes and fuel to prepare your food? Why or why not? What kinds of stoves/fuels do people use to prepare foods in this camp?
78 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Do you grow fruits or vegetables in your garden? Why or why not?
If yes, what do you grow? How much do you get everyday to eat from your garden? Are there other people who do not grow them? Why? Are there people in the camp that have more land for the garden than some other people have?
Do you buy foods at the local markets? What are the main foods you need to buy? Where do you go to buy them? Can you afford to buy the foods you need? Why or why not?
How the price of different foods changes during the year? Are all foods available around they year or are there some foods that are available only in certain months? What these foods are and when are they available?
We saw some chicken in the camp. Do many people have chicken? Is it easy to keep chicken in the camp? Are you happy that some people have them? Does it influence sanitary conditions or cause any other inconvenience? Do you know if anybody has been complaining about this?
Food Beliefs and Attitudes
What foods do you think are healthy? What foods are unhealthy? Why some foods are considered healthy, and some – unhealthy? How do you think these foods can influence your health? Can some foods cause disease? Prevent disease?
Did somebody tell you which foods are healthy and which are not? What did they tell you? If you need such information, whom would you ask?
What foods do you or your family like but unable to afford? What foods are eaten only by rich people? Can you tell how wealthy the family is when you see what food they eat? What specific foods would you look for to tell this?
Counselling on Healthy Eating
Who do you ask when you need to know what to eat (for example, when you or somebody in your family was sick, or you were pregnant or breastfeeding) or how to feed your baby?
Could you tell use specific examples when you asked somebody? What did they tell you? Did you follow their advice? Did it work well for you?
Would you ask for such advice health workers in the camp? Traditional birth attendants? Mother-in-law? Your friends?
79 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Health Facility Forms
Health facility checklist
Interagency Health Assessment Mission for Bhutanese Refugees in Nepal
Health Facility Form
Location: 1. Camp 2. VDC: Name of VDC or Camp:______
Facility level: 1. BHU 2. PHCC 3. SHP 4. HP 5. AMDA hospital 6. Govt hospital (name)______
Date of visit: ______/ ______/ 03 Time of visit: __:__ AM / PM IDNUM_____
Day Month
About how many people are waiting to be seen? 1. <20 2. 20-40 3. >40
How many minutes has the next person waiting to be seen, been waiting? ______
Does the facility have privacy for OPD consultations? 1. Yes 2. No
Does the consulting room have the following? (CIRCLE ALL THAT APPLY) Working stethoscope Working BP cuff Thermometer Weighing scales Growth cards Gloves
5. Does the facility have in patient beds? 1. Yes 2. No
6. Is the facility using disposable needles or syringes? 1. Yes 2. No
IF NO SKIP TO Q8.
7. If yes, does it appear they are being reused? 1. Yes 2. No
PHARMACY
8. Are drugs kept in an area that can be locked? 1. Yes 2. No
9. Is the drug stock register up to date? 1. Yes 2. No
COMMENTS:______
80 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
10. Ask to see the pharmacy and complete the table below
Medication Type In stock If out of stock How many days? 1 Syrup 1 Yes 2 No Amoxycillin 2 Capsule 1 Yes 2 No 3 Pediatric 1 Yes 2 No Cotrimoxizole 4 Adult 1 Yes 2 No 5 Cephalosporin IM 1 Yes 2 No 6 Gentamycin IM 1 Yes 2 No 7 Syrup 1 Yes 2 No Chloroquine 8 Tablets 1 Yes 2 No 9 Fansidar 1 Yes 2 No 10 Quinine Tablets 1 Yes 2 No 11 Quinine IM 1 Yes 2 No 12 Quinine IV 1 Yes 2 No 13 Penicillin IM 1 Yes 2 No 14 Aminophyllin Tablets 1 Yes 2 No 15 Syrup 1 Yes 2 No Albendazole 16 Tablets 1 Yes 2 No 17 Metronidazole Syrup 1 Yes 2 No 18 Aspirin Tablets 1 Yes 2 No 19 Syrup 1 Yes 2 No Paracetamol 20 Tablets 1 Yes 2 No 21 ORS 1 Yes 2 No 22 Ferrous sulphate Tablets 1 Yes 2 No 23 Chloramphenicol Ointment 1 Yes 2 No 24 Benzyl benzoate Ointment 1 Yes 2 No 25 Whitfield’s Ointment 1 Yes 2 No 26 Gentian violet 27 Antacid 28 Vitamin B Complex 29 Condoms 1 Yes 2 No 30 OCs 1 Yes 2 No 31 Depoprovera IM 1 Yes 2 No 32 Growth cards 1 Yes 2 No
MCH CLINIC
11. Does the MCH clinic have privacy for examinations? 1. Yes 2. No
Is there a maternity cot? 1. Yes 2. No
Is Depoprovera available? 1. Yes 2. No
Is post abortion care given 1. Yes 2. No
15. Is the following available? (CIRCLE IF YES) BP cuff Stethoscope Fetascope Weighing scale
81 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
IMMUNIZATION ROOM
16. Is there a working freezer? 1. Yes 2. No (IF NO SKIP TO Q18)
17. If yes, is the temperature chart filled out? 1. Yes 2. No
18. Is there a working refrigerator? 1. Yes 2. No (IF NO SKIP TO Q20)
19. yes, is the temperature chart filled out? 1. Yes 2. No
20. Is there a vaccine carrier with vaccines inside? 1. Yes 2. No (IF NO SKIP TO Q22)
21. If the vaccine carrier has vaccine inside, are the icepacks: Frozen Melting Liquid Warm
22. Is there a cold box with vaccines inside? 1. Yes 2. No (IF NO SKIP TO Q24)
23. If the cold box has vaccine inside, are the icepacks: Frozen Melting Liquid Warm
24. Which of the following vaccines are in stock in the facility? BCG DTP OPV Measles
25. If there is OPV, is the VVM good? 1. Yes 2. No
26. Is there a working steam sterilizer? 1. Yes 2. No (IF NO SKIP TO Q23)
27. Does it have a color monitor? 1. Yes 2. No
28. Are there sterilisable BCG needles? 1. Yes 2. No
29. Are there sterilisable DTP needles? 1. Yes 2. No
30. How many days a week does the facility do immunizations at the clinic? ____
31. Is there a functioning latrine? 1. Yes 2. No
32. Is water available in the facility? 1. Yes 2. No
82 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
33. If yes, where does the water come from? Tap in the facility Tap outside the facility Well Other (describe)______
34. How many of each of the following staff are assigned to the facility (indicate if full or part time, and if part time, # days per week
If part time days/wk) Doctor ___ Male ___ Female ______Health assistant ___ Male ___ Female ______Nurse midwife ___ Male ___ Female ______ANM ___ Male ___ Female ______MCHW ___ Male ___ Female ______CMA ___ Male ___ Female ______VHW ___ Male ___ Female ______Other ___ Male ___ Female ______35. Catchment population of facility ……………………..
36. Average number of patients per week? ______
37. If refugee facility average number of local population per month?______
38. If Government facility average number of refugees per month? ______
39. Review the OPD logbook for previous two weeks. What were the top five causes of morbidity?
40 Number of HFMC Meeting in the last 6 months……………..
41 Significant decisions implemented………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… ……………………………………………………
42. Is there a protocol present in the OPD on treatment of ARI? 1. Yes 2. No
43. Is there a protocol present in the OPD on treatment of diarrhoeal diseases? 1 Yes 2. No
44. Are there case definitions written down in OPD for notifiable diseases? 1 Yes 2. No
83 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Record abstraction form Interagency Bhutanese Refugee Community Survey Location: 1. Camp 2. VDC: Name of VDC or Camp: ______Facility level: 1. BHU 2. PHCC 3. SHP 4. HP 5. Other______Abstractor name______IDNUM: ______
Record # Age Sex HF Diagnosis Medicine prescribed, Correct? # tablets, # IM/IV injections 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
84
Annex 2 Mission Timeline
September 16th: Meetings with implementing partners (IPs) and other UN agencies in Kathmandu
September 17th: Travel to Biratnagar
September 18th-20th: Meetings with IPs in Damak
September 22nd: Meetings at Mechi Zonal hospital, DHO, DPHO, and RCU, visit to Beldangi I
September 23rd: Visits to Beldangi II and Sanischare
September 24th – October 2nd: Field work Beldangi I and II
October 3rd: Visit to Goldhap and Timai
October 4th: Debriefing in Damak
October 5th: Travel to Kathmandu
October 8th: Meetings with Director General of MoH
October 10th: Debriefing Kathmandu
85
Annex 3 Proposed ToR for Consultants
Nutrition TOR
Assess current status of infant feeding (including breastfeeding and complementary feeding); identify feeding problems and culturally appropriate, available and affordable complementary foods. The WHO/UNICEF methodology for adaptation of IMCI nutrition module is recommended as one of the methods.
• Determine current breastfeeding practices (frequency, duration, complementary foods given, etc.). • Determine age of introduction of various complementary foods (especially, UNILITO, animal milk, rice, daal, vegetables). • Determine commonly used food recipes for infant feeding, amounts of foods given, and feeding/caring practices. • Identify the main problems in feeding of infants/children of different ages, develop appropriate advice guidelines for these problems. • Develop feeding recommendations (including concrete foods, ways of preparation, amounts, etc) for different age groups of infants and children. • Develop counseling guidelines for feeding of children with diarrhea or other sickness.
Specific problems that should be assessed and addressed in recommendations:
• Early introduction of UNILITO, water and cows milk. • Feeding of undiluted cow’s milk to children under the age of one. • Early or late introduction of rice, daal, vegetables, noodles, biscuits and other foods. • Ways to make complementary foods more nutritious and energy-dense (e.g. feasibility or recommending recipes with added oil, sugar, etc). • Prolonged (1 year and beyond) exclusive breastfeeding. • Options for counseling and support in situations where mother perceives to not have enough breast milk. • Assess the utility of distribution of UNILITO to mothers with infants aged 0-6 months (considering the propensity to introduce this food into infant’s diet too early), suggest alternative ways of nutritional support to breastfeeding mothers.
Assess the ability of the staff to understand weight-for-height, weight-for-age, and height-for-age scores; and ability to interpret weight-for-age curves plotted in the Road to Health card. Assess the ability of the staff to follow-up and counsel children with detected faltering in growth patterns and children in supplementary feeding programme that fail to gain sufficient weight.
Assess the existing staff capacity vis-à-vis the envisioned workload and the number of beneficiaries served. Recommend additional staffing if necessary, help recruiting those additional staff.
8 7 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Assess the skills of staff in measuring and weighting of children and adults (including height, recumbent length, MUAC, weight). Conduct standardization measurement exercise to detect those in specific need of refresher training.
Assess the functional state of measuring devices (measuring boards, Salter scales) in the camps, advise as appropriate.
Conduct the training on measuring techniques for all old and new staff of nutrition units.
Develop the recommended schedule of counseling for pregnant women (e.g., compulsory for all pregnant women within 4 weeks of ANC registration) and mothers of young infants (e.g., after birth and at 6 months of infant’s life).
Advice on SFP guidelines: create clear guidelines on discharge criteria, frequency of measurement of malnourished children, counseling and follow-up frequency, etc.
Advice on TFP guidelines: method of delivery (e.g., day care setting in the camps or therapeutic feeding unit in the hospital), technical guidelines, staff training, counseling and follow-up, admission, discharge and transfer criteria.
Review the methodology and reporting style of annual nutritional surveys using the HAM report and recommendations as a basis. Advise implementing partner on sampling issues and analytic techniques as needed. Review the coverage of children by monthly monitoring and annual mass screening exercises; recommend the ways to improve coverage. Advise on the age cohorts to be included in monthly monitoring and yearly screening.
The end-product should include the adapted “feeding” page of the IMCI "Counsel the Mother" card, and the comprehensive counseling guide for the staff that includes recommended ideal patterns of feeding for different age groups of children, feeding problems and recommended solutions for each of the problems. The guide should also include the guidelines (frequency, counseling techniques, etc.) for follow-up of children that fail to gain weight in supplementary feeding programmes, or those showing pattern of decline in their growth. Included in the guide should also be the locally adapted advice on healthy eating for mothers during pregnancy and lactation, and correct way to prepare and use supplementary food (UNILITO).
Using this guide, conduct training for all (new and old) staff of nutrition units and MCH units. Include training on counseling techniques and creative ways to counsel/follow-up.
The materials developed, especially those relevant to adaptation of IMCI nutrition module, should be proactively shared with the UN organizations (WHO, UNICEF) that implement IMCI in Nepal. It is recommended that workshop on IMCI nutrition module adaptation is held in Kathmandu for all IMCI implementing partners to ensure wide dissemination of findings and buy-in of all implementing agencies.
88 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
TOR Reproductive Health
A. CONTEXT
In September – October 2003 UNHCR and WHO engaged in a joint effort to assess the health programme in Bhutanese refugee camps in Nepal. Two consultants from the Centre of Disease Control and Prevention (Atlanta, USA) with expertise in nutrition and epidemiology were invited to participate in the mission, as well as another consultant from the International Centre for Reproductive Health (Ghent University, Belgium). The reproductive health assessment covered several key issues such as safe motherhood, family planning, STI/HIV/AIDS, SGBV, male involvement and adolescents’ RH. On basis of the findings of the mission, UNHCR decided to send a consultant with RH expertise to contribute to the improvement of the RH programme for the refugees in the Bhutanese camps.
B. OBJECTIVES AND KEY-ISSUES
1. Overall Objective
The overall objective of the consultancy mission is to improve and complement the current RH programme in the camps by addressing and responding to the gaps and needs identified by the HAM mission.
2. Specific Objectives
2.1. Overall RH Programme Aspects a. To improve the monitoring and evaluation of the RH programme. Special attention will be given to the following issues:
Determination and definition of the mandate of the RH coordinator within the Community Services Unit in UNHCR's Sub-office; Clarification about the role and function of the RH supervisor employed by AMDA; Redefinition of the role and function of the RH Unit in the camps; Coherence with the RH policy and strategy of HMG; Regular and adequate monitoring and supervision of health staff and health workers; and Identification of quantitative and qualitative indicators that will enable adequate monitoring and evaluation of the programme. b. To promote a rights-based approach of RH. Special attention will be given to:
RH-training programmes for health staff and community health workers on women’s rights, the rights of the child, sexual and reproductive rights. c. To mainstream the RH programme on gender equality. Special attention will be given to the following issues:
Gender equality training for both UNHCR staff and its implementing partners;
89 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Promotion of gender equality mainstreaming of the policies, strategies and activities of both UNHCR and its IPs who are directly and indirectly involved in the implementation of the RH programme; and Active promotion of the employment of female health staff and health workers. d. To improve confidentiality and privacy at the health facilities. Special attention will be given to:
The physical adaptation of the health facilities in the camps. 2.2. Family Planning a. To increase the CPR in the camps in line with the national targets put forward by HMG Tenth Five Year Plan (2002/2003-2006/2007). Special attention will be given to:
Promotion of modern contraceptives for family planning and birth spacing Reliable and regular supply of modern contraceptives to the camps. b. To address the problem of infertility in the camps. Special attention will be given to:
The assessment of the prevalence of infertility in the camps; The possible relationships between infertility and STI; Infertility as a possible cause of SGBV; and Measures to be taken to respond to infertility related problems. 2.3. Safe Motherhood a. To increase the number of deliveries attended by skilled staff. Special attention will be given to:
Midwife training for refugee women; and Redefinition of the role of TBA with respect to antenatal and post-natal care of pregnant women. b. To properly address the practice of unsafe abortions in the camps. Special attention will be given to:
IEC programmes on the risk of unsafe abortions; and Performance of abortion under conditions stated by the law. 2.4. STI/HIV/AIDS a. To develop a coherent and high-quality STI/HIV/AIDS programme. Special attention will be given to:
Regular training of health staff in STI/HIV/AIDS diagnosis and treatment; Community based IEC programmes on STI/HIV/AIDS; Promotion of partner notification, counseling and treatment.
90 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Provision of a confidential and non-stigmatizing environment for STI/HIV/AIDS counseling and treatment. 2.5. Sexual- and Gender-Based Violence a. To develop an appropriate and needs-based approach to SGBV. Specific attention will be given to the:
Development of an information system and data-analysis process tracking SGBV-prevalence in the camps which will help to identify, prioritize needs and gaps in the current response to SGBV, and provide support in developing appropriate interventions. b. To develop a joint approach to SGBV prevention and protection and support of SGBV survivors. Specific attention will be given to:
Adequate and efficient communication by UNHCR to stakeholders and vice versa; Ongoing training programmes for UNHCR staff and implementing partners on the different social, cultural and legal aspects related to SGBV, paying particular attention to issues such as polygamy, domestic violence and alcohol abuse; Provision of human rights education to all stakeholders involved (the community, to police, courts, national and international humanitarian actors). Cooperation with other UN agencies and non-governmental organizations in the advocacy for legislative changes in Nepal to protect women and children’s rights. c. To develop a community based approach to SGBV. Specific attention will be given to the following key issues:
Enhancement of community participation in SGBV awareness and prevention programmes, particularly with regard to the active participation of the BRWF, the BRCF, the camps management committees and schoolteachers; Community-based IEC programmes for awareness raising and prevention of SGBV and support to SGBV survivors targeting men, women and children. Support provided to economic, social and legal empowerment programmes for women and adolescent girls. 2.6. Male Involvement in RH a. To promote male involvement in RH. Specific attention will be given to:
Information, education and counselling services on sexuality and RH for men; Male contraceptive use; Couple counselling and peer-group sessions.
91 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
2.7. Adolescents’ RH a. To develop a comprehensive programme for adolescents’ reproductive health. Specific attention will be given to:
Enhanced support to the BRCF for the development of appropriate life skill training programmes that also pay due attention to sports, recreational and cultural activities and exchange programmes with Nepali youth organization. Provision of youth-friendly services for RH counseling, treatment and psychosocial support. IEC and peer education programmes targeting both school-going and non- school-going children in the 10-to-19 age group of on all aspects related to sexuality and RH, and more particularly on the risks of early marriage, early pregnancy, the benefits of education for both girls and boys, STI/HIV/AIDS and SGBV. Active promotion of education for pregnant girls targeting adolescents as well as their parents and schoolteachers. Training programmes for schoolteachers in sexual education and RH- related issues. 3. Methodology
The RH programme will be developed in accordance with the guidelines and policies that have been made up by or with the support of UNHCR with respect to RH programmes for refugees, including HIV/AIDS and SGBV. The existing RH programme and the report of the HAM mission will be used as basic starting points.
The RH programme will be developed in a participatory way, paying major attention to the active involvement of all stakeholders at all stages of the project cycle (conception, implementation, monitoring and evaluation), and more particularly of:
1. UNHCR staff at the Community Services Unit; 2. The implementing partners, more specifically AMDA (health), Caritas (education) and the Lutheran World Foundation (support to BRWF and BRCF); and 3. The refugee community, more particularly health staff and health workers in the camps, the BHA, the BRWF, the BRCF, the Camp Management Committee and the schoolteachers.
In the development of the RH programme due attention will be paid to cooperation with other UN agencies in Nepal such as UNICEF, UNFPA and WHO and the MoH. In the RH programme priority should be given to:
1. STI/HIV/AIDS prevention, counseling and care; 2. SGBV prevention; and 3. Adolescents’ RH.
92
Annex 4 - Nepal Evaluation Questionnaire Regarding Follow Up to Recommendations
Questionnaire to Follow Up Pilot Evaluations
In 2003 and 2004, several Pilot Interagency Evaluations of Humanitarian Crises Health Programmes were carried out in Pakistan, Nepal and Zambia, as a preliminary activity of the Interagency Health Evaluations in Humanitarian Crises Initiative (IHE-HCI). In July 2004, a Project Coordinator was appointed to manage IHE- HCI activities, including following up on the outcomes of the three Pilot Evaluations. The results and lessons learned from the Pilot Interagency Evaluations will be used in developing a set of guidelines for carrying out interagency health evaluations in the future.
The IHE-HCI Working Group has asked the Project Coordinator to contact agencies involved in the three Evaluations, in order to determine which actions were taken as a result, and to obtain feedback regarding the processes and outcomes of the Evaluations. Agencies whose programmes were evaluated in this exercise are kindly requested to complete the attached questionnaire below, providing feedback to the IHE-HCI Working Group.
93 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
NEPAL EVALUATION QUESTIONNAIRE REGARDING FOLLOW UP TO RECOMMENDATIONS:
Name: Jayshree Jayanand
Post/Title: Community Services Officer
Organisation: UNHCR
Duty Station: Nepal
Date: 22 October 2004
To what extent were you involved in the planning of the Evaluation? Local manager of Interagency Health Evaluation
1 …………………..5…………………10 low high
To what extent were you made aware of the results/feedback from the Evaluation?
1……………………5…………………10 immediately before team left low high
Evaluation Process:
Which aspects of the preparation/planning of the Evaluation went smoothly?
Due to the security situation in Nepal, and a serious security incident preceding the visit, the Evaluation team was not able to visit all the camps and obtain the information they would have liked to gather.
Which aspects of planning could be improved upon and how?
A better understanding of the security situation in Nepal would have helped. Involving local partners in the planning would have helped in creating a better understanding of the expectations and issues involved.
In what ways did this Evaluation differ from a single agency evaluation?
This evaluation differed from single agency evaluations in several aspects, as there were 3 different experts from 3 different organization examining different aspects of the program. Instead of it being conducted as a comprehensive integrated evaluation the experts carried it out more as an individual assessment.
How were the recommendations presented/shared with stakeholders?
Briefings were held with the Evaluation Team, and all of the main issues were shared with key stakeholders before the team departed. In some cases, recommendations were felt to be too strong, and some stakeholders became defensive. This may also be due to the fact that the ToRs were not shared with everyone in advance and some stakeholders may not have been entirely aware of or in agreement with the purposes of the Evaluation.
94
What, if any, were the constraints to carrying out the Interagency Evaluation of the health programme?
The security situation was the major constraint, preventing the evaluation team from moving freely and carrying out the study as planned. There also seemed to be a lack of co-ordination among the team in the way the procedures they wanted to adopt to carry out their evaluation.
What suggestions can you make to improve the Interagency Evaluation Process?
The IHE process needs more and better planning, prioritizing of issues (for example, financial issues and constraints and certain cultural issues which were not taken into account by the evaluators). The follow-up interview and questionnaire from HQ 6 – 12 months after the evaluation is helpful to ensure that recommendations are followed up on. A focal point in the country should be nominated to take part in the initial evaluation and to take responsibility to provide follow-up on recommendations. Continuity is important and lacking in this respect.
Evaluation Outcomes:
Do you feel the conclusions of the Evaluation are relevant to the programme?
Some conclusions were very relevant, others not. In some cases, the Evaluation Team compared the programme to programmes of standards that are not available in Nepal. In others, cultural factors were not taken into consideration in the recommendations. The recommendations were not prioritised and it is difficult to determine which are the most important.
If not, what could have been done differently to improve their relevance?
Increased participation of stakeholders in planning and carrying out the evaluation would improve the outcomes and conclusions. Prioritization of core areas needed evaluating. Existing ToRs, were very broad and non-specific. Furthermore, the evaluation did not take in consideration a phase out strategy to alter the nature the care and maintenance assistance that was at the time adopted by the country programme. Participation of local consultants on the Evaluation Team would have helped to improve understanding of local cultures and customs.
In terms of recommendations made, were they the right number, too few, too many? Too many recommendations were proposed, and in fact some were not recommendations but observations without clear actions to be taken. Some of them seem to be redundant.
Although many of the recommendations are important, it is of limited value to have a long list of recommendations or observations that cannot be implemented due to insufficient staff and funding. Rather, targeted recommendations, the achievement of which could be easily measured and monitored in the field, would be more useful than the ones, which involve various factors. For example, integration of the PHCCs in the local facilities requires various factors including the proactive involvement of the host government. More realistic or stepwise goals would have been useful.
95 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
What steps/actions were taken following the Evaluation to follow up on these recommendations?
Unfortunately, the UNHCR health coordinator left a few months after the evaluation report was submitted. The Health Co-coordinator in the Health NGO had also left. We therefore did not have the staff who could have followed up on the recommendations. With the recent arrival of a new HC there is more opportunity now to address the recommendations and implement actions.
96 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Nepal evaluation questionnaire regarding follow up to recommendations:
Overall Recommendations Follow up Comments regarding constraints to completed follow-up, relevance of (Check one) recommendations, results for programme, YES NO etc. (1) Replace the implementing partner with a more experienced NGO. X There are very few medical NGO’s in Nepal; this option was not fully explored so this recommendation is not realistic. Rather than changing the NGO it may be better to improve its capacity to do the job. (2) If it is not possible to replace the current implementing partner with one with more public health experience, the capacity of the implementing partner must be improved in X Consultants would be welcome if available three key areas: (1) IMCI; (2) nutrition and (3) reproductive health/SGBV This should be and funded. done through three consecutive consultancies of no less than two months each in each of the three areas. A key activity of these consultants would be to work alongside the main implementing partner and UNHCR field staff in order to build capacity. The consultants should also begin looking at the integration of MoH and refugee health services and work closely with other implementing partners such as WFP as well as involving other potential partners such as the MoH, WHO, UNICEF and UNFPA. (3) In time, following the above interventions, UNHCR might consider handing over these new more efficient clinics to the MoH. Not a recommendation.
(4) UNHCR should engage a health coordinator with experience in overseeing public X Since Sept 2004 health programs in refugee situations.
(5) UNHCR should consider the possibility of collaborating with UNFPA or another partner for the development of a comprehensive RH program.
(6) UNHCR should have a designated focal point for RH within the Community Services X CH is RH coordinator Unit.
(7) UNHCR should ensure that a well functioning community mental health programme X UNHCR has plans to improve the present
9 7 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL is put in place prior to withdrawal. community health programme in and it will be implemented in 2005. The budget for this expansion and improvement has already been incorporated into the 2005 budget need to identify appropriate partners to take on the work. SPECIFIC REPRODUCTIVE HEALTH RECOMMENDATIONS Reproductive health is not only a matter of physical well-being, but also of mental and X UNHCR will try to get women’s social well-being, and considering the major role that community based organisations participation in this area. Plans are being such as the Bhutanese Refugee Women’s Forum and the Bhutanese Refugee Children’s made for nutrition and health talks with Forum play in the organisation of life in the camps, due attention should be given to the women’s organisations to begin by next reinforcement of the refugee organisations and to promote their active participation in June the development of RH programmes in the camps. It is recommended to assign a RH coordinator at the level of UNHCR who will be in X See above charge of the overall monitoring and supervision of the RH programmes in the camp. The RH coordinator should not necessarily be a medical person. A comprehensive and needs-responsive RH program should be developed in a X In the planning process. participatory way involving all implementing partners whose activities may have an impact on the population’s SRH (such as AMDA, Caritas and the Lutheran World Federation) as well as the refugee community. This RH programme should identify quantitative and qualitative indicators in order to X Not accomplished yet. be able to properly monitor and supervise the implementation of the program and to evaluate the effectiveness of its activities. In the development of the SRH programme due attention should be paid to the X Reproductive Health programme has promotion of the employment of female health workers. female workers and UNHCR has insisted on gender balance in this respect. Confidentiality and privacy in the provision of RH services should be issues of priority concern. In the development of the SRH programme, priority should be given to the prevention of: STI/HIV/AIDS SGBV Early detection of pregnancy is part of SBGV programme. Early marriages and early pregnancies.
98 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Specific Recommendations Follow up Comments regarding constraints to completed follow-up, relevance of recommendations, (Check one) results for programme, etc. YES NO It is recommended that the IMCI consultant look into the reasons for such over use and assist the implementing partner in designing a community education program around the use of OPD services. The role of the community health care worker as a point of first contact should be considered. Laboratory confirmation must be obtained on several specimens to identify the organism. Indicators have been identified for all Treatment protocols for the specific disease must be put in place. The role of water, X samples sanitation and hygienic practices should be investigated and appropriate action taken. Sanitation and hygiene standards are being met. AMDA must confirm whether the above cases were adequately investigated, and if they Drug resistance is an emerging problem. were confirmed. All new cases of suspected TB should be reported to the health X coordinator, so that they can be followed up on. The HIS should record injury at least as being intentional or unintentional. If cases of X This has been implemented and the HIS attempted suicide are occurring these should be tallied separately. Injury record is being monitored. Attempted suicide cases are also being recorded and followed up. The current mental health programme needs improvement. An investigation should be X Programme has been reviewed and conducted as to what types of mental illness are being reported and what are the activities will be incorporated in the field of underlying causes. mental health next year. Protocols for the management of STIs must be put in place as soon as possible. Organisms should be tested for drug sensitivity. Partner tracing should be strictly adhered to. A community education program aimed at men may be needed. Perhaps through the UNHCR community assistants, the actual amount of water being Standards are being maintained and collected per family should be determined. This may either be below 20 liters per person monitoring is done not only by the IP staff per day, or that amount may not be sufficient for this population. but also by UNHCR Field Assistants At least a proportion of suspected malaria cases among locals and non-travelled refugees X Currently being done. should have blood slides taken. The most important recommendation is that UNHCR send an experienced consultant for Guidelines are being developed based on at least two months to work with the implementing partner to improve the delivery of the guidelines of DPHO. primary health care. This consultant should conduct IMCI training for all clinicians,
99 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
develop treatment protocols and institute use of standard case definitions. Part of the TOR should be to work with the MoH and other possible health partners such as WHO and UNICEF. Recommendations for the PHCCs: 1) In Beldangi I and Beldangi II (which serves Beldangi II extension), upgrade drugs and services to match what should be theoretically available in a government PHCC. This will improve in-camp services to a third of the refugee population. 2) Conduct IMCI training for PHCC staff, and invite MoH staff. 3) Institute use of standard case definitions in all PHCCs. 4) In Beldangi II PHCC, Increase the overall number of PHCC staff that see patients. 5) Make treatment protocols available in all PHCCs. 5) Fund the MoH/WHO to conduct the appropriate prescribing practice workshop for all health workers. Recommendations for integration of the PHCCs. Beldangi II extension PHCC must X In light of the serious security situation, it is remain after handover by UNHCR, as should Beldangi I. The IMCI consultant should unrealistic to expect that local health again ensure that services and staffing and protocols are uniform between the refugee facilities will be fully staffed in the near PHCCs and the MoH PHCCs. The refugee PHCCs should operate at the same level as the future. government PHCC at Mangalbare AMDA, the RH implementing partner of UNHCR in the camps, is mainly a clinically Not a recommendation. oriented association with major expertise in medical care, but does not necessarily dispose of the required expertise for the organisation of SRH awareness raising and education programs In spite of all international efforts to promote SRH in refugee settings, the SRH program Indicators have been developed for 2005 in the camps is still lagging behind and does not respond to minimal quality standards. There is a huge need for programme development and adequate supervision and monitoring of the SRH services. The decision of UNHCR to create a Community Services Unit in the Sub-office of Damak, Not a recommendation. which will also be in charge of the supervision of the SRH programs, and to increase the number of field assistants is a first and important step in the promotion of SRH in the camps. However, it should be admitted that these measures were mainly inspired by the need for the development of an adequate response to the SGBV prevalence in the camps, rather than by a real concern about the overall SRH status of the refugee population. In order to promote a comprehensive approach to the sexual and reproductive rights of the refugee population and to improve the quality of SRH services in the camp, the HAM
100 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
mission strongly recommends the assignment of a SRH coordinator at the level of the UNHCR Sub-office. The SRH coordinator should be in charge of the development of an appropriate and Indicators have been developed comprehensive SRH programme according to the guidelines that have been developed by the UN agencies. The SRH programme should respond to the specific SRH needs and problems of the refugee population and set priorities in the SRH needs to be addressed in close collaboration with all stakeholders involved, including the implementing partners as well as the refugee population, and more specifically men and women in their reproductive age and adolescents. This programme should also determine quantitative as well as qualitative indicators that may enable UNHCR to supervise and monitor the programme in an adequate way. Serious efforts should also be taken to increase the number of female health staff in the There is a scarcity of suitable, qualified camp level health services and to improve confidentiality and privacy at all health staff. facilities in the camps. Family planning services in the camps seem to be widely accepted and known by the Planned for 2005. UNHCR will carry out a population in the camp, both for limiting the number of children and for birth spacing. survey first on FP needs. The utilization of FP, however, is still rather low and could be increased. Measures should also be taken to guarantee regular and reliable supply of modern contraceptives. It is recommended to analyse the problem of infertility in the camps and to investigate if Infertility is not a priority issue at the there is a relationship between infertility and neglect of STI cases and treatment on the present, but will be reviewed in the context one hand, and sexual and gender based violence (SGBV) on the other. of STDs. Men should be involved in FP programs as a first step of involving them in other SRH Planned for 2005. issues such as the prevention of STI/HIV/AIDS or SGBV. Contraceptive use by men enables them to share the responsibility of FP with their wife. Activities may include couple counselling, condom promotion (not only for the prevention of STI/HIV/AIDS but also for FP), and peer group sessions. Confidentiality and privacy at the BHU for both men and women should be improved, This recommendation will be looked into in particularly when counselling is needed regarding sexuality related issues. For FP 2005 counselling and supply women prefer to go to the MCH where they are also attended by female health staff. Men, however, have no alternatives. The HAM mission strongly recommends reconsidering the policy of home deliveries Home deliveries are being restricted. attended by TBAs. In the camps we are facing a situation whereby skilled midwives are unable to gain experience and consequently face a real risk of losing their skills because
101 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
of lack of practice. Moreover, a revision of the home delivery policy would also conform to the decision of the Nepali Ministry of Health to no longer promote home deliveries attended by TBAs. Fathers should be encouraged and enabled to stay with their wives during the period of This recommendation is not seen as a labour and delivery, if both man and wife wish to do so. priority. The practice of unsafe abortions in the camp should not be neglected. Appropriate provisions should be taken to inform the refugees, including adolescents, about the risks of unsafe abortions and to perform safe abortions under the conditions as stated by the law. The refugees’ knowledge about STI/HIV/AIDS is extremely low, completely inadequate A massive campaign is planned, linking and very abstract. STI services are absolutely deficient, particularly for men. Moreover, with organisations in the area. health workers are not properly trained to deal with STI/HIV/AIDS cases. There is a clear need for a coherent, comprehensive and high quality STI/HIV/AIDS Repeat of other recommendations. programme in the camps for both adults and adolescents. This program should focus on prevention and awareness raising, training of health staff, the establishment of a confidential environment for treatment and counselling and regular supervision and monitoring. The employment of female staff at all levels of the health services should be encouraged. Attention should be given to make both refugees and health workers feel more comfortable to talk about all aspects related to sexuality and SRH in a language that people really understand. The programme should also specifically target the male population and partner notification; counselling and treatment should be taken up more seriously. The HAM mission welcomes the efforts of UNHCR and its implementing partners aimed at the legal protection and psychosocial support of the survivors of SGBV and the organization of training, prevention and awareness raising activities. In spite of all these efforts, however, a programmatic approach of SGBV awareness raising and prevention is still lacking which is reflected also in the lack of quality and coherence in the activities that are carried out in the field. The HAM mission strongly emphasizes the responsibility of UNHCR to develop a common and programmatic approach to SGBV that is adapted to the specific needs in the camps as well as the urgent need for constant monitoring and supervision by UNHCR of the quality of the programs that are being developed by its implementing partners.
102 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
In the view of the recent declaration of the UNHCR High Commissioner concerning the phasing out of the humanitarian aid programmes in the Bhutanese refugee camps the HAM mission wants to express its deep concern that the possibilities of reduced funding for the Bhutanese refugee camps in Nepal in the near future may not result in a cut down of the social services programmes. In this respect the mission wants to recall previous experiences referred to in the HRW report where it is stated that “the programmatic choice to minimize UNHCR staffing in the camps contributed to grave problems in the administration of justice, especially in cases of gender-based violence” (p.22) and that “Bhutan, Nepal, UNHCR and international monitors have a responsibility to guarantee that gender-based violence programming is not abandoned, and that refugee women’s rights are fully respected in each step” (p.72). In this respect the HAM mission wants to highlight the importance of UNHCR’s decision to strengthen the social services in the camp and calls upon all implementing partners and the donor community to take up their full responsibility and to provide financial and logistical support for both technical and social aid programs that are particularly aimed at the protection of women’s and children’s rights. It is completely acceptable that cases of SGBV are being handled with utmost confidentiality and secrecy in order to fully protect the rights of the victims and the alleged perpetrators, but it is difficult to understand why the refugee community’s role should be limited to mere reporting and registration, whereas it could play a major role in awareness raising and sensitisation in order to really prevent and combat a further increase in SGBV in the camps. Because of the silence with which SGBV cases are covered it will be difficult if not impossible for the refugee community to gain a real understanding of the seriousness of SGBV prevalence in the camps. Moreover, the refugee community has a right to information and is entitled to be duly informed about situations that may directly affect their physical and mental well-being. Access to information can be easily organized without violating the victims’ and (alleged) perpetrators’ rights. Good and reliable information will motivate the community in taking up its responsibilities in the identification of SGBV cases in the camps. It will also contribute to more transparency and higher accountability of stakeholders involved in the fight against SGBV. By providing public information UNHCR will also encourage effective participation of
103 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
the refugee community with respect to the identification of needs and gaps related to the community’s responses and attitudes towards SGBV and the changes that are needed to meet these gaps. The refugee community, and more particularly refugee women, should be involved in all aspects of the development and maintenance of programs to combat SGBV in the camps. Their involvement should not be restricted to the mere reporting of SGBV incidences in the camp. Systematized information and data analysis on the types and frequency of SGBV is still needed in order to be able to identify and prioritise needs in the prevention of and protection from SGBV and to develop appropriate programs. Data analysis and basic statistical information are also needed in order to identify indicators for the assessment of the effectiveness of the interventions that will be undertaken. The HAM mission draws special attention to the need for setting up programmes for specialized gender-training and sensitisation of all stakeholders involved in the management of the camps, including the Refugee Coordination Unit (RCU) administrators, police officers, the senior management and the staff of the aid agencies as well as the members of the CMC. UNHCR should also explicitly encourage its implementing partners to gender- It is part of our policy and we are mainstream their policies and to develop strategies to promote the employment of female implementing it as much as possible. staff at all program levels. Comprehensive awareness raising and sensitisation programs that do not exclusively deal with SGBV from a strictly medical/clinical or legal point of view should be developed. These programs should highlight SGBV within the broader scope of SRH and also point at the long-term impact of SGBV on the mental and social well-being of its victims and their families. The HAM mission urges UNHCR and its implementing partners to fully address the It is being addressed problems of polygamy and domestic violence in the camps and to recognise these explicitly as SGBV in the interagency procedure manual The HAM mission fully adheres to the recommendation of the HRW report where it calls upon UNHCR to cooperate with other United Nations agencies and non-governmental organizations to advocate for legislative changes in Nepal to protect women and children’s rights. 46. Marriage “by elopement” is very common in the camps and is mainly practiced by young people between the age of 13 and 18. In-school and out-of-school programmes
104 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
should be set up to raise awareness among the young about the risks of early marriage, early pregnancy and the benefits of good education. Considering the very young age at which girls elope (13-15 years) it is important to consider the organization of SRH awareness raising programs that target the age group between 10 to 15 years, and not to wait till they reach 9th or 10th grade at school. Education of girls should be actively encouraged at the level of the whole community. Steps should be taken to encourage pregnant girls to finish their education and to raise awareness among parents, schoolteachers (young and old) and the students themselves about the importance of woman’s education not only for her own well being, but also for her children and the whole family. Attention should be given to the development of proper sexual education programmes for school going and non-school going children and adolescents. These programs should include quality peer education and pay due attention to the creation of a confidential environment where boys and girls can feel assured to talk about SRH related issues. In the camps special SRH services for unmarried young people should be developed where they can go for counselling, treatment and psychosocial support. Priority should be given to supporting the Bhutanese Refugee Children’s Forum in the camps and to the development of appropriate life skill training programmes that also pay due attention to the provision of recreational and creative opportunities for children and adolescents. It is also recommended to consider the possibilities of exchange programmes with their Nepali peers. The prevalence of acute malnutrition in refugee children has not changed substantially during recent years and still poses a public health problem in this post-emergency context where refugees are provided with consistent and sufficient food ration. Other factors such as chronic of frequent acute infections and inappropriate infant feeding practices may contribute to these relatively high rates of acute malnutrition. It is recommended that in the future nutrition surveys the prevalence of stunting is disaggregated according to age (e.g., 0-11 months, 12-23 months, 24-59 months). It is also recommended that prevalence of stunting be measured in 6-10 year old schoolchildren. To further improve the quality of reporting, it is recommended that 95% confidence intervals (or values for standard deviation) be reported with all major prevalence indicators. Also, tests for significance of association should be reported when bi-variate
105 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
(e.g., 2*2 tables) or multi-variate analyses are presented. Reporting acute malnutrition prevalence using Z scores is preferable as it allows for comparison with other national and international data where acute malnutrition prevalence is reported using Z scores. In addition reporting the prevalence in percentage of the median in the survey report is also recommended The correct method of calculating the required number of households is as follows: suppose the required sample size of 396 children has been determined assuming simple random sampling and expected prevalence of wasting of about 10% with required precision of 3%. Then, the required number of households to be included in survey is determined as follows: number of children divided by average household size and by proportion of children under 5 in the total population. For example, if average household size is 6.0 and proportion of children under 5 in total population is 0.08 (8%), then the required number of households is determined as follows: 396/(6*0.48)=825 If only children under 5 are of interest in the survey, then those of 825 selected households that have no such children can be skipped. It is not necessary to go to neighbouring households until a child under 5 years old is found. As usual, all children under 5 found in selected households should be measured. Additional provisions should be made to ensure effective monthly monitoring of children that are older than 1 year if such monitoring is deemed essential. Possible solutions may include a system of small incentives for monthly visits, more proactive follow-up of no-show cases by community health workers, measuring children in their homes, etc. If the shortage of staff and/or other logistical problems make it difficult to ensure compliance in cohorts older than 1 year, an alternative monitoring strategy may be advised: to include in monthly screening only children under 1 year of age AND children under 5 years of age who had borderline low (85% WHM or lower) nutrition status at the annual nutrition screening. The latter cohort (under 5 with borderline low WH scores) should be included in monthly nutrition screening for at least 6 months or until the child has WHM score over 85% on three consecutive monthly measurements. Urgent efforts must be undertaken to enhance expertise of nutrition staff in the area of counselling and follow-up. Specific field guidelines on counselling regarding infant feeding and follow-up of growth monitoring should be developed and implemented in all camps. The staff capacity of nutrition units should be increased as appropriate to
106 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
meet new workload demands. IMCI guidelines on nutrition counselling can be used as a reference, if needed. Similarly to what was recommended regarding growth monitoring, additional provisions should be made to ensure full coverage by mass screening of children under 5 years of age. One of the possible solutions may be to invite for monthly follow-up those children who during the screening have WH % of median score just above the cut-off point (e.g., children with 80-85% of median WH score). This may be especially important for children 2-5 years old who are not usually targeted for routine monthly growth monitoring. The practices of discharge observed in the supplementary feeding programme in Bhutanese refugee camps are unacceptable and demonstrate a lack of expertise and supervision. These practices must be reversed as soon as possible. Clear and uniform guidelines of discharge must be communicated to the staff of nutrition units in all camps, and strict adherence to these guidelines must be closely monitored. Under such discharge practices, the exit statistics provided in monthly report are largely meaningless and cannot be used for objective evaluation of program performance If the current implementing partner is to administer selective feeding programs for Bhutanese refugees in the future, urgent technical assistance should be provided to correct irregularities and ensure that the programs are administered according to internationally accepted guidelines. Constant monitoring and follow-up on the part of UNHCR is advisable. At this time, it is not recommended or advisable to decrease or eliminate supplementary feeding programme for malnourished children or other categories of beneficiaries. Only if economic conditions of refugees, access to jobs and access to alternative food sources beyond those currently distributed in the general ration meaningfully change to the better, should the exit strategies for selective feeding program be considered involving all partners concerned. The HAM mission strongly emphasizes the need for additional training of the staff of nutrition units. Such training should include internationally accepted guidelines on supplementary feeding for young children, the methods of preparation of supplementary ration, the guidelines on the amount and frequency of feeding for children of different ages, appropriate ages at which various supplementary foods should be introduced, and
107 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
counselling techniques. A full course of counselling for mothers should be mandatory on admission to feeding programmes. The staffing of nutrition units should be increased, to meet increased workload. Close monitoring and follow-up of “chronic” cases of acute malnutrition should be instituted, and children with chronic medical problems should be referred for further treatment as appropriate. Clear and comprehensive guidelines for monitoring and follow-up of children who fail to improve their WH scores should be developed and distributed to the staff. The average length of stay is a crucial indicator to evaluate the quality of the supplementary feeding program. It should be calculated on a regular basis and included in monthly reports. Measurement of malnourished children should be done at least once in 2 weeks. These standards should be adhered to by all staff of nutrition units, and implementing partner should ensure appropriate monitoring of measurement practices. The HAM would like to emphasize that according to international standards, the Severely malnourished children are being programme administered to severely malnourished children in Bhutanese refugee camps hospitalised. cannot be called a “Therapeutic Feeding Programme.” Urgent measures should be taken to ensure proper care and feeding for severely malnourished children. It may be argued that because of the small number of cases it is not cost-effective to have day care setting for therapeutic feeding in each camp. An alternative solution might be to have the therapeutic feeding programme in the closest referral hospital (e.g., AMDA hospital) where children from all camps could be referred. Care should be in strict compliance with international guidelines and norms. At this time, it is not recommended or advisable to decrease the amount or quality of foods distributed as a general ration. Only if economic conditions of refugees and access to alternative food sources meaningfully change to the better, should such decrease be considered involving all partners concerned. If the amount of supplementary vegetable ration provided by UNHCR is to be decreased or such distribution is to be stopped altogether, close monitoring of micronutrient status of the refugee population is strongly advised. To ensure the transparency and uniform access to information regarding the amount of food entitlement, it is recommended that clear posters be placed at each distribution site.
108 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Such posters must be in native language and simple enough to be understood by the least educated members of refugee community. They should include exact amount of food entitlement for all food types being distributed, and should contain aggregate amounts for families of different sizes. To ensure impartial and independent monitoring, a system of random surprise checks by outside staff (preferably WFP or UNHCR) should be instituted. Monitoring may need to specifically target poor and less educated members of refugee community. The case definition of beriberi should be formalized and such information communicated to health facilities in the camps. More discriminate approach to diagnosis and reporting of beriberi cases is recommended by the HAM mission. Case definitions for all micronutrient deficiencies prevalent in the camps should be developed, and the staff should be trained accordingly. Severity of the cases should be routinely ascertained. The correctness of diagnosis may need to be confirmed by medical staff with higher qualifications and experience in diagnosing and treatment of such conditions. If reported incidence of scurvy and Vitamin A deficiency is correct, further nutrition investigation is warranted and additional preventive interventions may be required depending on the outcome of such studies. The recommended iron and Vit A dosage should be standardized among camps according to the latest international guidelines, and written instructions should be available in each MCH unit. The uniformity and adherence to instructions should be closely monitored. As mentioned in previous recommendations (see Supplementary Feeding section), much more attention should be paid to nutrition counselling of pregnant women and breastfeeding mothers. Special emphasis should be given to the timing of introduction of complementary foods, appropriate ways of preparation, frequency of feeding and amount of food given. Comprehensive guides to assist the staff in counselling should be developed, and the staff of both nutrition units and MCH units should be required to provide mandatory counselling to the women. IMCI materials may be instrumental in developing such counselling guidelines. External technical assistance may be required because the implementing partner does not seem to have the necessary technical expertise and experience
109 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Special care should be taken to counsel the mothers that perceive that they “do not having enough milk,” and prevent early introduction of other foods, especially UNILITO and cows milk which seem to be commonly given in such situations.
UNHCR should support IMCI training, conducted by the MHO/WHO for all Bhutanese and implementing partner staff MoH staff working in health posts and clinics should also attend the training, to improve contact and coordination UNHCR should advocate with UNICEF and WHO that Jhapa and Morang districts be included as special focus districts for IMCI. UNHCR should also support a WHO/MoH workshop on rational drug prescribing.
As part of the disengagement process, UNHCR should give support in terms of basic equipment to surrounding government facilities, if these facilities will be expected to cope with an increased workload as a result of disengagement. There should be regular meetings between MoH public health staff, UNHCR and implementing partner staff on disease surveillance. Government case definitions and protocols for case management should be made used in all camp facilities.
110 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
Annex 5: List of Acronyms AMDA Asian Medical Doctors Association (AMDA), ANC Antenatal Care ARI Acute Respiratory Infection BHU Basic Health Unit CBR Crude Birth Rate CHS Community Health Supervisor CHV Community Health Volunteer CHW Community Health Worker CPR Contraceptive prevalence rate in CSU Community Services Unit DHS Demographic and Health Survey EDCD Epidemiology and Disease Control Division of the Ministry of Health of Nepal EPI Expanded Programme of Immunization FHS Female Health Supervisor FCHW Female Community Health Worker FMO Female Medical Officer FP Family planning FSMO Field Supporting Medical Officer (PDH supervisor of health services) GAM Global Acute Malnutrition HAC Health Action in Crisis HIS Health Information System HPO Health programme officer IMCI Integrated Management of Childhood Illness IP Implementing Partner JAM Joint Assessment Mission KAP Knowledge attitudes and Practice LWF Lutheran World Federation MCH Maternal and Child Health MNSS Micronutrient Status Survey of 1998 MO Medical Officer MoH Ministry of Health
111 EVALUATION OF HEALTH AND HEALTH PROGRAMMES IN BHUTANESE REFUGEE CAMPS IN NEPAL
NIN National Institute of Nutrition NRCS Nepali Red Cross Society NWFP North West Frontier Province OCs Oral contraceptives OP Operational Partner OPD Out-patient departments ORS Oral dehydration salts PDH Project Directorate for Health PHC Primary Health Care PMS Pharmacy Management System RCU Refugee Coordination Unit SCF Save the Children Foundation SGBV Sexual and gender-based violence SHP Sub-Health Posts SFP Supplementary Feeding Programme STI Sexually Transmitted Infection SFP Selective Feeding Programme SRH Sexual and Reproductive Health TBA Traditional Birth Attendant TFP Therapeutic Feeding Programme TOR Terms of Reference UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children’s Fund UNV United Nations Volunteer VCT Voluntary Testing and Counseling (VCT). WFP World Food Programme WHO World Health Organization
112