Current activities
We support national TB control programme to implement its activities, particularly to reach and serve the unreached group and we are implementing different activities of the national strategic application (NSA) as one of the sub recipients.
Programme Based Operational Research
The main thrust of HERD is to deliver evidence based quality research and translate the generated knowledge into policy and practice. Till date HERD is engaged in many research programs, networks and project in collaboration with wide variety of partners in diverse field and subjects. Researches are done on identified issues by engaging with the national programmes since inception phase.
Current major areas of operational research are:
- TB and TB HIV collaboration
- Public Private Mix (PPM)
- Urban Health
- DR-TB (Drug Resistance TB) management
- Gender Equality and Social Inclusion (GESI) in TB program
Health System strengthening
Public Private Mix in TB control
Public Private Mix (PPM) in TB control has been one of the core areas of its engagement since inception. It started with the conduction of an operational research on public private partnership in Lalitpur Municipality from 1998 to 2001. This approach proved to be highly successful. After that it put its continuous effort on scaling up this approach to other parts of the country and could incorporate this component in routine program with a plan for phase wise expansion in major cities under the Global Fund round 7 grant. Its one of the key component in national strategic plan 2010 to 2015.
PPM approach is imperative for TB control because significant number of people is still seeking care in the private sector where quality of care is diverse and often questionable. Hence it is being implemented to engage public and private health care providers to ensure provision of quality TB services in line with NTP policy, Stop TB Strategy and ISTC.
We developed urban TB control guideline, training material for different groups, modules, and IEC materials. Mapping of the service providers and detail situation analysis of each city is conducted at the beginning followed by sensitization meeting, working group formation, action plan development, capacity building activities, support to establish/strengthen service outlets, establishing linkages between different care providers, reporting workshops etc.
HERD is implementing PPM activities in 10 cities of Nepal, as a Sub Recipient of NSA in line with the urban TB control guideline by engaging the municipality, district public health office, formal and informal care providers, community people, local leaders, faith healers, medical students etc.
HERD is playing a crucial role in initiating and incorporating the TB HIV collaborative services into the regular program of National TB Control under the Global Fund round 7 grant as well as the National Strategic Plan. Its one of the key component in national strategic plan 2010 to 2015. HERD is implementing TB HIV Collaborative activities in five districts of Nepal. In Chitwan and Parsa activities are being implemented in partnership with NAP+N.
The major activities conducted by HERD for the collaboration includes development of TB HIV collaborative programme implementation guidelines and TB HIV Training/orientation manual for different groups, conduction of VCT and basic Tb HIV training for health workers at different sectors, establishing and strengthening VCT and DOTS centers, conducting situation analysis of each district at the initiation of programme implementation, implementation of other programme based operational research in TB HIV collabotation based on need e.g. on Provider Initiated Testing and Counseling, establishing cross referral mechanism between VCT and DOTS centers etc, intensified case finding of TB/HIV among the vulnerable groups, empowerment and income generation activities to affected communities, awareness and other capacity development activities.
Capacity development of affected and infected: We believe in empowering the affected and infected people in delivering services to those groups. Thus we have been partnering with the NAP+N (National Association of People Living with HIV) to implement TB HIV collaborative activities, where the infected and affected families and individuals are implementing the community level activities with needed technical and financial inputs. (linked with TB HIV section..)
(Partnership with NAPN in implementing TB HIV collaborative activities)
National Association of People Living with HIV/AIDS in Nepal (NAP+N) is a non-political, non religious, non-governmental, non-profitable, autonomous network of People Living with HIV/AIDS and as such, a platform for collaboration, cooperation, joint action and collective endeavor between PLHA and HIV/AIDS organizations in Nepal.
NAPN has focused on building the capacity of local PLHA groups to respond appropriately to the needs of PLHAs in area of advocacy, care and support, counseling, raising community awareness, providing information and education and improving access to the healthcare and legal services. NAPN is the largest network of grassroots organizations working on the frontlines of this epidemic.
NAPN is committed towards the promotion of autonomy and empowerment of PLHAs which will help them make informed decision. NAPN ensures that PLHAs are in the forefront of policy making debates and their meaningful involvement at all levels is essential.
Objective of partnership
Immediate objective of the partnership is to implement NSA TB Grant activities under TB HIV Collaboration and reach the unreached group. Whereas the long term objective of the partnership is to develop capacity of NAP+N to implement such community level activities by engaging their network.
Process of Partnership
HERD is engaged with NAP+N since the preparation of concept note for NSA TB grant. We assessed their capacity in terms of M&E mechanism, financial management system, human resource capacity etc. After finding reasonably strong mechanism in place agreement was signed between HERD and NAP+N for partnership. We provided financial and other technical support, oriented them on the reporting and other requirements. NAPN conducted the TB HIV collaboration activities at Parsha and Chitwan with close monitoring and supervision from HERD.
Achievements
We could reach the unreached group by partnering with NAPN which facilitated the TB HIV collaboration.
Delivery of essential health care service at urban area
In Nepal, squatter settlements, slums, street dwellers, vendors, marginal farm families, and scavenging groups are categorized as poor urban communities. The urban poor are hidden, living in rented accommodation and small pockets of squatter or slum settlements spread over the city. In Kathmandu, 35.6 per cent of households are below the poverty line, and due to the escalation of land prices and rents, they have no alternative but to live in slum or squatter settlements or in sub-standard rental housing. At present, there are 63 slum and squatter settlements in Kathmandu valley, and its population is growing by 25 percent per year. Most of the slums and squatter settlements are located in city core areas and the river banks of Bagamati, Bishumati and Manohara rivers without adequate water supply, basic sanitation and proper nutrition, overcrowded, with little or no access to safe drinking water or functional toilets amongst others. The urban poor encounter difficulties in access to quality health care services due to economic, social, psychological, and geographic factors. The urban poor face lack of access to health care services in spite of reasonable or good availability of heath care facilities in towns and cities.
Considering the strong need of essential Health Care Services (EHCSs) for urban poor, HERD/Nepal established Manohara Community Health Center on 15 March 2008 in Madhyapur Thimi Municipality. The main aim of MCHC is to increase access and utilization of quality health services among slums-dwellers, seasonal migrants, internally displaced, socially excluded, and poor and marginalised groups in urban areas at affordable cost. The centre also provides services for seasonal migrants, factory workers and slum people living in the areas of Lokanthali, Jadibuti and Manohara (Pragatinagar).
Recently, Government of Nepal has endorsed Urban Health Policy, 2011. In this context, HERD has conducted series of meeting and discussion with Primary Health Care Revitalization Division of GoN and Kathmandu Metropolitan City. HERD is planning to work in close coordination and collaboration with Primary Health Care Revitalization Division of GoN and Kathmandu Metropolitan City for Urban health. HERD has been working with National Tuberculosis Center (NTC)/Nepal and implementing DOTS services to urban dwellers through Urban DOTS centres. Furthermore, It has conducted different studies on Urban poor. (Link with detail of MCHC…)
Advocacy, Communication and Social Mobilization
Advocacy, Communication and Social Mobilization (ACSM) interventions are focused on improving case detection and treatment adherence, combating stigma and discrimination, empowering people affected by TB and mobilizing and generating political commitment and resources for TB. Advocacy helps in gaining and maintaining the support of and motivates decision makers, opinion builders, stake holders and policy influencers while communication is oriented towards increasing the awareness level on areas of TB. Likewise, social mobilization aims at bringing together all feasible and practical inter-sectoral social allies to demand for a particular development programme, to assist in the delivery of resources and services and to strengthen community participation for sustainability and self reliance.
Till date activities under ACSM have been carried out in districts like Dolakha, Ramechhap and Kathmandu valley targeting communities to the policy builders.
Practical Approach to Lung Health
The Practical Approach to Lung health (PAL) is a syndromic approach which is aimed at managing respiratory patients in primary health care settings while expanding TB detection and good-quality TB services. The PAL strategy targets multi-purpose health workers, nurses, doctors, and managers in primary health care settings with National Tuberculosis control programme.
PAL focuses on the most prevalent respiratory diseases at first-level health facilities – pneumonia, acute bronchitis and other acute respiratory infections, TB, and chronic respiratory conditions including chronic bronchitis, asthma and chronic obstructive pulmonary disease.
PAL works for the standardization of health service delivery through the development and implementation of clinical practice guidelines. It further works with the coordination among different levels of health care as well as between TB control programmes and the organization and management of general health services.
During the FY 2067/68 HERD worked in the development of human resources for PAL in two districts i.e. Rupandehi and Kathmandu. After the logistic supply from NTC, PAL programme is planned to start its services in those two districts.
HERD's involvement in MDR TB treatment and knowledge generation:
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Completed research /survey on effectiveness of financial and social support to MDR TB Patients in Nepal-2009 to estimate effectiveness of financial plus social and social support alone to DOTS PLUS treatment defaulters.
Key finding and conclusion: treatment default rate is 7, 4 and 10 per 1000 person/months respectively among combined support, social support and no support group. Combined support (89%) and 94% of social support group discontinued jobs due to disease and >80% of patients have economic problem to continue and were managed through loan, selling assets etc. Self esteem increased, decreased fear about disease and treatment, relieved tension, and raised level of confidence among social support group: money used for food, extra diet rent, travel cost schooling of children and increased confidence among social plus economical support group.
Now, Government of Nepal is providing NRS 1500/- monthly to each MDR TB patients who are under treatment.
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Started MDR TB treatment in Manohara Community Health Center
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Conducting a study on "Risk factors of Multi Drug Resistant Tuberculosis: A case control study at selected DOTS Plus clinics in Nepal" as identified by the national and regional level researchable I ssues identification workshops
- Going to develop supervision and patient support approach for Drug resistant (DR) TB case management in context of Nepal's National TB Program
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Training are generally focused on enabling learning and development for people as individuals which extend the range of development way outside traditional work skills and knowledge and creates far more exiting, liberating, motivational opportunities for health service providers. Training is a learning process that helps to increase the level of knowledge, sharpening of skills, concepts and rules or changing the practice of service providing to people affected with TB.
Proper training and education is a base for providing quality TB services. So, context specific training is required to cover essential work related skills, techniques and knowledge for which updated and quality training materials play a key role.
HERD has developed different training and orientation materials (for different target groups) for National Tuberculosis programme (NTP) on areas of TB, TB HIV co-infection management and Public Private Mix in TB control. etc. These materials have been developed in coordination with National Tuberculosis Centre (NTC), National Centre for AIDS and STI Control (NCASC) and other concerned stakeholders (I/NGOs and CBOs). Series of workshop, meeting, discussion and in-house workshops are conducted to develop the materials. Moreover sourcing out of relevant expertise is also being practiced to ensure quality and appropriateness.
One of the key areas of HERD's engagement is capacity development of individuals groups, concerned organizations, and stakeholders to increase their abilities: to perform functions, solve problems and achieve objectives. Capacity development is targeted both to the HERD's staff members, partner organizations, programme implementers as well the demand side including community people, local influential people at different level etc.
For the capacity development of staff members it conducts several in house as well as outside activities based on the need. Similarly, it also engages in developing capacity of its partners on identified areas e.g. providing training on Research methodology, relevant statistical packages e.g. SPSS;, management skills, incorporating the appreciative inquiry aspect in routine trainings etc. Moreover, for the skill development of the programme implementers its conducts capacity development activities at different levels ranging from the central level to the community level providing trainings, orientations, organizing workshops, etc.
Moreover, its one of the major strategy is to engage affected people in the programs by supporting to develop their capacity e.g in implementing the TB HIV collaboration activities it is doing partnership with association of infected people (NAPN) by providing them with needed technical and other assistance. Similarly, it is supporting the TB patients to raise their voice and demand for quality care in line with the Patients Charter for TB Care.
National TB control programme has been facing several challenge as around 60% of the adult population is infected with tuberculosis, there is an increasing number of TB HIV co-infection and an upsurge of Drug Resistant TB. More number of private institutions are extending their services in the area of TB but not staying in line with NTP policies. health seeking behavior of community people is poor, TB case finding is still low while the public health institutions are limited comparing with growing population and in several instances they are not functioning well.
To mitigate and overcome these challenges, health service strengthening is an important strategy and NTP has recognized the need for well-functioning general health systems. Developed or strengthened health system will help achieve the Millennium Development Goals (MDG). Hence HERD has pursued initiatives to contribute to collaborative services as a Sub Recipient (SR) in TB service strengthening through different approaches such as the practical approach to lung health (PAL), community engagement through Advocacy Communication and Social Mobilization (ACSM) public-private mix (PPM) and TB/HIV collaboration. During the past two years, in line with these approaches, we have been initiating to conduct different activities in different districts with coordination and collaboration of concerned D(P)HOs .
We have strengthened several existing DOTS centres with coordination of concerned D(P)HO and Municipalities of PPM (Private Public Mix) working districts. By providing the physical assets (e.g. cupboard, Chair, Table, water filter, weighing machine, medicine tray, box bench, curtain etc) to the different DOTS centres, we hope this will help to run the centre effectively as well as smoothly. Three new VCT centres were established in Kaski, Kathmandu and Bhaktapur as a part of the approach. Total 13 DOTS centres were established in PPM working districts (KTM 1, Kaski 2, Lalitpur 2, Bhaktapur 3, Banke 3, Kailali 1 and Rupendehi 1) with the coordination and support from concerned DPHOs and municipalities. Before establishing the new centre Memorandum of Understanding is signed between service providers, HERD and DPHO. We provide needed support for physical Assets and create their linkages with concerned district health office and other institution for routine monitoring/supervision, logistic supply and other management.
Nutritional interventions
We work with other NGO working in the education sector to provide nutritional information and support to school children; particularly the urban poor and unreached children, at the Manohara slum.
Supervision and Monitoring
Monitoring and supervision is very essential part of any programme to ensure its quality and success. HERD has been delivering various activities independently and in collaboration with different partners especially District Public Health Offices, municipality, other NGOs including National Association of People Living with HIV/AIDS in Nepal and private health care providers (medical college, nursing home and private hospital) aiming to support and strengthen government's primary health care delivery system. HERD has developed strong M&E unit to trace the programme implementation through regular monitoring of the activities focusing input, process and output of activities. Similarly it conducts periodic supervision activities to ensure the achievement of targeted outcome. HERD develops log frame for all its programmes for efficient planning and monitoring with programme objective, definite indicators and means of verification.
To facilitate the system, standard monitoring tools are developed and used e.g. activity planning form, activity reporting form, monthly planning form and progress report form for individual staff , supervision forms etc.
HERD has a strong monitoring system of activity implementation which included preparing detail activity plan, getting approval from concerned in advance, reporting in detail of all activitires with suggestion and feedback, organizing regular programme review meeting among the stakeholder, etc. Similarly follow up of previously implemented activities is done while conducting new activities in the district allocating few extra time considering the cost and time of planning extra regular monitoring visit to the district. Besides monitoring during implementation of activities, special supervision visits are made to programme districts involving staff from Regional Health Directorate, DPHO and other relevant. On site feedback and technical support as well as the detail feedback reporting to concerned is done after supervision as a routine.
We disseminate research findings through different means e.g. scientific articles, policy briefs, organizing workshops, submitting reports etc. Likewise we contribute to take policy to people e.g. by advocating patients charter for TB care and International Standards for TB Care.
Health camps
We organize health camps including specifically the chest camps, particularly targeting the unreached groups. An example:
