Dear Friends, Family, and Donors,

I write to you on the 1st anniversary of the Nepal earthquake to extend my heartfelt thanks for your contribution last year. I also want to take a moment to remember the victims. Above, you can see the picture of Chini Maya Tamang. She is from Lakuri Bhanjyang and her home and most of her village was destroyed by the earthquake. When we visited her community, the resilience and commitment she showed to her village health post inspired  and encouraged our team to work with her. In this brief letter, I hope to provide you with an update of government activities in reconstruction and recovery. I also want update you on our activities with the funds that were raised and our plans going forward.

 Background

On Saturday April 25, 2015, at 11:56 am a 7.8 magnitude earthquake shook Nepal followed by major aftershocks including one of 7.3 magnitude on May 12, 2015. Almost 10,000 people died and more than 22,000 were injured. More than 800,000 houses, 50,000 classrooms, 1,000 health facilities were damaged, and 500,000 livestock were killed. After a year, it is estimated that 4 million people are still living in temporary shelters and almost a million are homeless. Major economic and political activities in Nepal came in the way of recovery in the last year. The Nepali government ratified a constitution in September 2015, but this was followed by unrest along the Nepal-India border. This led to a blockade of import and exports through the border, causing further economic damage and pushing hundreds of thousands towards the brink of poverty. It was not until 8 months after the earthquake that the National Reconstruction Authority (NRA, the government arm responsible for reconstruction and distribution of funds to the victims) was formed, and then another 3 months more for the first person to receive the promised $2,000 to rebuild homes. It has been a year, but the NRA has not helped many people. Many Nepalis spent rainy seasons and the winter homeless. There is some hope going forward now that the NRA is fully in place, but the lack of coordination impacted many lives.

After the earthquake, you poured in support for the post-earthquake health advancement of two villages: Lakuri Bhanjyang and GhumarChowk. These villages are predominantly settled by Tamangs: communities that have been marginalized and oppressed in Nepal for decades. I promised you that I would best utilize these funds to make a long-lasting impact in these villages. The following is what we have done so far.

In the summer of 2015, my team in Nepal and I visited these two communities. The human and infrastructure damage in these communities was vast, and there was not much activity from aid agencies or the government there at the time. After conducting focus groups and interviews, we decided to build a temporary health center in Lakuri Bhanjyang. We also concluded that we must utilize this disaster as window of opportunity to improve long-term health service delivery in these villages. Since then, our team along with much needed guidance from friends, teachers, and advisors, has been thinking about how to best utilize the funds we raised to make a meaningful impact in these villages. Technical support was given to us by a Austin based NGO, Hem-Sarita Pathak Foundation (HSPF). HSPF has been working in Tamang community of GhumarChowk for a number of years and, it was through HSPF I was introduced to this community in the first place. The president of HSPF, Jeny Pathak, traveled with us to these communities and provided us invaluable inputs.

In December of 2015, I went back to Nepal. After a long thought process and advice from a wide range of people, we decided to pilot two different community-centred health models in these villages. Before getting into the details of these two models, it is important to understand the current structure of Nepal’s health system. Nepal has a centralized health system and a health post is the local level health facility. Each village has a health post. There are some services and medications that are supposed to be universally available in these health posts according to the law. This includes maternal services as well. Each health post also has a management committee that oversees the financial and operational management of the health post. But in marginalized villages like Lakuri, the management committees are not made up of people who know the village and the village’s health problems. Rather, people who don’t belong to the village and are from a different caste are appointed to these positions. For example, we checked the surnames of some of the people in the management committee for the Lakuri Bhanjyang health post, and most of them belonged to the Brahmin caste whereas no Brahmins live anywhere close to the area. Locals from Lakuri Bhanjyang did not know many members of the management committee and had never seen them.

Throughout Nepal’s poor, rural areas, there exists a major disconnect between what the government supplies and what is needed by the community, in terms of healthcare. For example, in these Tamang communities, chronic conditions due to long-term alcohol abuse are one of the major health problems. Unfortunately, this is not part of the mandate in the centralized structure and local health posts of these communities do nothing to manage these health issues. Furthermore, these communities don’t receive the already mandated services because of their rural and disenfranchised status. In these two villages, maternal and delivery services are either unavailable or so poor that the farmers who reside there use private hospitals in Kathmandu for healthcare and services during pregnancy. Health post workers’ timings are also not feasible for the farming communities. These health posts are open for 2-3 hours a day maximum. All these issues have led to a high out-of-pocket spending for health care that is supposed to be available for free. Our focus groups found that utilization and satisfaction of these communities with respect their health post is very low. When it was most needed during the earthquake, these facilities were not able to handle the burden. The need for strengthened health systems in these places is very apparent. We designed two models for these villages in hopes to synchronize the supply side with the demand side of health care. The goal is to increase utilization and satisfaction, while lowering out-of-pocket expenditures on health care. If proven successful, these models could pave way for many other rural villages in Nepal.

 A Three-way Partnership

 The model we have created is a partnership between three key partners. The below image shows the community-centric health model for the two communities. It is important that the community that is being served has a key stake in the decisions made around healthcare delivery and our model allows us to advance that notion.(Graphic representation of the model can be found in the images below.) 

Partner 1: First and foremost are the HACs (Health Advancement Committees). The HAC will consist of a group of representative from the specific village that will serve as the community arm of the model. The HAC would include women leaders, village teachers, local police, youth leaders, VDC secretary and other village activists interested in health advancement. The HAC will be the voice of the community and help everyone involved understand the community’s specific health problems. In effect, they are the representatives of the demand side of the model. (In the pictures below, HAC members from GhumarChowk and Lakuri Bhanjyang can be found.)

Partner 2: The second partner is the government health service entity in each village. These include the health post employees and the officers from the District Public Health Office (DPHO). These villages lie in 2 different districts, so we engaged with the DPHOs from both Kathmandu and Lalitpur district. This is the supply aspect of our model.

Partner 3: Finally, the third partner is our team, HAPSA-Nepal (Health Advancement Programs in South Asia – Nepal). Founded in 2011, HAPSA started out as a student organization from UT Austin doing health awareness programs and fostering educational initiatives for a few children in the slums of Lucknow. While HAPSA is undergoing the process of being registered as a 501(c) non-profit entity in the US, HAPSA-Nepal has completed registration as an NGO in Nepal. To partner with the Nepali government, we were required to have a registered entity in Nepal. (You can see the picture of HAPSA-Nepal team below.) This team is primarily youth that belong to the medical, pharmaceutical and business fields. These are youth leaders eager to serve the health needs of these communities’ and have worked very hard to get the logistics set up in Nepal. HAPSA works with both the supply side and demand side to bring their interests together.

 Proposed plan for Lakuri Bhanjyang: Private-Public Partnership

After the earthquake, we used some of the funds to build a temporary health post in Lakuri Bhanjyang. Following my meeting with the District Public Health Officer (DPHO) of Lalitpur, the health post workers, and the HAC, we decided to create partnership there that would be unique. We verbally agreed to sign a memorandum of understanding (MOU) with the DPHO that will allow HAPSA to help the government strengthen its already existing services and add additional ones as well. For example, DPHO is unable to provide a birthing center in this village although this is mandated. HAPSA will provide some funds and help the government to establish this. In return, the DPHO will allow the HAC and the HAPSA team to oversee the management of the health post. Furthermore, we will also incentivize the health post workers to work more hours by increasing their salary by 20%. In partnership with Tribhuvan University – Teaching Hospital, we will also bring physicians to these villages for special care at least once a month. A formal MOU between the DPHO and HAPSA-Nepal has not been signed yet, and is currently a work in progress.

Proposed plan for GhumarChowk: Private Clinic Model

In GhumarChowk, the existing health post is too far for the villagers and utilization has been low because of this. Focus groups in this village strongly reflected the need of a closer health facility. The Rotary club had sponsored a clinic for a long time in this village, but stopped doing so because they ran out of funds. Furthermore, this facility was destroyed in the earthquake. The villagers and the HAC of this village proposed a plan of turning an existing community building into a HAPSA-run clinic. (A picture of this building can be seen below.) The municipality has also agreed to donate some of their funds for transforming this building into a clinic. We will be coordinating with the health post and will conduct a needs assessment with the villager to prioritize services. Our plans include hiring a Health Assistant and a nurse for the clinic. We hope to partner with the health post to provide basic lab services. Management of chronic illnesses and awareness surrounding alcohol use will be main focus of this center. We will be working closely with the HAC to conduct regular needs assessments and understand demand. We will also work closely with the health post to keep track of supply. The clinic will function independently. Our partners from Tribhuvan University – Teaching Hospital will help with healthcare delivery. The clinic construction process has begun and an agreement with the HAC has been reached.

Concluding Thoughts

As you can see, the HAPSA team has stayed busy this year. We are truly searching for a way our funds can have the biggest impact. Thus far, we feel like we have found a good model to work with in these villages. Ultimately, we hope that our pilot projects can lead to relevant, useful policy revisions at the Ministry of Health that make healthcare delivery more community-centric and more effective. Through our models, we are engaging with and hopefully empowering community members to fight both for the right to their health care as well as the decisions around it.

To use medical jargon, an earthquake might be considered an “acute on chronic” event. In this sense, the countries that have weak systems and are chronically ill will do worse in an acute crisis. The steps we have taken in these communities are steps to strengthen the health system of these villages. We believe resilience will be built through active community engagement. As donors, friends and well wishers, you have played a big part in inspiring us to take on this project. You generously answered the call when I requested of you to help us help Nepal, and I could not be more grateful. Similarly, none of this would be possible without the active participation of community members and the HACs. These are people who are volunteering a lot of their time in hopes that their neighbors will have better healthcare. I am grateful for them for welcoming us to their communities and allowing us to work together. I am also grateful to have a wonderful HAPSA team in Nepal, and especially to Pankaj Bhattarai for taking a leading role and spending numerous hours working on this project. I am also grateful to all the work HSPF does for these communities, and their support in our project. Further, I want to thank all my advisors in this designing this project. Many friends and professors at Harvard and outside have provided valuable insights.We hope to create something that will be long lasting and benefit the communities for years to come. Your continuous support and thoughts in this project are appreciated. As we become more formal, we will have a website and media presence through which you can follow HAPSA’s work. In the meantime, I can be reached at anytime at rak370@mail.harvard.edu.

Thank you,

Ramu Kharel,

Founder-HAPSA, MD/MPH Candidate 2017                                                                                 Harvard T.H.Chan School of Public Health                                                                                           UT Southwestern Medical Center

 

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