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Index ! ! 1. Description
5 page
2. Introduction
7 page
3. Justification
19 page.
4. Beneficiaries
25 page
5. Strategic lines
28 page
6. Objectives and Actions
30 page
7. Location
40 page
8. Implementation Schedule
43 page
9. Expected results
48 page.
10. Monitoring and Assessment
53 page
11. Project viability
55 page
12. Budget
60 page
13. Appendix
63 page
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1. Description Cross-sectoral project dedicated to constructing a permanent medical clinic in a rural region of Nepal and improving the quality of life of its population through local development, by and generating medical centre activities. In Nepal, 40% of the population lives below the poverty line, infant and maternal mortality is very high and the majority of diseases could be easily prevented. Furthermore, there is a restricted access to health services due to the mountainous terrain, poor infrastructure and lack of quality health services provided by the government. In addition to basic health care, the medical clinic will also provide basic training in health and hygiene, aimed primarily at women, but also focusing on training rural doctors and support staff to ensure the viability of the project. Its cross-sectoral approach is rooted both in the extensive network of local and international collaborators, but also in activities that will be generated by the centre, making it an economic engine for the medical clinic’s future selfsustainability and providing services to the community. ! ! ! ! ! ! ! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ! ! !!!!!!!!!!! ! ! ! ! ! ! ! ! ! ! ! ! ! !
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2. Introduction Geographically, Nepal is located in the Himalayas; to the north it is bordered by the People's Republic of China and to the south, by India. This small country, lying along 650 kilometres of the southern Himalayas, is home to 8 of the 14 highest peaks on the planet, reaches the northern edge of the Gangetic plain, and has a fertile farming area called Terai!which crosses the country from east to west.
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NEPAL, ONE OF THE WORLD'S POOREST COUNTRIES According to contemporary poverty registers, Nepal is one of the world's poorest countries, with annual growth of 2.6%. More than half of the adult population is illiterate and 77% of its 28 million people are living on less than two dollars a day. Endemic poverty and food insecurity are critical issues, especially among the tribal population living in remote rural areas. The mountainous topography means that a large part of rural Nepal remains isolated due to a lack of markets and roads (less than half of the ! population has access to allweather roads). Limited access to many rural areas of the country has been one of the major impediments to sustainable and effective development. Sanitary conditions are far below average. There is no preventive education. There is no awareness of cleanliness and hygiene. In many places, water is contaminated by stagnation. Meals are not always fit for consumption. There are enormous deficiencies in the people’s nutritional habits; the basis of their diet consists of yak meat and cereals, as well as various homemade liqueurs drunk to alleviate problems related to the adverse weather conditions. In terms of maternity, a very large number of children die in childbirth due to infections, malnutrition, and lack of food. Sometimes mothers also lose their lives, due to excess bleeding and lack of care during delivery or during the postpartum period. ! !
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Another important factor is the high levels of child malnutrition and vitamin A imbalance, as well as problems related to hygiene and care of the elderly. Many people live in abandoned and isolated houses, without access to health care in cases of emergency. OROGRAPHIC OBSTACLES AND HARSH WEATHER CONDITIONS In rural Nepal, there is no road communication network to access and provide nursing services. People have to make long trips lasting several days with very high travel expenses. Solukhumbu district is located in one of the highest zones in the world. The weather conditions in most of these places preclude access to the nearest towns or cities. The nearest place equipped with all of the necessary services is Kathmandu, and the journey time is 1 whole day by bus or 2 days walking through the mountains. It is possible to undertake this journey in normal
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conditions, but if there is a serious emergency, things get more complicated. When a sick person needs an operation, has cholera, the flu, or is a woman who needs assistance in childbirth, people must carry the patient on their shoulders for two days to reach the nearest place where transport, such as buses, can be found. There are other transport possibilities, but they are only available to tourists and people with high purchasing power (airplanes or helicopters). Moreover, there is another problem: mountain landslides and snow avalanches in winter. These prevent the free circulation of traffic on normal transit roads, leaving many of these populations isolated.
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Walking to Chaulakharka – 2 days ! )!!
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WOMEN AND CHILDREN AREAS OF NEPAL
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THE
MAIN
INHABITANTS
IN
RURAL
Since Nepalese society is mainly patriarchal and does not promote the participation of women, there is a serious lack of equality and fundamental human rights. Women constitute 52% of the total population of Nepal. In the rural mountain areas of Nepal it is common for young men and boys, (those who are in a position to do so), to leave to seek employment in the city, India or other Asian countries, leaving the women in charge of all of the work in these inhospitable places for most of the year.
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ONE OF THE FEW COUNTRIES WHERE WOMEN DIE YOUNGER THEN MEN
In Nepal the life expectancy of women is lower than that of men; it is one of only three countries in the world where women die younger than men. According to the Nepal study on maternal mortality and morbidity held in 2008 and 2009, induced and spontaneous abortion is the third highest direct cause of maternal mortality, credited with almost 14% of hospital deaths. In addition, 27% of Nepali women suffer abuse. The lack of roads, extreme weather conditions and mountainous terrain with capricious topography are also major obstacles to rural families who need maternal or neonatal attention. As a ! result, women often give birth at home without the assistance of a nurse, a doctor or a midwife. In fact, according to UNICEF only 19% of all births in Nepal are attended by a professional trained in obstetric care.
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MORE THAN 50% OF BABIES DYING IN NEPAL DIE BEFORE REACHING 1 MONTH OLD According to experts, to provide basic services during home births, like proper cleaning of the new-born, covering with blankets, putting the baby in contact with the mother's skin to prevent hypothermia and asphyxia after birth, and monitoring serious infections, could avoid up to 67% of all neonatal deaths. But much effort is still required at a human, technical and economic level for this hypothesis to become reality. About 50% of babies who die in Nepal fail to reach one month of life due mainly due to preventable causes such as hypothermia, asphyxia, complications related to low birth weight and infections in the first week of life. INFANT MORTALITY IN NEPAL AND ITS RELATIONSHIP WITH THE LACK OF VITAMIN A
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Nepal has one of the highest rates of infant mortality in the world. According to UNICEF: "A child dies every 7 minutes, 205 die daily and 75,000 die each year." Almost half of Nepalese children suffer stunted growth and malnutrition. Infestations with parasites, which are a chronic health problem in the country, further limit the amount of iron that they can absorb, which then causes weakness and anaemia. Experts estimate that if Nepal does not distribute vitamin A twice a year, about 12,000 children would die annually from preventable or curable diseases. Studies in the country have shown that consumption of vitamin A may !
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reduce infant mortality by 23%. Lack of this vitamin makes them more vulnerable to infections and increases mortality in children as well as in pregnant women. Also, diseases such as measles cause the deaths of about 5,000 children each year. Despite national immunization campaigns and vitamin distribution, an average of 194 children younger than five years old die from diseases such as diarrhoea and acute respiratory tract infections every day. TYPES OF HEALTH CARE CONVERGING IN NEPAL There are four main types of healthcare in Nepal: (a) Traditional medicine practised by healers and shamans, who act as mediators between the material and spiritual world (very common in rural areas with few resources and limited access), and professional Tibetan doctors who have an extensive medical system in the mountainous regions of Nepal. (b) Ayurvedic medicine is the ancient practice of medicine that uses roots, herbs and medicinal plants, and is based on the tridosha theory of disease. Ayurvedic medicines are inherent in Nepal and grow naturally in the country. However, due to population pressure and unplanned development, hills and mountains are being cleared and stripped of their heritage of indigenous medicinal plants. In addition, people with knowledge about plants and Ayurvedic therapies are reaching old age and dying, taking with them knowledge learned over a lifetime. This problem raises serious questions about the future of Ayurvedic practice, although taking into account proximity, accessibility and sustainability, it is the most appropriate medicine and that most demanded by the communities. (c) Allopathic or modern medicine has only been recently established in comparison with the previous types of medicine. Recently, many medical schools have been established in the private sector. (d) Chinese medicine is considered one of the oldest forms of oriental medicine. It applies the philosophical bases of observation and knowledge of the fundamental laws governing the functioning of the human organism and its interaction with the environment, through following the cycles of nature, looking for a way to apply this understanding to the treatment of disease and applying different methods to prevent illness.
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These types of therapies include herbal medicine and nutrition, physical exercises that restore health, meditation, acupuncture and massage repair. The Health Centre in Chaulakharka will use seven main treatment methods found in Traditional Chinese Medicine. - Acupuncture Today, acupuncture treatment is very well known in Western countries and it is an accepted technique of traditional Chinese medicine. Its effect is explained in Chinese physiology; the functions of the organism, its effect on blood circulation, nervous system and the substances produced by the body (hormones, acids, toxins, etc.). Through the results of research done in Europe, China and the United States, we know that acupuncture is an effective treatment for pain, allergies, and many internal and external diseases: neurological, endocrine, skin, muscle, or joint, including asthma and irritable bowel syndrome, etc. It is being used in a growing number of public and private hospitals as adjunctive therapy and has been proven effective in many cases, leading to an increase in the number of Western doctors who are learning or sharing this knowledge. - Tuina This therapy involves making hand movements on the surface of the body, applying these movements to very specific parts or key points. - Moxibustion This is an oriental medicinal therapy that uses the pressed root of the altamisa or mugwort plant, which is formed into a cigar, called a moxa. It is used indirectly with acupuncture needles, or applied directly to the patient's skin. - Suction cup therapy This is one of the therapeutic methods used in TCM in which a suction cup is placed on the surface of the skin. A local congestion is caused by eliminating air in the suction cup by introducing heat. This method is used to warm and promote the free flow of Qi and blood in the veins, reducing swelling and pain, and dispersing cold and moisture.
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- Chinese Fitotherapy This form of treatment develops formulae based on ingredients that are herbal, mineral and animal in origin. - Physical practices Integrated exercises in meditation practices related to breathing and circulation of energy, such as Chi Kung (or qigong). -
Chinese Dietetics
POOR STATE OF HEALTH SERVICES In spite of these types of medicine, health care in Nepal is far below worldwide standards. In rural areas, the facilities, cleanliness, food hygiene standards and health centres are usually in a very precarious condition.
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A country like Nepal, where it is estimated that more than 1/3 of the population is indigenous, has many potential socio-economic problems and discriminatory factors, encouraged by an unstable, corrupt and centralistic government, meaning that this sector of population is one of the most neglected at a health care level.
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LACK OF FREE HEALTH CARE CENTERS Health care in Nepal always costs money. Doctors are categorized according to the amount a person can pay. If a patient wants to be medical assistance, besides paying administration fees, they must also go out and buy all of the things the doctor might need: gauze, utensils, medicines, etc. in the chemists found near the centre. The hospitals are inhospitable places, where the lack of cleanliness and sanitation is obvious. Furthermore, they are overflowing with patients, who are often found standing out-side. Hundreds of people are begging in the surrounding area to try to get some money to be able to pay for cures or visits from a doctor. Money-lenders are often found at the hospital entrance, offering loans or directly buying the patient’s belongings so they can pay for cures, treatments and operations. Normally the neighbourhoods and streets adjacent to the hospitals are full of poor people begging to be able to pay for health care, either for themselves or for seriously ill family members. Every day, hundreds of people die in the streets because they do not have enough money for treatment or for prescription drugs. In the case of serious illness, or the need for surgery, the patient's families have to sell their homes, animals and land, if they are the lucky few who own material goods. Some of the major diseases found in the country, which often lead to death if they are not treated on time or due to a lack of economic resources, are: diarrhoea, gastrointestinal disorders, goitre, intestinal parasites, leprosy, tuberculosis and acute child malnutrition that affects half the infant population of Nepal.
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THE IMPORTANT ROLE OF COMPLIMENTARY AND ALTERNATIVE THERAPIES (CAM) AND INTRODUCING INTEGRATIVE MEDICINE As has been seen, in Nepal there is a wide variety of traditional medicine systems, the most prominent being Ayurvedic medicine, Tibetan medicine and faith healing. Generally speaking, the alternative medical systems are very popular in Nepal. The possibility of introducing integrative medicine to pre-graduate medicine training programmes is an initiative that should be considered. !
Likewise, complementary and alternative medicine professionals should also ask for greater integration between both medical systems (Allopathic medicine and CAM (Complimentary and Alternative Medicines)) so they can use this knowledge to enrich and merge techniques and therapies that will benefit the needy people of Nepal. DEFORESTATION OF WOODS AND LOSS OF PROTECTED SPECIES AND MEDICINAL HERBS THAT CONSTITUTE THE COUNTRY’S BIOLOGICAL HERITAGE In Nepal, more than 75,000 people depend on forests to survive. There are various different factors behind deforestation, which in many cases affects the communities that use these protected plants for their medicinal or curative properties. This problem directly affects the health of the mountain inhabitants because, as has been seen, in rural and remote areas of Nepal medicine is dominated by traditional healers and physicians who treat diseases with herbs, roots and medicinal plants. Added to the above situation is the fact that Nepal is basically an agrarian society with a high unemployment rate (almost half of the population). Around the 80% of the employed population depends exclusively on agriculture, which makes up 41% of the GNP. However, agricultural productivity is low, and farmland is increasingly fragmented and less fertile.
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3. Justification HUMAN RIGHTS AND MILLENIUM DEVELOPMENT Although Nepal is one of the world's poorest countries, everyone has the right to good health and a dignified life. This is clearly expressed at the Universal Declaration of Human Rights. Among the UN’s Millennium Development Goals (MDG) that this project wants to address are: - MDG 1: eradicate extreme poverty, - MDG 2: reduce child mortality, - MDG 5: improve maternal Health. This is a region where there has been no census for the last 10 years. This means that there is no record of population increases, the mortality rate, disease statistics, etc. It is crucial to be able to hold censuses in order to be able to allocate resources appropriately determine the effects of different activities and assess the current state of the population. ACCESSIBLE HEALTH SERVICES FOR THE MOST ISOLATED COMMUNITIES This clinic will make an intermediate point available where a stabilization protocol could be practiced in case of emergencies and also assist in cases of basic/primary health issues, childbirth, malnutrition, hygiene and common disease care that can be easily addressed and solved. There is a building available in the area. This building requires some minor repairs and improvements. In addition, there is another house nearby with 4 bedrooms that could be used as accommodation for doctors; it only needs minor building work and equipment. This would create a medical clinic and accommodation for doctors at minimal cost.
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Exterior – Medical Clinic Chaulakharka
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Interior!–!Medical!Clinic!Chaulakharka!
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FREE HEALTH CARE This centre will be available to people with no financial resources and will provide them with free treatment. In exchange, they will perform services for the clinic, like collaborating with control groups, cleaning and hygiene for the centre, assisting with cleaning for the community, assistance/care for people with terminal illness, care for small children whose mothers must go to work, etc. THE RISING VALUE OF TRADITIONAL MEDICINE Hospitals normally combine traditional medicines with allopathic medicine, because the previously mentioned treatments are far more accessible, due to the lower cost, for the majority of the population. Furthermore, CAM healers are familiar with the social and cultural context, they are accessible, respected and have greater experience. Many students in India and Sri Lanka have joined Nepali medical schools to study traditional and Tibetan medicine. The ratio of foreign students to locals is 60:40. It should be noted that Nepal is seeing a considerable amount of foreign student exchanges due to the so called “medical education tourism�.
JOINING FORCES TO MEET THE SANITARY NEEDS OF A COUNTRY Traditional medicine is known for combating diseases in a spiritual and integrative way, while modern medicine, being based in logic and needing verification through experience, provides a scientific and empirical basis. The professionals of complementary and alternative medicine that live in the rural and remote areas of Nepal could be integrated into the existing health network (after receiving appropriate training) in order to collaborate, increasing the country's poor health care coverage, particularly in rural areas. The trained community health volunteers, (those trained in CAM as well as modern medicine), could be an important force used to improve the general health of a community. A good example in Nepal is the case of traditional healers who have been trained to identify and refer patients with sight problems.!
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Some of the characteristics of Integrative Medicine (IM) are the consideration of the person as a whole (body, mind, spirit) the use of the best available alternatives, the incorporation of conventional systems of allopathic medicine and CAM. Integrative medicine taught in many medical schools in the West emphasizes teaching the “human dimension” in clinical settings. RECUPERATION OF TRADITIONAL MEDICINE AND MEDICINAL PLANTS Expert knowledge of plants used in Tibetan and Ayurvedic therapies is disappearing, as elders die and take a lifetime’s experience with them. It is essential to preserve this knowledge to maintain sustainable medical care, because it is the most appropriate type of medicine and that most demanded by communities. The cultivation of medicinal plants means being self-sufficient and also helps to fight against the disappearance of these people’s biological and cultural heritage. Also, through the transfer of knowledge of Ayurvedic medicine, more of these plants will be requested from other continents so it may open up the possibility of creating new markets.
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4. Beneficiaries This project is mainly aimed at the Chalaukharka population, particularly women and children. Regions bordering Chaulakharka (Goli, Vakanje, Bhusinga and Bamti Vanddar) will, in turn, also see benefits. This means medical support that is less than one day’s journey for approximately 9,000 people, plus medical personnel and centres.
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Direct'Beneficiaries:' - Local people experiencing social exclusion and without financial resources. - People that, due to health or mobility problems, or that do not have the resources to travel cannot attend other health care centres. - Pregnant/parturient women. - New-borns attending paediatric programmes and nutrition controls. - Health care professionals working in Nepal. - Nepalese people interested in being trained as midwives, nutritionists, paediatricians, etc. - People that need to obtain information and advice on family planning, preventive medicine, nutrition and STD prevention. - Sanitary Institutions, NGO’s, hospitals and national and international health care centres interested in being part of the cooperative network.
Indirect'Beneficiaries:' - Population that is able to access the information on the website or through the print media (newspapers, specialized medical magazines, radio or TV). - Foreigners travelling in Nepal. - Nepali Ministry for Health (government of Nepal). - Health care institutions and centres that provide Ayurveda, Tibetan, Chinese, and allopathic medicine from Nepal. - Health care institutions that are committed to natural medicine and strive to use alternative healing therapies. - Educative and academic institutions, NGO’s, local and international associations and groups related to world health, local medicine and local and alternative therapies. - University students with scholarships and professional researchers that collaborate on joint volunteer programs.
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5. Strategic Lines Based on the issues detected in the region and defined in the introduction, seven strategic lines have been established that will be worked on in this project. These strategic lines will define the objectives and action to be implemented in the region: 5.1. Provide Chaulakharka region with health care facilities. 5.2. Train local doctors and support staff in health care and hygiene issues. 5.3. Study and research the current local health care and hygiene situation. 5.4. Raise public awareness and appreciation of sanitary and hygiene issues. 5.5. Preserve and maintain traditional medicine. Promote integrative medicine. Study and research integrative treatments. 5.6. Create self-sufficiency and develop local activity. 5.7. Local participation and collaboration with national and international institutions.
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6. Objectives and actions 1. Provide Chaulakharka region with health care facilities
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Code
Specific Objective
Actions
1.1
Creation of a medical clinic in the region of Chaulakharka
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Meet health care needs that do not require surgery
Rehabilitation of the building and adaptation of the building’s infrastructure. Integration of furniture and health care equipment. Acquisition of Tibetan, Chinese and allopathic pharmacopoeia. Hire a permanent resident physician. Consolidate existing support staff: Nurse. Process!the!transfer!of!delivery!room!equipment. Process!the!transfer!of!minor!surgery!operation!room! equipment.! Set up a Tibetan medicine consultation. Set up an Allopathic medicine consultation. Set up a Chinese medicine consultation.
1.3
Home visiting
1.4
Emergency Service
1.5
Stabilization of patients to enable transfer to the city
1.6
Care for the terminally ill
1.7
Delivery care
Census of those households that require health care monitoring due to an inability to travel. Establishment of a weekly visiting service. Establishment of a home emergency service. Establishment of an emergency service protocol in the medical clinic. Set up a night shift. Establishment of an emergency evacuation and transportation protocol for patients in an urgent condition. Establishment of vital signs stabilization protocol. Start up the evacuation and transportation protocol. Census of people in a terminal condition. Specific condition and location of these people. Life expectation predictions. Monitoring and action protocol for the terminally ill. Start-up of a companionship programme for the terminally ill. Research the future creation of a hospice for abandoned or terminally ill older people.
Census of pregnant women and documentation of their condition.
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1.8
Childhood malnutrition control
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Assistance for disabled people
1.10
Psychological treatment and therapeutic support for victims of abuse
Monitoring and support programme during pregnancy. Healthy and safe pregnancy. Support program for delivery. Postpartum support: quarantine and lactation programme. Census of children under 2 years old with malnutrition. Detection, tracking and action protocol for childhood malnutrition. Co-participation of UNICEF for purchase of supplementary baby-food for children with malnutrition. Census of disabled people (physical, mental, sensory or mixed). Setup of detection, tracking and action protocol. Agreement with Western institutions for donation of prostheses for the physically disabled. Family member support campaigns to help understand these disabilities and work with them. Determination of programmes for promoting social skills. Setup of an assistance centre for the disabled. Census of population with psychological issues and/or suffering abuse. Setup of detection, tracking and action protocol for cases of ill treatment and psychological issues. Family life workshops for men and women.
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2. Training of local doctors and assistants on sanitary and hygiene issues. Code
Specific Objective
Actions
2.1
Midwives training
2.2
Support staff training in the hospital
2.3
Rural doctors training
2.4
Support staff training in palliative care for the terminally ill
2.5
Scholarships for medical students that are predicted to join the health care centre
2.6
Practice centre for Western students. Integrative Medicine
Signature of agreement with Spanish clinic Aquario to train midwives. Creation of a permanent support and assistance group for pregnant women. Group for tracking control. Discussion groups. First aid training. Customer service and patient care training. Nursing support training. Groups for tracking control. Discussion groups. Processing of approval from the Ministry of Health in Nepal to establish a school to train rural doctors. Planning of studies and subjects. Selection of teachers. Selecting people for integration into the course. Formal training of rural doctors. Groups for tracking control. Discussion groups. Training workshops for assisting the terminally ill. Psychological/emotional support and personalized care. Care protocols for people with a terminal illness. Groups for tracking control. Discussion groups. Negotiation with Nepal government to grant 5 higher education scholarships at the medical university of Kathmandu. Signature of collaborative agreement. Raising funds. Groups for tracking control. Discussion groups Setup of a programme for reception of students with Western university scholarships to receive tuition in integrative medicine. Planning, monitoring and content. Reception of students. Groups for tracking control. Discussion groups. Set up of a Nepal-Spain cultural exchange programme between medical students that decide to expand their knowledge of alternative and integrative medicine.
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3. Study and research on health and hygiene in the area. Code
Specific Objective
Actions
3.1
Register and documentation
3.2
Study and research
Creation of a medical database with the personal files of local inhabitants. Health care census. Detection of major causes of illness and death. Climate, soil, geology, natural resources, habits, history, etc. and their direct relationship with health and hygiene. Lifestyle of the inhabitants of the region. Respect of traditions, history, anthropological and cultural features, sociology. Origins of illness and causes of death. Treatments based on integrative medicine (combination of allopathic and alternative).
4. Raising awareness of the population in issues concerning health and hygiene. Code
Specific Objective
Actions
4.1
Creation of a multilingual handbook for local mothers and other women so they can improve maternal and child hygiene Sensitization about the medical centre and it’s functions
Handbook written by Karuna-Shechen Project. Translation to Sherpa dialect. Distribution campaign for this book and tuition to a control group for further dissemination.
Improve knowledge about pregnancy, risks and prevention for a healthy pregnancy.
Informative workshops about pregnancy, delivery and after-birth care. Selection of women able to act as future midwives after receiving the relevant tuition. Groups for tracking control. Discussion and reinforcement groups.
4.2
4.3
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Awareness and information about the need to visit the doctor. Awareness and information about medical examinations and adherence to medical treatments. Informative workshops about general health, sickness and treatments.
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4.4
Improve hygiene in households and communities
Awareness and information workshops about food conservation and hygiene. Healthy cooking workshops. Personal hygiene awareness and information workshops. Household and family hygiene awareness and information workshops. Recycling and managing waste awareness and information workshops. Community good hygiene awareness and information workshops. Groups for tracking control. Discussion groups. Register and documentation of personal, family and community hygiene practice. Register and implementation of improvements.
4.5
Improve information about care for toddlers (children under 2 years)
New-born awareness and information workshops. Eating and life habits during pregnancy and their effects on new-born babies, awareness and information workshops. Care and prevention for infants under 2 years old, awareness and information workshops. Major infant illnesses and vaccination campaigns: awareness and information workshops. Infants hygiene and feeding awareness and information workshops.
4.6
4.7
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Knowledge about maternal and infant illnesses.
Knowledge about sexual transmitted diseases
Groups for tracking control. Discussion groups. Rotating infant care groups to assist during mothers’ working hours. Major feminine gynaecological illnesses awareness workshops. Major feminine illnesses derivate from poor hygiene or bad habits awareness and information workshops. Relevance of mother-child relationship during first two years of life awareness and information workshops. Groups for tracking control. Discussion and reinforcement groups. Masculine sexually transmitted diseases awareness and information workshops. Feminine sexually transmitted diseases awareness and 34!
information workshops. Young people and teenagers sexually transmitted diseases awareness and information workshops. Census and control of population with STD’s.
4.8
Knowledge about children’s vaccinations
4.9
Knowledge about issues derived from alcoholism and smoking
4.10
Mental health and good family habits
Protocol for tracking and action. Groups for control and tracking. Discussion groups. Infant vaccination campaigns. Purchase of vaccines programme. Census and control of infant vaccination. Study and investigation of traditional medicines that serve the same purpose as vaccines. Groups for control and tracking. Discussion groups. Alcohol problems awareness and information workshops. Smoking problems awareness and information workshops. Drugs, addictions and intoxication problems: awareness and information workshops. Groups for control and tracking. Discussion groups. Mental health awareness and information workshops. Prevention of common conditions as depression and anxiety: awareness and information workshops. Importance of mental health to maintaining a good relationship with family and society: awareness and information workshops. Workshops to promote good mental health and attitudes towards family, oneself and others. Groups for control and tracking. Discussion groups.
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5. Preservation and conservation of traditional medicines. Development of integrative medicine, study and research on integrative treatment. Code
Specific Objective
Action
5.1
Documentation and archiving
5.2
Study and research
5.3
Promotion and spreading
Local medicinal plants. Diagnostic methods and treatments used in local traditional medicine. Phototherapy and herbal formulae of traditional medicines of the area. Techniques and health resources of traditional medicines of the area. Relation and use of integrative medicine (merged use of Tibetan, Ayurvedic and Chinese medicines with Allopathic medicine). Efficacy of the combination of traditional medicines with allopathic medicines. Spreading of research drill results. Possibility of participating in Dr. Ngawang programme on the study of Tibetan medicine as a mean for cancer prevention.
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6. Creating self-sustainability actions and developing activities. Code
Specific Objective
Actions
6.1
Creation of local development
6.2
Professional Training
6.3
Training offers courses overseas students
6.4
Self-sufficiency in vitamin A sources
Growing medicinal plant crops. Creating a spa or therapy centre for westerners. Creating an alternative medicine-training centre (Tibetan, Ayurveda, and Chinese) for westerners and integrative use with allopathic medicine. Training on medicinal plant cultivation. Preparation and packing of medicinal plants. Masseurs and therapists. Customer service. Distribution of courses and contents related to traditional medicines via internet. Internship programmes for students with a masters in international cooperation. Internship programmes for students of alternative medicines. Internship programs for students of allopathic medicine. Research on vegetables rich in vitamin A and their possible cultivation. Pilot test on cultivation and adaptation to the environment. Study of viability of farming in the area.!
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7. Local participation and collaboration with national and international institutions. Code
Specific Objective
Actions
7.1
Community involvement in improving health and hygiene
7.2
National collaborations
7.3
Collaboration with international institutions
7.4
Creation of networks and forums
Establishment of monitoring committees to deal with different problems, such as maternity issues, child mortality, men, the elderly, community issues, and psychological abuse. Establishment of monitoring committee to integrate the five areas that will receive health care. Establishment of discussion forums and community debate. Cooperation agreements with the University of Seville. Sending students doing practicals and students and teachers to work on revision and prevention campaigns. Cooperation agreements with Spanish universities. Working with research and study groups on integrative medicine. Collaboration agreement with the Brotherhood of San Bernardo of Seville on co -financing the project. Review of collaboration with Rotary Spain for cofinancing the project. Project was chosen in 2011 by Rotary Club Valencia. Collaboration agreements with universities in Nepal: exchange of medical students and expanding student training for integration in rural environments in Nepal. Collaboration agreement with Karuna-Shechen Foundation in Kathmandu. Collaboration agreement with Apple to integrate all the documentation and archives in icloud and iTunes U. Development of a knowledge transfer network and an ideas forum to help find solutions to real problems in the area through social networking.
7.5
National and international training and diffusion
Establishment of collaboration agreements with national or international institutions on issues related to training and international cooperation. Creation of audio-visual, graphic and text documents about the area, its history, health status and possible methods of improvement and development.
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7. Location The project is carried out in the Chaulakharka area. This is a region in Solukhumbu, in the northeast of Kathmandu, the capital of Nepal. Mainly the Sherpa and Shetri caste inhabit this region. The population lives at an altitude of between 2,500 and 3,700 metres. The medical clinic will be constructed at an altitude of about 2,800 meters. !
In this area, travelling by road is very difficult and living conditions are very harsh. During the monsoon and snowy winter periods, people can be isolated and roads cut off for several day or weeks. There are only two ways to get to this area: on foot or by helicopter.
Solukhumbu District is one of the six districts of Sagarmatha Zone, in Nepal. Its capital and headquarters is Salleri. It covers an area of 3,312 km2 and the last population census (2001) estimated 107,686 inhabitants. Mount Everest is located in the Northern District in the Sagarmatha National Park. !
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8. Implementation Schedule Chronology ! Specific objectives
First& Second& Third& semester& semester& semester& 1. Provide health care facilities for Chaulakharka region 1.1 Creating a medical ! ! ! clinic in Chaulakharka region 1.2 Meet hygiene and ! ! ! health care needs that do not require surgical treatment 1.3 Home visits ! ! !
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Control of child malnutrition 1.9 Assistance for disabled 1.10 Psychological treatment and therapeutic support for victims of abuse
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First& Second& semester& semester& Support staff training ! ! in palliative care for the terminal ill Medical student ! ! scholarships for later incorporation into the medical centre Practice centre for ! ! Western students. Integrative medicine ! !
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3. Study and research of health and hygiene in the area. 3.1 Registration and ! ! ! documentation 3.2 Study and research ! ! ! ! ! !
4. Sensitization and public awareness in health and hygiene 4.1 Create a multi! ! ! ! language manual for women and mothers in the area, in order to improve maternal and child health and hygiene 4.2
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Specific objectives child care for the under-twos 4.6 Knowledge about mother and child diseases 4.7 Knowledge about sexually transmitted diseases 4.8 Knowledge about childhood immunization 4.9 Knowledge about the problems of alcoholism and tobacco addiction 4.10 Mental health and good family relationships
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5. Preservation and conservation of traditional medicines. Promoting integrative medicine, study and research on integrative treatments. 5.1 Documentation and ! ! ! ! ! ! archiving 5.2 Study and research ! ! ! ! ! ! 5.3 Promoting and ! ! ! ! ! ! spreading ! ! ! ! ! !
6. Creating self-sustainability and developing activities in the area. 6.1 Creation of local ! ! ! ! development 6.2 Professional training ! ! ! ! 6.3 Training ! ! ! ! programmes for overseas students 6.4 Self-sufficiency in ! ! ! ! vitamin A sources !
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First& Second& Third& Fourth& Fifth& Sixth& semester& semester& semester& semester& semester& semester& 7. Local participation and collaboration with national and international institutions. 7.1 Community ! ! ! ! ! ! involvement in improving health and hygiene 7.2 National ! ! ! ! ! ! collaboration 7.3 Collaboration with ! ! ! ! ! ! international institutions 7.4 Creation of networks ! ! ! ! ! ! and forums 7.5
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9. Expected results In broad terms, the expected results for this project are: -
Improving the overall quality of life of the population in Chaulakharka. Creating the medical clinic and accommodation for doctors. Providing quality health care to the population of Chaulakharka region. Reduction of mortality in new-borns and women of reproductive age. Reduction of mortality caused by infectious diseases. Consolidating a network of rural doctors and support staff to guarantee accessibility to health care.
- Making people accustomed to healthy and hygienic habits, helping them to integrate them into their way of life by developing a culture of prevention and health care. - Preserving the heritage of traditional medicine as a viable health care option for the population. - Integrating the different existing medicines in order to achieve consistent and sustainable integrative medicine. - Self-sustainability of the centre through local development activities. - Involvement of local people to ensure the project’s viability and the campaign’s success. - Collaboration of an extensive network of national and international bodies to acquire the necessary resources and share knowledge. In order to assess the results achieved, a series of indicators have been determined that will allow the project’s actions to be monitored and evaluated.
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1. Provide health care facilities for Chaulakharka region Number people being treated in the centre. Number of households requiring health monitoring due to an inability to travel. Number of home visits. Number of people at the terminal stage. Number of pregnant women based on census. Number of participants in the monitoring and support programme for pregnant women. Number of participants in the support programme for childbirth. Number of participants in the support programme for the postpartum period. Number of children younger than 2 years old with child malnutrition based on census. Kilos of porridge obtained for children with malnutrition. Number of disabled people based on census. Number of participants in the support campaigns for families to help understand disabilities and work with them. Number of people with mental health problems and / or suffering abuse based on census. Number of participants in the workshops on family relationships between men and women.
2. Training for local doctors and support staff on health and hygiene Number of people trained in first aid, nursing support, as rural doctors and in treatment for the terminally ill, customer service and patient treatment. Number of higher education scholarships awarded by the government to medical universities in Kathmandu. Number of scholarships for students from Western universities for training in integrative medicine. Number of participants in the Nepal-Spain medical student cultural exchange programme to increase knowledge about alternative and integrative medicine. !
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3. Study and research on health and hygiene in the area Number of people in health care census. Number of cases of disease and death. Number of studies carried out on the natural environment, habits, history, traditions, anthropological and cultural characteristics, and sociology. Number of treatments based on integrative medicine. 4. Knowledge and public awareness of health and hygiene Number of books distributed. Number of trained people who can further disseminate knowledge. Number of participants in the different workshops, such as: awareness and information on the need for doctors’ assistance, awareness and information on food preservation and hygiene, awareness and information on personal hygiene, care and disease prevention in children under two years old, etc. Number of people registered with sexually transmitted diseases. Number of participants in the children’s immunization campaign.
5. Preservation and conservation of traditional medicines. Promoting integrative medicine, study and research on integrative treatments Number of medicinal plants in the documented area. Number of treatments and diagnostic methods of traditional medicines in the documented area. Number of herbal formulae and fitotherapy in traditional medicines in the documented area. Number of technical and health resources of traditional medicines in the documented area. Number of actions that help disseminate the research results. 6. Creating self-sustainability and developing activities in the area Number of people working in the cultivation of medicinal plants. Number of users of therapeutic centre for Westerners. Number of users of the alternative medicine-training centre (Tibetan, Ayurvedic and Chinese) for Westerners and its integration with Western medicine. Number of people trained in the cultivation of medicinal plants, preparation and packaging of medicinal plants, masseurs and therapists, customer service. Number of participants in the student internship programme. !
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7. Local participation and collaboration with national and international institutions Number of monitoring committees to deal with different problems. Number of participants in the discussion forums and community debates. Number of medical student exchanges with the University of Nepal in order to increase students’ knowledge of integration in rural settings in Nepal. Number of users of the knowledge transfer network and the ideas forum.
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It is very important that the project is correctly monitored and assessed in order to measure improvements and effects on the quality of life of the population of Chaulakharka region. For this reason a series of actions has been planned in order to assess whether or not it is functioning correctly: - There will be monthly reports based on the established indicators. - A general summary of the global results will be published on a quarterly basis and sent to partners and sponsors. - There will be an annual presentation to sponsors; a meeting to share developments and feedback. - Our website, blog, and social network accounts will constantly publish texts, photos, videos and everything needed to monitor and disseminate the project’s progress. - A restricted exclusive channel (intranet) will be established to publish the results of research on integrative medicine, developments in cancer prevention, local studies, etc. Later, other documents will be produced in order to publicise the most relevant results. - A newsletter will be sent to all of our website users, partners and sponsors on a quarterly basis. - Interested sponsors will be able to make visits and see the results of their actions in the field.
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11. Project viability Self-sufficiency, responsibility and sustainability. These are the key words in this cross-project approach. It is the belief in human beings’ willpower and their ability to escape poverty by themselves.
Guarantee of receiving the community’s support. This project is supported by government representatives of the 5 VDC in the region and the Maoist parliamentary responsible for development in the region. Locally, it also has the support of the tribal leaders in the region. In the territory we work with the NGO Be Human Nepal, a local organization that has 5 years’ experience working on projects in the area. It is mostly comprised of people from the Sherpa ethnic group who have the necessary contacts to achieve support and the project’s viability. Because they are natives to the area they know it perfectly and also have the backing and support of the government and tribal leaders. It is registered with the Government of Nepal as a legally established organization with operational capacity.
Economic and financial viability of the project. Firstly, the building (which has been negotiated and authorized by the community), needs restoration. It will be used to start the project and provide it with sufficient infrastructure for the first two years. Furthermore, there is another building at the disposal of the project (currently the centre for nurses) that will be used as accommodation for doctors that will work in the area. There are 2 hectares of land to start plantations of medicinal plants, which can increase to 75 hectares in the future, following negotiations with representatives in the region.
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There are no problems with supplying water and electricity in the area. The highest expense will be the cost of heating the hospital during the winter months. Regarding human resources and medical materials, there will be a residential Tibetan doctor, a Western doctor and a nurse, who will live there permanently. Revision and training campaigns will be carried out through signed agreements with various Medical Colleges at Spanish Universities. During 2011, a collaboration scholarship was signed with the University of Seville (Universidad de Sevilla), agreeing to send 4 people for 2 months with all expenses paid. Furthermore, important contacts have been established to create institutional collaboration between the University of Seville and several universities in Nepal, which will guarantee a constant flow of students for training. Initially the most significant costs will be: transportation of materials, monthly maintenance of pharmaceutical supplies and medicines. Doctor Nagwang, who is interested in collaborating with this project to be able to start research, leads the cancer research project. Contacts have also been arranged with the Clinic Acuario in Valencia, Spain, to provide midwifery training, and negotiations are underway with the Community of Madrid regarding the possibility of sending a minor surgery operating room and a maternity room to the hospital. In addition, it has the support of the Rotary Club of Valencia and Rotary Spain. Funds have been raised for the project that will aid the total budget for 2011. This project was selected in district meetings as a project for the year 2011. Organizational and technical capacity to implement the project. Various collective groups take part in this project. In Spain, the project is coordinated by CIDEN and Fundaci贸n So帽adores sin Fronteras (Dreamers without Boundaries Foundation). Both organizations have been carrying out different activities supporting projects in Nepal since 2009. They both also represent a solid body of professionals with the capacity to develop the project effectively and safely.
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At a technical level, the project has the support and advice of Doctor Nagwang, a Tibetan doctor. He is in charge of Tibetan Medicine at Shechen Monastery and its humanitarian project, the Karuna-Shechen Foundation (http://www.karuna-shechen.org/). His advice and guidance has been fundamental to organising this project, helping to direct it using a Nepalese approach, and assisting with the real demands and problems the project has faced. This, together with the development coordination of the Be Human Nepal project and its long extensive experience in implementing various campaigns in this region, assures the success of the actions proposed for this project. Training for the addressee (beyond promoters) in order to give continuity to the project and its autonomous maintenance. Local NGO Be Human has committed to the development and continuity of the project. In addition, it has governmental support and a good relationship with other organizations. By following the viability plan, the project will be autonomous within 2-4 years’ time. However, other projects will be developed to provide an economic boost that will make the initial project self-sustainable:
(a) In Spain: " Campaign “SMS Solidario con Vodafone” –Supportive SMS with VodafoneWord Nepal at 28052 (all year). " Distribution and sale of alternative therapy materials: Chinese Medicine, Tibetan Medicine and Ayurveda Medicine for centres, stores and institutions in Spain through CIDEN (licensed fair-trade and import-export). Physical store in Valencia or Online channel (web store and Facebook). " Distribution and sale of courses over the Internet: downloadable certified courses on Tibetan and Sanskrit Languages (both highly requested by
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International Buddhist communities), Introduction to Tibetan Medicine, Introduction to Chinese Medicine, Introduction to Ayurveda Medicine, online thematic courses for medical colleges at weekends. All available on a web platform already confirmed with a business subsidiary of Apple Spain. The platform has already been created and is ready for operation and distribution.
(b)In Nepal: " Information Centre for integrative medicine and alternative medicine (Ayurveda, Tibetan, Chinese). " Spa or relaxation centre and massages (trade school for children of CIDEN orphanage in Pokhara). " Solidarity tourism. " Reception of students doing practicals from Spanish centres, schools and universities, that have a master’s or degree in international cooperation. " Growth and commercialization of medicinal plants.
Environmental, social and cultural impact of the project. Sustainability for the receiving community and its environment.
The impact of the clinic will affect its environment in several different ways. The medical waste will cause a negative impact on the natural environment. Therefore, implementing a garbage collection system in the area is under consideration.
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The small town already has electricity and will therefore not require any further disturbance to its environment for electricity production. In cultural terms, the impact will be positive. Until now, in the case of an emergency, patients have been attended by a nurse, (often too late) and it has been impossible to monitor treatment. Now treatment will be more adaptive, and patient will be able to switch between the two medicine types, making the most of the positive aspects of each, which will lead to improvements in their quality of life. This project intends to support the local culture; this is the reason why a boost will be given to traditional medicine of the area, recovering part of the cultural heritage of the community and promoting the conservation and cultivation of medicinal plants that are currently disappearing.
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Appendix NEPAL IN NUMBERS Main problems. General Data on the Nepalese Population. • • • • • • • • • • • • • • • • • • • • !
65% of the population in Nepal lives below the poverty line. Literacy rates: 40% males and 25% females. Nepal has nearly 150,000 refugees from Bhutan and nearly 80,000 Tibetans. 3,000 Tibetan refugees escape every year from China. They arrive to Nepal in an indescribable state of health and nutritional condition. The international community finances more than 60% of the Nepalese development budget and more than 28% of total budgetary expenses. It is possibly one of the problems that prevents growth in the country. 40% of the total Nepalese population is under 15 years old. Nearly 53% of the population is part of the working population. Aged between 15 and 59 years. 2/3 of the population survive with 1.25 dollars a day. 1/3 of the population are indigenous. Out of 28 million inhabitants, 31% live below the poverty line. In a country where 50% of the population is nearly illiterate, there is not the time or the tools to critically assimilate and interpret all of the rapid processes of change the country is undergoing. In Nepal there are about 30,000 educational institutions. Many of them still have 80-100 children per classroom. The literacy rate among adults covers 57% of the population. Around 1/3 of the population between 5-14 years old does not go to school. There are no institutions providing free health care. There is an Ayurvedic hospital in the capital with 100 beds, a hospital in the western region with 15 beds, 14 areas that are around 55 years old and 216 dispensaries spread across the country. Facilities, cleanliness, food and hygiene of the in health care centres are often very poor, particularly in rural areas. A high percentage of the population suffers from diseases caused by a lack of hygiene and health care. People die on the streets every day due to diarrhoea, pneumonia and the flu. There are dalit, dami, kami (lower social caste), children, women and the 64!
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elderly living on the streets, as well as lepers and tuberculosis patients. There are sectors of the population without resources, without the possibility of having access to basic health care. Weather conditions affect a country where 80% of the population depends on agriculture. In Nepal 75,000 people depend on forests for their livelihood.
Caste system. The Dalit. • • • • • • • •
80% of Indian population. There is an established caste system. Dalit communities (untouchables) represent nearly 20% of the population (more than 5,000,000 people) Dalit women are half of that population (2.5 million). Dalits have little political representation. 90 % of Dalits do not have political representation. In the Dalit Community: only 10% are literate, and only 2% of women. Dalit status (untouchable) was declared illegal in 1963. In the Kathmandu valley and some rural areas it is still practiced. 650,000 children live in orphanages in Nepal.
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27% of Nepalese women are abused. Widows more than 60 years old receive a monthly pension of 500 rupees by law (4.5 euros). 52% of the total population in Nepal are women. Their participation in politics is only at 3.4%, one of the lowest figures in Asia. It is one of the few countries where the life expectancy of women is lower than men. The government is calling for measures to end maternal mortality: education in healthy pregnancies, increasing the age of marriage, improved roads and communications. 14% of hospital deaths are due to abortions or miscarriages. The government aims to establish safe abortion services nationwide to reduce mortality. There are 331 places for safe abortions around the country. There is often no road communication network that can be used to access these health care services or assistance; it requires a long trip lasting several days and travel expenses that cannot be paid. 19% of births in Nepal receive hospital assistance at least once. 79.2% of wealthy women give birth to their first child in a health facility, compared to 25% of the poor. 65!
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Nepal is a country where girl trafficking still exists. Families sell their daughters to businessman in the cities, who become their slaves. Girls are sexually abused and many of them end up working as prostitutes. Others are sold in Indian markets. Girls that are sold to brothels can generate up to 250,000 dollars each for their captors during their career as prostitutes. Girls and women that are victims of trafficking in Nepal cannot return to their homes for fear of discrimination and neglect. Families are often accomplices in trafficking in Nepal; therefore, they do not accept the return of their daughters.
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32% of children aged 5-14 years old work. This percentage rises in rural areas where 46% of girls do this work. As for their working hours: 16% work 40 hours, 26% work between 20-40 hours, 58% work 20 hours a week. 17% of children in Nepal neither work nor attend school. This percentage reaches 27% in the poorest communities. Over 50% of babies who die in Nepal fail to meet one month of life. Experts estimate that if vitamin A is not distributed in Nepal twice a year, around 12,000 children will die from preventable or curable diseases every year. Measles has caused the deaths of around 5,000 children each year. Despite national vaccination campaigns and the distribution of vitamins, an average of 194 children under five die from diarrhoea and acute respiratory tract infections every day. Every 7 minutes a child dies in Nepal. 205 lose their lives daily. 75,000 die annually. Problems of malnutrition preclude optimal growth and development in nearly 50% of children in Nepal. Consumption of vitamin A could reduce child mortality by 23%. Lack of vitamins makes children more vulnerable to infections and increases mortality in children and pregnant women, and death due to diarrhoea, malaria and measles. In Nepal thousands of children and young people aged between 5-20 years wander around in the cities under the effects of inhaling glue. For 5 rupees (5 cents of a euro) a child gets a shoemaker or a boot-cleaner to let him/her inhale the glue once. This allows him/her to escape symptoms of discomfort, pain, hunger or sorrow. For 50 rupees (0.50 cent of a euro), an amount easily obtained the tourists, they get a dose of glue to inhale all day. 66!
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Many start inhaling glue from the age of 5. In three years they have managed to poison their lungs and respiratory tract to the same degree as a person who uses snuff for years. 50% of children in Kathmandu are addicted to glue inhalation. The majority of children suffer from irreversible respiratory or neurone diseases; they wander around the streets disoriented and many of them die. There are no laws that forbid the sale of glue to children and young people or their consumption of it. Only 34% of children born in Nepal are registered.
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70% of NGOs that exist in Nepal are inactive and are kept registered for another purpose. Many of them are family and local business. Only 35 Nepalese NGOs are legally registered.
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There are about 800 orphanages in Nepal. Only 450 of them are registered, and only 42 of them fulfil the standards established by the Nepali Government. None complies with the regulations established by the United Nations. 60% of children in Nepal have parents, and family reunification programmes could be developed. In Nepal there is a latent and active market of illegal adoptions and child trafficking. In August 2010 the USA government forbade the adoption of children from Nepal. Another ten countries (Germany, Canada, Denmark, Spain, France, Great Britain, Italy, Norway, Sweden, and Switzerland) have adopted similar measures. A cooperation network has been created with 32 orphanages acknowledged by the Government of Nepal and all organizations operating in the area in order to prepare a report with precise recommendations. One of the best orphanages seen by the Government of Nepal, emphasized that this alliance of orphanages will work closely with the government to implement regulatory laws designed to meet the minimum requirements established by the Hague Convention. Among the 800 centres for children estimated to exist in Nepal, only 44 are recognized by the Ministry of Women, Children and Social Welfare.
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