Valued Behavior for Healthy Families

The project assessed the magnitude of social barriers of the local community in order to design programme approaches that could foster local acceptance of family planning (FP) services and instill a sense of adoption of intended practices in marginalised communities. This was accomplished through tailored behaviour change interventions specific to the culture and language of the beneficiaries; full community participation in defining quality services; strengthening of NGO participation in the provision of services; and building sustainability of activities.

Participating NGOs worked to empower women by increasing knowledge of and interest in FP services through participatory learning and action (PLA)/radio listening groups (RLG). PLA is a behaviour change intervention that is based on nonformal education. PLA/RLG groups were comprised of marginalised community women who studied key FP messages while learning to read and write. Participants in these group dialogues made their own action plan for improving their own and their community's FP/RH behaviours. To foster this, organisers trained local women to become PLA facilitators. Using interactive approaches, the facilitators taught women how to read and write, and introduced them to good health practices (e.g., the importance of the 4 antenatal care visits, taking iron tablets during pregnancy, and immunisation for children). The class messages were reinforced by radio programmes, which PLA groups listened to and subsequently discussed. Organisers had adapted the Ministry of Health's FP radio programme (via JHU/CCP) to local languages and designed the broadcasts to be culturally and religiously appropriate. The programme, called "Knowledge is Power" was later used by Muslim communities. Organisers also addressed issues affecting the Dalits, Muslims, and marginalised reproductive-aged women living in remote areas by involving local authorities, including Muslim Maulanas (religious leaders). To make these activities more appropriate and practical for the intended populations, NGOs conducted a rapid assessment to identify the barriers to RH services. Project staff collected baseline information on the PLA participants' knowledge and practice of family planning, and coordinated with the District Health/Public Health Offices throughout the project.

The partnership-defined quality (PDQ) approach was used to improve the quality and accessibility of health services with community involvement in defining, implementing, and monitoring the quality improvement process. Four Dalit and Muslim representatives joined the government-authorised Health Facility Operation Management Committee to create a Quality Improvement Team. PDQ teams held focus groups with local community members and found that the majority of problems concerned infrastructure of the health centre itself, a lack of information about services, inadequate FP counselling by health workers, discriminating and/or rude behaviour, and inadequate supply of medicine and instruments. Almost all health facilities resolved at least 3 quality issues by getting community support and working together with communities and other stakeholders. Service providers became more accountable for their service responsibilities due to a raised level of service expectations and quality of care demanded from the community.

According to organisers, voluntary surgical contraception (VSC) outreach is one of the annual events for the FP service delivery system of the government in Nepal. Due to the technical and logistical difficulties and low awareness of the available services, Dalits and other marginalised populations have limited access to those services. The project supported the District Health/Public Health Office to extend comprehensive FP services beyond the regular service sites, which are all centrally located. Based on the client choice and decision, the project also provided temporary FP methods (injectables and pills). The project worked with existing health facilities to extend FP/RH services to marginalised areas through outreach and mobile clinics. The VSC service was expanded beyond the winter season to dispel a popular myth urging people not to have a VSC procedure during summer months.

In order to improve the social and policy environment for FP/RH services and behaviour, organisers worked to build the capacity of NGO staff, District Public Health, and other stakeholders to do programme design and monitoring, develop a Detailed Implementation Plan, and conduct PDQ and strategic health communication and advocacy. The project used the NGO Institutional Capacity Tool (NICAT) to target improvements in organisational policy and management issues, so that the NGOs and their government counterparts could continue working with new donors to empower local communities after the project ended. At the district level, the Reproductive Health Coordination Committee (RHCC) was the main platform for different stakeholders to share RH programmes and build consensus on a common agenda. The project encouraged the use of the RHCC forum to inform other stakeholders about the programme. NGO partners built the capacity of local community-based organisations (CBOs) to run PLA/RLGs, and 300 copies of PLA Facilitators' Guidebook and PLA Process Implementation Guidelines were published by the Ministry of Education, enabling partner NGOs to implement the PLA approach.

Family Planning.

According to organisers, Nepal remains among the economically poorest and least developed countries in the world. About 31% of the population - most of them marginalised, low-caste, and socially excluded groups - live below the national poverty line. Furthermore, political instability and security issues continue to plague parts of Nepal even after the signing of the Comprehensive Peace Accord on November 22 2006. There are many myths and misconceptions that play into the underuse of FP services among rural and poor communities. For example, almost 70% of men believe that male sterilisation is the same as castration. Religious beliefs among certain groups also limit access to services. For example, a common belief among the Muslim community is that religion prohibits the use of FP.

Despite the political conflict situation in the country during and after the project, evaluation results show that the project's holistic model of PLA, radio health programmes, PDQ, and comprehensive FP services have led to a sustained impact on the demand for FP services among the intended population. For instance, project data showed an increasing trend in FP use in both marginalised and non-marginalised communities of the project districts.