Community Action for Health in Conflict

Nepal has undergone considerable political change in recent decades. In the spring of 1990 following the mass civil protest of the Democratic Movement, King Birendra conceded to democracy. (1) Democratic rule, however, provided little palpable change in the deeply-rooted social inequity, poor governance and maintenance of wealth and power among the state’s elite. Out of the disillusionment and discontent that followed democracy, the Communist Party of Nepal - Maoist grew in number and strength, and in February 1996 declared a "People's War" against the government and initiated a rebellion from the grass-roots of rural Nepal. Since then, some 11,000 people are reported to have been killed and the intensification of civil war is reflected in the three thousand reported deaths in the last two years alone. Although many of the senior personnel within the Communist Party of Nepal - Maoist are from Nepal's traditionally high social groups the "People's War" has taken up the causes and frustrations of the marginalised and disadvantaged, many of whom fill the swelling, disciplined and trained rank and file of the insurgents. What began as an underground movement rapidly became a substantial and well-organised paramilitary group, consisting of thousands of cadres throughout the entire country.

Rural health services

Health infrastructure in Nepal has become a casualty of the conflict, largely due to its physical proximity to government buildings in rural areas. Health posts and local government administration offices (called Village Development Committees or VDCs)(2) have customarily been constructed as joint buildings, and health posts have been destroyed in the frequent incendiary attacks on local administration structures. Aside from direct fears concerning personal safety, health personnel have become increasingly stressed by emergency legislation under which they may be arrested if accused of treating suspected insurgents. (3) Equally they face abduction and punishment by paramilitary forces if they refuse to treat sick or injured rebel fighters. The prohibitively protracted process of seeking government permission to treat injuries combined with the lack of safety has prompted many medical staff to maintain a low profile and geographically contained sphere of action, with many withdrawing to the comparatively greater security of urban centres or moving abroad. While the Nepalese government adopted a policy of decentralised health from 1999 (4), on the ground in rural areas public services are inadequately supported. Government policy, while supporting the concept of local self-governance and health administration, has not effected the requisite assistance to VDCs to enable them to initiate and implement effective community-based, decentralised health services. The health situation has also been aggravated by the lack of elected VDC officials to take responsibility for local health activities. International assistance to rural health in the form of projects has shrunk with the conflict. Since the USA provided support to the Royal Nepalese Army, American projects, development workers, and initiatives supported by American funds have come under risk. Although the insurgents tolerate projects that are perceived by rebel leaders to directly benefit communities, be transparent and not pay inflated salaries, many projects and NGOs have withdrawn from the periphery due to heightened security risks.

The Rural Health Development Project

The Rural Health Development Project (RHDP) is a bi-lateral initiative jointly funded by the Swiss Development Cooperation (SDC) and His Majesty’s Government of Nepal. (5) SDC has been supporting primary health care in the rural eastern hills since 1991 and the project has a strong reputation in the region and among the development community for effectively supporting community action for health as well as political neutrality. Managed directly by SDC, the RHDP belongs to the "Livelihood and Inclusion" component of the Swiss Cooperation Strategy Nepal 2005-2008. The project has been implemented in 43 Village Development Committees (VDC) of the total of 51 in Dolakha District and in 30 of Ramechhap District’s 55 VDCs, covering approximately 44 percent of the population of the two districts. The overall goal of the project is the improved health status of women, children, adolescents and men through participatory development of a locally adapted and affordable health system. (6) The project is based on principles that in addition to guiding activities towards accessible and sustainable health, ensure its orientation towards the poor, gender equity, social equality and community empowerment. This is important in addressing access to health and peace-building within Nepal’s highly stratified society in which the poor, women and those of low caste and ethnic groups are traditionally marginalised.

The Rural Health Development Project’s approach combines supporting community decision-making and action for local health with strengthening good governance practice and empowering disadvantaged community members, while developing a sense of responsibility for health, ownership and the right of access to public services. The project also develops and adapts the local health system to meet the demand it encourages for quality local health services. This process is conducted in partnership with community groups, schools, local government health workers and crucially in an area with a strong indigenous healing culture, integrates traditional healers and birth attendants to create a two-way referral system. Government health care providers, local NGOs, voluntary health mobilizers and social groups are all provided with management training that enables the establishment of appropriate accounting practices and improved record-keeping and information sharing. This not only encourages good governance and transparency that support sustainable local health systems, but also helps protect health care providers from suspicion of mismanagement of local health funds, which is essential to the maintenance of services especially within insurgent-controlled areas. (7) With the same objective of increasing transparency in order to ensure the sustainability of the interventions and security of the people involved, RHDP regularly organises social auditing with the local communities.

The project adapts and supports a number of pre-existing community structures to address local health requirements. In order to establish local level mechanisms for community health initiative funding, the project facilitates reform of the government-initiated VDC Health Management Committees (VDCHMC) which had become inactive due to political upheaval and the dissolution of elected members to take responsibility for community health. Using this model, RHDP broadened the committee membership to include additional social workers and more women and men from disadvantaged groups to create VDC Health Coordination Committees (VDCHCC). By building local capacities through basic and refresher management and technical training to elected VDC members, government health staff, other health service providers and community organisations, the project has strengthened an existing, yet weak institution to effect local health services and good governance.

Ownership of health initiatives is encouraged by communities identifying and problem-solving health issues and the project provides technical support for initiatives which VDC Health Co-ordination Committees prioritise themselves. RHDP’s financial inputs into community health micro-projects is usually 40 percent of the total cost and is provided in the form of hardware and technical assistance, while the communities themselves are required to meet 60 percent of outlays in the form of labour, materials and cash. An example of how this translates on the ground is provided by the Ron Jyoti school water and sanitation initiative in Ramechhap district, where villagers and the school teacher addressed the lack of drinking water and latrine facilities at the school by first discussing solutions for the problem and then devising an action plan which they presented to their VDC Health Co-ordination Committee. The Committee discussed the merits and practicalities of the project and decided that it was a priority for RHDP support. The project provided the hardware for two latrines, a water tank and taps equivalent to 40 percent of the micro-plan’s overheads. Villagers, the school teacher and pupils provided the remainder of inputs in a mix of donated labour, goods such as wood, mud and cow-dung (for mortar, flooring and plaster) and cash donations. The initiative was successful on a number of levels: The improved drinking water availability and sanitation had the expected direct benefits on children’s health, however, information and awareness of these issues were also reinforced at the community and household levels throughout the discussion and implementation processes. Several years on, the system installed at the school is well-maintained by pupils and parents who made personal investments in the venture.

Female health and empowerment form particular foci of RHDP’s activities. Awareness-raising concerning pertinent health issues enables women to make informed decisions about personal and family health. Female capacity-building and empowerment are addressed through several main project strategies. RHDP preferentially recruits local women as its paid frontline fieldworkers, called Community Health Facilitators. These women receive in-service training in health and health facilitation, which not only builds their skills and knowledge, but also enhances their social standing and confidence. The Community Health Facilitators have been successful in negotiating health activities with local insurgents and government forces as they know and are known by the communities in which they work and have a good understanding of the local conflict dynamics.

RHDP also reinforces female development and capacity for action for health by adapting and revitalising demotivated and inactive government-initiated groups, particularly Mothers’ Groups and Female Community Health Volunteers to meet health objectives. Mothers’ Groups were established under the government’s health policy at the village level with the objective of raising awareness of female health issues. However, Mothers’ Groups received very little support and many became stagnant. In project areas RHDP provides small funds and training (for example in participatory rural appraisal techniques) to restart these groups to provide an inclusive and democratic female forum that encourages female health awareness and problem-solving. Capacity-building in management and recording skills has enabled Mothers’ Groups in project communities to run their own micro-credit saving schemes that particularly favour disadvantaged women. In many project villages Mothers’ Groups have developed a sense of solidarity that transcends traditional social boundaries, and women act together to resolve local health and safety concerns (such as unsafe trails and tracks) as well as gender issues such as male alcoholism, violence and sexual harassment.

The project has also adapted voluntary community health motivators introduced by the government in 1996. The original concept was for Female Community Health Volunteers to be selected by Mothers’ Groups to receive training and act as health motivators and points of contact regarding health matters at the village level. This important cadre of grass-roots health motivators also suffer from a lack of government funds and support and have not fulfilled their designated vision. RHDP, however, has adapted the government model and strengthened the Female Community Health Volunteers’ knowledge and mobilisation skills. This enables them to raise demand for government health services, refer cases to appropriate local bio-medical health services in a timely manner and also to support national health campaigns such as immunisation days. The project has also enhanced the visibility, motivation and security of these female volunteers by providing them with identification badges and subsidised uniform saris.

Community health activities have also been focussed upon the specific needs of socio-economically disadvantaged groups, particularly those of the “untouchable” Dalit caste. The project has addressed the needs and situation of this group in a number of ways that include strengthening Dalit people’s representation in community groups and committees. Health initiatives and micro-projects among Dalit communities also receive greater financial input from RHDP, with 90 percent of costs being met by the project and only 10 percent by the disadvantaged communities themselves (rather than the 40:60 cost sharing ratio that generally applies).

Access to affordable and continuous essential drug supplies has been ensured by the project’s adaptation of the government Community Drug Programme model, which has largely failed in rural areas due to poor management of funds and stock control. By providing drug management training to ensure transparent accounting and management, together with improved drug supply techniques, RHDP Community Drug Schemes fill the gap between inadequate government supplies and expensive private pharmacies. The low-mark up of 20 percent on the cost price of drugs enables accessibility to the poor at the same time generating community health funds with the profit margin. This supports the schemes’ sustainability and enables further creative community health initiatives. One of the most important outcomes is that the Drug Schemes enable communities to extend government outreach clinics. These clinics are run at sub-health post-level in the periphery, usually up to four or five days each month. In project areas where sub-health post staff are supported with RHDP training and project Community Drug Scheme funding, the clinics are open daily to serve the health needs of rural communities at the village-level.

Communities within project areas are also encouraged and supported with training and technical assistance to form their own NGOs. In this way, local people’s capacity is built to guide and implement project activities themselves. At the same time, project support to create NGOs provides new livelihood options at a time when local income-generating options are shrinking.

Efficacy of the Community Action approach in conflict

In spite of the on-going civil war and occasions of heightened tension and insecurity, the Rural Health Development Project has maintained its activities throughout the conflict. Because of the insurgents’ perception of Swiss political neutrality and the efforts of the project to support rural health and the needs of the disadvantaged using principles of inclusion, equity and good governance, RHDP has suffered little disruption in its activities. On occasions that insurgents have required the postponement of training activities, local people have been known to directly and successfully request the insurgents to allow their continuation.

The combination of community ownership of health services and initiatives and commitment to the project has contributed to measurable improvements in positive health behaviours and health indices. Local health outlets’ registers record that in project areas the number of people seeking medical assistance at the sub/health post level has increased. This has been especially marked among the project’s special target groups of women and disadvantaged groups. The 2004 RHDP-commissioned Knowledge, Attitudes and Practices (KAP) survey has shown this increase to have been most striking in Ramechhap District where between 2001/2 and 2003/4, there was a 97 percent increase in disadvantaged groups accessing health care at the sub/health post level, and a 75 percent increase in female and a 107 percent increase in the adolescent client flow. (8) This most likely reflects the impact of the project on raising awareness about health issues and services and empowering people to make use of local health services, to which they feel they have a right.

There has also been a measurable reduction in morbidity in project areas. For example, between 2001/2 and 2003/4, there was a marked fall in diarrhoeal incidence among children under five in all sampled project areas, (9) with a decrease of 26 percent in Dolakha and 39 percent in Ramechhap. Similarly, certain behaviours associated with safer motherhood, such as a 25 percent increase in ante-natal clinic attendance in Dolakha and 26 percent increase in Ramechhap and improvements in pregnant women’s tetanus toxoid vaccination by 29 percent in Dolakha and 26 percent in Ramechhap between 2001/2 and 2003/4.

Conclusions

Community-initiated health activities within the Rural Health Development Project have been successful within the Nepal conflict setting in two key ways. Firstly, at a time when government health services are particularly inadequate and many non-government health organisations are withdrawing from rural areas, RHDP has continued the majority of its activities, with only short withdrawals of field staff in response to heightening insecurity. Secondly, within the conflict arena, the project has managed to achieve measurable positive impacts on health and health-related behaviour that are especially marked within its priority groups of women and the disadvantaged. As a consequence of these experiences, the project which was due to complete in July 2005 is to undergo an additional new phase beginning in January 2006.

In response to the developing conflict, community- and externally-identified needs and lessons-learned, RHDP is preparing to adapt its activities to include community emergency health funds, training of health and voluntary workers in dealing with the effects of conflict, broadening the operational definition of disadvantaged groups to include more economically marginalised people and to create national links between community groups. The project is also scaling-up its activities to cover the entire population of Dolakha and Ramechhap districts and also set to expand into neighbouring Okhaldhunga district.

*Kate Molesworth works in public health specialising in integrated health and social development with the Reproductive Health and HIV/AIDS unit of the Swiss Centre for International Health at the Swiss Tropical Institute in Basel. She provides regular technical advice to the Swiss Agency for Development Co-operation SDC under a backstopping mandate, and, under this mandate, she represented SDC at the MMS Symposium. Contact: kate.molesworth@unibas.ch.

Notes:

1. Gellner, D.N. (1997). Caste, Communalism, and Communism: Newars and the Nepalese State. In: Gellner, D.N., Pfaff-Czarnecka, J. & Whelpton, J. (eds.). Nationalism and Ethnic Identity in a Hindu Kingdom. Amsterdam: Harwood Academic Publishers; US Department of the Army (1993). Nepal and Bhutan Country Studies. Area Handbook Series. 3rd Edition. Federal Research Division, Library of Congress.

2. Village Development Committees, referred to commonly as VDCs, are administrative areas at the sub-district level.

3. District Health Support Programme (2003). Conflict and Health in Nepal: Action for Peace-building. DFID/SDC/RHDP/GTZ/HSSP. Kathmandu; March 2003.

4. Ministry of Health (1999). Second Long-Term Health Plan. His Majesty’s government of Nepal. Ministry of Law and Justice. (1999). Local Self-Governance Act, 2055 (1999). HMG, Law Books Management Board. Kathmandu, Nepal.

5. Rural Health Development Project (2004). Yearly Plan of Operation for 16 July 2004-15 July 2005. (Last Year of Phase 3). His Majesty’s Government / Swiss Agency for Development Cooperation. Kathmandu.

6. Swiss Agency for Development Cooperation / Rural Health Development Project (2004). Experiences and Achievements: Community Empowerment For Health.

7. Molesworth, K., Karki, Y. & Koirala, I. (2005). Rural Health Development Project Nepal. Report of the 2005 External Review. Basel/Kathmandu: Swiss Tropical Institute on behalf of the Swiss Agency for Development Cooperation.

8. Valley Research Group (2005). Evaluation/KAP Study on Health in Ramechhap District. Submitted to RHDP, SDC, Lalitpur, Nepal. January 2005. Centre for Development and Management Studies (2001). Baseline Health and KAP Survey of Ramechhap District. Submitted to RHDP, SDC, Lalitpur, Nepal. December 2001.

9. Valley Research Group (2005). Evaluation/KAP Study on Health in Dolakha District. Submitted to RHDP, SDC, Lalitpur, Nepal. January 2005 Centre for Development and Management Studies (2001). Baseline Health and KAP Survey of Dolakha District. Submitted to RHDP, SDC, Lalitpur, Nepal. December 2001.