NANGAN Project

Objectives:

The specific stigma/discrimination problem that NANGAN is addressing is to ensure that PLHAs receive proper care in Nepal’s hospital setting. The success of this project is important as there is no existing approach to address this problem. NANGAN’s approach is innovative and unique as it will unite the major policy makers at the Ministry of Health-Population and NCASC with NANGAN’s grassroots member organizations.

An estimated 10,300 Nepalese are infected. This number is growing amongst the vulnerable groups of FSWs, IDUs, MSMs, migrant males and unprotected village housewives. Through NANGAN's Regional Secretariat and NANGAN's member organizations, PLHAs have related countless painful experiences of stigma/discrimination against them within hospitals. This information gathered during NANGAN’s 2007 Regional Consultative Meetings and Regional Activists’ monthly reports supports NANGAN’s project idea 100%.

The information shows that attitudes of health care providers are influenced by fears and misconceptions about HIV transmission, and that there is inadequate awareness training and practice procedures ensuring staff safety and respect for PLHAs. Stigma/discrimination in the health care system leads to marginalization of PLHAs in need of treatment. It discourages those affected by the pandemic from accessing care.

NANGAN's goal therefore is to work in improving the government hospital environment towards PLHAs. The objective’s activities undertaken in collaboration with its Regional Secretariat, Activists and Task Force Committees in conjunction with the Ministry of Health and NCASC will reduce stigma and discrimination towards PLHAs resulting in creating a more supportive and safe environment at all levels of the hospital's infrastructure for both PLHAs and hospital staff.

Objectives:

1. To enable the Nepalese' government Health care system to provide quality care that is compassionate, confidential and non – discriminatory for PLHAs.

2. To address PLHA rights, including the rights to safe and quality hospital services, free from stigma and discrimination and the right to be treated with dignity, compassion and respect without discrimination from the regional to district hospitals to Out Patient Department levels.

3. To address the rights and needs of service providers to be safe from infection by training all staff to practice HIV Infection Prevention precautions throughout the government health system.

4. To ensure that hospital staff and workers have access to post exposure prophylaxis (PEP).

5. To reduce the HIV rate of transmission and other blood borne infection at government health care facilities.

6. To improve the quality of PLHA’s clinical services through a regular structured program of quality improvement activities.

Proposal Implementation:
MONTHS: 1ST-4TH

OBJECTIVE#1:
ACTIVITIES:
1. Secure collaboration: Ministry Health/Population; NCASC
2. Select 3 health care levels; a. Regional b. District c. Public Health Centre
FEASIBILITY:
HIV/AIDS statistical and epidemiological information documented by NCASC, MoH as basis for hospital selection
CHALLENGES:
 Secure collaboration of chosen hospital administrations
 Negotiate with new Health Ministry due to Nepal’s elections.

OBJECTIVE#2:
ACTIVITIES:
1. Put together a collaborative “Working Task Team”; PLHAs, Lawyers, Doctors, Social Activists to advise/complete project
2. Develop “Base Line Attitudes Survey” by interviewing 150 professional, technical and supportive hospital workers determining key determinants of HIV related stigma/ discrimination
3. Give survey to hospitals specific target groups
4. Establish effective M&E system
5. Complete, compile “Base Line Attitudes survey”
6. Disseminate report
7. Develop “Client Satisfaction Survey” according to results of “Base Line Survey” being user friendly for literate/illiterate clients.

FEASIBILITY:
Use NANGAN’s already established Regional Activist, Task Force Committees

CHALLENGES:
 Secure representatives from Civil Society
 Establish comprehensive yet not cumbersome M&E system
 Organize system to give “Client Satisfaction Survey”

MONTH 5-12:
OBJECTIVE#3,4,5:
ACTIVITIES:
1. Document role of language/labels in perpetuating stigma/discrimination and incorporate into trainings.
2. Establish, prepare Training of Trainers [TOT] around “Base Line Attitude Survey”;
a. services access, b. testing/counseling, c. confidentiality, d. quality care
e. stigma/discrimination f. infection control h. staff safety.
3. Give 10 day TOT training to 30 health care providers
4. TOT’s provide training to respective hospitals’ target groups
5. Develop stigma/discrimination IEC materials
6. Establish “Client Satisfaction Committee” monitoring results of given staff training.
7. Give randomly “Client Satisfaction Survey” to PLHAs
8. Compile, send to hospital management for work towards their hospitals service improvement
9. Develop “PHLA Friendly Hospital Achievement Checklist” according to international/national, HIV/AIDS human rights’ policies
10. Develop consultative roundtable one day workshops for policy-decision makers
11. Approve “PHLA Friendly Hospital Achievement Checklist” by Ministry Health/Population as annual “Red Ribbon Award”.

FEASIBILITY:
NANGAN’s excellent rapport with NCASC, Ministry of Health
NANGAN’s association with Sahara Paramarsha Kendra HIV/AIDS and TOT training centre

CHALLENGES:
 Develop practical activities systems
 Establish committees

OBJECTIVE#6:
MONTH 13-16:
ACTIVITIES:
1. Give one refresher training target groups depending on “Client Satisfaction Survey” compilation
2. Establish “Red Ribbon Award” across Nepal’s hospitals through Regional Activists.

MONTHS 17-18:
ACTIVITIES:
1. Evaluate, disseminate report to stakeholders/beneficiaries through national/regional level workshops

FEASIBILITY:
NANGAN’S Regional Activists, 2 trained volunteers

CHALLENGES:
Administrators giving time for staff training

Results and Measurability:

The Project Coordinator is responsible for the overall M&E. A comprehensive M&E framework is developed by the “Working Task Team” under the direction of the Project Coordinator.

The “Base Line Attitudes Survey” results establish the bench mark indicators for the pre/post tests given to TOT and trainee hospital target groups. The immediate effect of training is measured by pre/post test evaluation by both the participants/trainers.

“Working Task Team” establishes number of PLHAs randomly surveyed monthly. The “Client Satisfaction Survey” randomly given to PLHAs is compiled monthly by the “Client Satisfaction Committee”. Results sent to the hospitals’ administration are reviewed for continuous improvement. During months 13-16 one refresher training with pre/post tests are given to each of the 3 hospitals if “Client Satisfaction Survey” indicates poor impact.

At month 11th and 14th consultative round table one day workshops engage decision-makers in the monitoring process and information flow.

During the project’s last month the 3 chosen hospitals fill in the “PHLA Friendly Hospital Achievement Checklist” comparing their results with the original pre tests given prior to training. Results are reported to the Project Coordinator for final evaluation.

Successful Implementation Indicators:
1. Time line outlined within the objectives is set in collaboration with the Ministry of Health/Population and NCASC, which is verified by Project Coordinator monthly so that the project initiatives continuously move.
2. According to “Base Line Attitudes Survey” bench mark indicators of staff knowledge, attitudes, practices regarding PLHAs demonstrates 60% improved for objectives#3,4,5; “a-e” in activity #2.
3. Staff infection prevention practices 70% improved for objectives#3,4,5; “f-h” in activity #2.
4. Access to post exposure prophylaxis is 100% accessible in 3 chosen health settings
5. “Client Satisfaction Committees” effectively operative 85% as indicated by monthly attendance records and meeting minutes.
6. Monthly random surveys of PLHAs indicate in a monthly graph a consistent and gradually shift in stigma/discrimination towards them.
7. Three hospital administrations follow “Client Satisfaction Committees” recommendations within a 60% improvement margin.
8. One Refresher training with pre/post test to 3 hospital target groups given demonstrate a 50% improvement margin from initial post test training.
9. At the project’s end the following tools are established within the health system; “Base Line Attitude Survey”, “Client Satisfaction Survey” “PHLA Friendly Hospital Achievement Checklist”.
10. “Red Ribbon Annual Award for “PLHA Friendly Hospital” is fixed.

NCASC established PLHAs service policies and procedures are disseminated to all Nepal’s hospitals/health care centers.

Proposal Details:

In Nepal there is no approach developed as yet that verifies, records and improves stigma/discrimination towards PLHAs, which remains a huge factor in the spread of HIV/AIDS.

NANGAN’s approach is innovative and unique as it unites for the first time the major policy makers at the Ministry of Health-Population and NCASC together with the grassroots in creating a tool called “PHLA-friendly Hospital Achievement Checklist”. This Checklist developed using the “Base Line Attitude Survey” information is in keeping with the national/international guidelines and policies on the human rights of PLHAs, HIV testing and counseling, infection control, and care and management of AIDS.

The 3 chosen hospitals’ managers are required to identify how well their facility reaches, serves and treats PLHAs without stigma/discrimination and identify their institution’s strengths and weaknesses. The “Checklist” enables health facilities managers to engage in participatory problem identification and solving issues of stigma/discrimination and quality of care.

The process and practice of establishing “Client Satisfaction Committees” at all health care facilities is in itself innovative. Such a practice would continue to elevate awareness amongst hospital staff while keeping the hospital administration abreast of the service quality given.

Eventually all health care facilities would be submitted to the same training. Regional and National prizes could be set for the “Most Friendly PHLA- Hospital” (The Red Ribbon Award) on an annual bases.

The above system can easily be shared with other developing Asian countries each adopting it to their particular socio-cultural environment.

Ownership:

The project will greatly benefit the PLHAs that heavily depend on the government’s health system as they cannot afford private care. They will be ensured qualitative treatment and care in government hospitals that is compassionate, confidential; non discriminatory, free from stigma/discrimination and the right to be treated with dignity/respect in regional to district level hospitals. The hospital staff’s confidence in working with PLHAs will increase due to awareness raising and training ensuring their rights and needs to be safe from infection, to have access to post exposure prophylaxis (PEP) and universal HIV infection prevention precautions. The government hospital management also stands to benefit as the quality of clinical service to PLHAs should continuously improve through a regular structured program of quality improvement activities.

The national/regional level dissemination project results workshops begin the acceptance process of “Most Friendly PHLA- Hospital” (The Red Ribbon Award). Generally human nature naturally loves to excel and be recognized. Such recognition would be incentive for hospitals to improve when awarded in a grand manner. PLHAs in local communities are informed through the Regional Activists and Task Force Committees. Such news will be welcomed as this project is based upon NANGAN’s five Regional Consultative meetings 2007results where PLHAs strongly raised the issue of stigma/discrimination.

PLHA and hospital staff being the beneficiaries is involved as follows; staff training and participatory monitoring and solution finding through the “Client Satisfaction Committee” while PLHAs will be involved through the Regional Task Force Committees who will keep PLHAs focused organizations informed.

Replicability and Sustainability:

This proposed project is structured in such a manner that it is intended to be replicated throughout Nepal's health care services. Because the project is done in collaboration with the Ministry of Health and NCASC this project is replicable throughout Nepal’s Regional Hospitals and Government Health Centers as both major decision-makers will have been intimately involved in the success and implementation of the project. In a developing country replication depends very much on political will. Therefore, NANGAN as an effective National Network, is well positioned to continue influencing and advocating to the Ministry of Health/Population through NCASC the processes begun in the eradication of stigma/discrimination towards PLHAs through the established tools within the health system; “Base Line Attitude Survey”, “Client Satisfaction Survey” “PLHA Friendly Hospital Achievement Checklist”.

As well NANGAN's Regional Secretariats, Activists and Task Force Committee intend to build a strong coalition of civil society actors that will carry the battle against stigma/discrimination far beyond the duration of the project life. If properly “marketed” throughout the government health care system and supported by the Ministry of Health’s political will the “Most Friendly PLHA- Hospital” (The Red Ribbon Award) could in itself be a strong factor in scaling up the project work started.

Since most Asian developing countries face the same issues as Nepal in terms of PLHA stigma/discrimination, it is feasible that the 3 above tools could be adapted to other Asian countries once socio-cultural adjustments are made.