Planning for Sustainability in Nepal’s Physical Rehabilitation Sector Sustainability Analysis Process Workshop III Report Consultation workshop “Physical rehabilitation sector in Nepal: current and future perspectives” 21 & 22 August 2014 Author: Dorothy Boggs Knowledge Management Unit Handicap International Contributors: Chiara Retis and Raju Palanchoke Handicap International Nepal Table of Contents Table of Contents .................................................................................................................................... 2 List of abbreviations ………………………………………………………………………………………………………………………….3 Executive summary …………………………………………………………………………………………………………………………..4 I. Introduction to the sustainability analysis process ........................................................................ 5 II. Sustainability analysis process in Nepal’s rehabilitation sector ................................................... 10 III. Objectives of the SAP III workshop ............................................................................................... 13 IV. Workshop activities conducted ..................................................................................................... 13 V. Key findings ................................................................................................................................... 14 Objective 1: Identify events that affected sustainability in the rehabilitation sector ...................... 14 Objective 2: Analyse challenges met during the 2012 sustainability measurement exercise.......... 21 Objective 3: Revise the list of 2012 sustainability indicators & standards ....................................... 24 Objective 4: Measure the new sustainability indicators chosen in 2014 ......................................... 28 Objective 5: Illustrate 2014 sustainability indicators with star diagrams......................................... 30 VI. The next steps ........................................................................................................................... 33 VII. Appendix I ................................................................................................................................. 34 VIII. Appendix II. ............................................................................................................................... 36 XIV. Appendix III…………………………………………………………………………………………………………………………42 2 List of Abbreviations AIN Association of International NGOs ANOT Association of Nepal Occupational CBR Community Based Rehabilitation CBRB Community Based Rehabilitation Biratnagar CTEVT Council for Technical Education and Vocational Training DDCC District Disability Coordination Committees DDRC District Disability Rehabilitation committee DPO Disabled People Organisations FCHVs Female Community Health Volunteers GPH Green Pastures Hospital HI Handicap International HRDC Hospital & Rehabilitation Centre for Disabled Children ICED International Centre for Evidence on Disability ICRC International Committee of the Red Cross LSHTM London School of Hygiene and Tropical Medicine MCBR Mobile Community-Based Rehabilitation MOF Ministry of Finance MOFALD Ministry of Federal Affair and Local Development MOHP Ministry of Health and Population MOLD Ministry of Local Development MOPR Ministry of Peace and Reconstruction MOWCSW Ministry of Women, Children and Social Welfare MOYS Ministry of Youth and Sport NASPIR National Association of Service Providers in Physical Rehabilitation NDF National Disabled Fund (NDF) NEPTA Nepal Physiotherapists Association NFDN National Federation of the Disabled – Nepal NGMC Nepalgunj Medical College NGO Non-Governmental Organisation NHPC Nepal Health Professional Council NHRC Nepal Health Research Council NNSWA Nepal National Social Welfare Association NPC National Planning Commission PHCRD Primary Health Care Revitalization Division POS Nepal Prosthetic and Orthotic Society (POS) Nepal PRS Physical Rehabilitation Services PRC Physical Rehabilitation Centres RCW Rehabilitation Community Worker SAP Sustainability analysis process SF Sustainability framework SIRC Spinal Injury Rehabilitation Centre SPK Sainik Punastahpan Kenfrs UNCRPD UN Convention on the Rights of Persons with Disabilities VDC Village Development Committee 3 VDRC Village Disability Rehabilitation Committee WHO World Health Organization 4 Executive summary Background In many fragile states, physical rehabilitation services are typically first provided during humanitarian responses; however, given the physical rehabilitation sector is not usually at the top of policymakers' agendas in subsequent reconstruction and development phases, this poses a challenge to the full development and sustainability of this system of services to respond to the needs of the population. The issues surrounding the sustainability of physical rehabilitation sector in fragile states was the focus of a 4 year, multi-country research by Handicap International and the International Centre for Evidence on Disability (ICED) at the London School of Hygiene and Tropical Medicine (LSHTM). The study, which analysed 5 countries 1 including Nepal, developed a participatory process tool, The Sustainability Analysis Process (SAP), that can be used by practitioners and decisionmakers to develop a collective vision on of what the rehabilitation sector should be working towards, as a whole. In Nepal, the physical rehabilitation sector is mainly formed by civil society organisations, including local organisations and disabled people organisations. Government institutions are mainly involved with social schemes for people with disabilities and community based programmes, while comprehensive policies on services are still missing. Even though existing services only partially address the rehabilitation needs in the country, the sector’s social network analysis continues to demonstrate a wide variety of actors in a dense network with high connectivity when the compared to the other SAP countries. During the study, which was carried out from 2009 to 2012, Nepalese stakeholders of the physical rehabilitation sector jointly identified standards for the sustainability of the rehabilitation system. Initially, a preliminary situation analysis of the sector was completed which provided a first baseline for identifying needs and gaps. The stakeholders then collectively set sustainability standards and measured current levels of sustainability indicators. The sustainability indicators are grouped into 6 different components with reference to the Sustainability Framework2, a model based on a holistic and multi-dimensional view of sustainability. The six different components include: health outcomes; health service delivery; ministerial and local organisational capacity and viability; community capacity; enabling environment.3 Rehabilitation sector and the definition of standards and indicators The 2014 sustainability workshop aimed to measure the sustainability indicators two years after the 2012 measurements to identify progress between 2012 and 2014 and confirm the relevance of indicators. However, instead of objectively measuring progress on sustainability, this workshop was similar to the 2012 where emphasis was placed on revising the list of sustainability indicators to ensure that they would be most relevant and more easily monitored by rehabilitation actors in the future. This was mainly due to: Changes in the political and civil society environments: The active mobilization of civil society has been important during 2012-2014. In particular, the disability working group, DPOs , professional organisations and the rehabilitation service providers created several 1 The other countries are Somaliland, Cambodia, Sierra Leone and Liberia. Sarriot et.al., 2008 3 See full reports, including sustainability indicator lists, are available on Sustaining Ability website http://www.sustainingability.org/case-studies/nepal/index.html 2 5 opportunities for awareness raising, professional development and networking to influence the agenda on disability. However, despite the recent inclusion of rehabilitation services in the new national health policy for the first time, the lack of coordination and leadership on policies and planning still represent a major barrier for any political engagement on services development for health. Difficulties in gathering data: Data collection is incomplete due to unclear responsibilities and mandates among government bodies, coordination issues and limited access to official data. Furthermore, rehabilitation service providers do not yet have sufficient links with the Nepali health system for information on health needs, facilities, coverage of health services and management of human resources. Lack of clear references for the definition of sustainability indicators and standards, both nationally and internationally. This limitation reinforced the importance of being thorough when documenting future indicator metadata. It is also important to remember that the definitions of a number of standards for rehabilitation are still ongoing at the global level under the leadership of WHO. Two new indicators were added to the list, to improve the enabling environment for the rehabilitation sector specifically related to rehabilitation professionals, such as the formation of a rehabilitation council for professionals. The participants felt that enhancing the environment for the rehabilitation sector was one of the most important factors for sustainability, and the selection of the two new indicators reflect concepts that the participants viewed as essential to understanding and improving sustainability of rehabilitation in Nepal. Main achievements 1. Consensus was achieved on the definition of a set of indicators for the rehabilitation system in Nepal by a multi-stakeholder national group, representing providers, users and authorities. Further work is needed to refine and better define and measure some of these indicators. 2. A core committee representing all the relevant stakeholders for rehabilitation was set up. The committee’s objectives will be to continue work on refining the indicators, collecting data and advocating for the development of the rehabilitation sector as an integrated part of the health and social care for people with disabilities. 3. The group of participants in the workshop was bigger in 2014 compared to 2012 and generally were more actively involved in the delivery of rehabilitation services and more focused on advocacy. In particular, professional associations were present for the first time, such as the physiotherapist, occupational therapist and prosthetics and orthotics associations, and the Ministry of Youth and Sport participated for the first time reflecting the engagement of this government ministry on disability. Further, the presence of organisations working on leprosy also reinforced the increased interest of the Leprosy Control Division in this sector. 4. In addition to measuring progress of the performance of the sector, the group of stakeholders is also contributing to two important things: 1) defining the requirements of responsive services 2) influencing the political agenda, especially MOHP and MOWCSW, to include the development and regulation of rehabilitation services in the ongoing policies for a better access. Next steps 1. One of the core committee tasks will be to lobby the GON for data collection and analysis related to disability and rehabilitation. The committee can technically support the government in this process, and then integrate the measurement of indicators in the 6 relevant government frameworks, in particular the MOWCSW and the MOHP. The MOHP is particularly important for indicators related to service delivery and workforce. The core committee will contribute to developing a more comprehensive understanding of the rehabilitation needs of the country in relationship to disability and health, in link with current policy development opportunities. 2. 2016 will be the right time to measure indicators again and analyse progress made. This measurement activity and subsequent analysis will constitute a crucial step for all actors of the rehabilitation sector in Nepal. 3. This experience of the SAP will be shared with other health and social sectors in Nepal and with rehabilitation actors in other countries, in order to build on similar experiences and promote sharing. Additional SAP country level case studies are available on Sustaining Ability website http://www.sustainingability.org/. 7 I. Introduction to the sustainability analysis process A. Background Handicap International (HI)4 and the International Centre for Evidence on Disability (ICED)5 at the London School of Hygiene and Tropical Medicine (LSHTM) initiated a joint four-year study with regards to the sustainability of the physical rehabilitation sector. The study focused on five fragile states / challenging environments, specifically Nepal, Somaliland, Cambodia, Sierra Leone and Liberia. In these countries rehabilitation services were first provided in the context of humanitarian response. However, since the sector of physical rehabilitation is not usually at the top of policymakers' agendas, the task of building sustainability in this system is even more challenging for local actors. The study, which ran from 2009 to 2012, developed a participatory process tool, The Sustainability Analysis Process (SAP)6, that can be used by practitioners and decision-makers to develop a collective vision of what the rehabilitation sector should be working towards, as a whole. B. Introduction to the methodology The Sustainability Analysis Process (SAP) is a coordinated planning approach that aims to facilitate the development of a common vision of sustainability amongst various actors in a system. Specifically, it is a participatory process which outlines how to achieve consensus on a common vision and define sustainability indicators that can be used to monitor progress towards this vision within the context of the national rehabilitation system. Ultimately, the SAP is a practical tool that can help all actors in a system understand the various components of sustainability and analyse the concept of sustainability in relation to their own system. The SAP is intended for relevant actors within a country's health and social system. In the rehabilitation sector, this might include people with disabilities, disabled people's organisations (DPOs), service providers, donors, authorities and international organisations. It aims to combine a scientific approach with a participatory approach through public and professional engagement, to reach consensus on a common vision of sustainability among the key actors of a sector, and to select and measure practical sustainability indicators focusing on the six components of the Sustainability Framework7 (Refer to Figure 1 and Table 2 for six components table1). Figure 1: Sustainability Framework Table 1: Six components of the Sustainability Framework (SF)7 Component 1: Health outcomes Component 2: Service delivery Components 3: Ministry organisational capacity and viability Components 4: Civil society organisational capacity and viability Component 5: Community capacity Component 6: Enabling environment 4 http://www.handicapinternational.org http://disabilitycentre.lshtm.ac.uk 6 http://www.sustainingability.org/publications/guideline/index.html 7 Sarriot E., et al (2008) 5 8 The SAP methodology combines the conceptual framework of the Sustainability Framework, and the step-by-step process of the Process Analysis Method. The method combines multi-stakeholder perspectives through a participatory workshop approach. The eight SAP steps are listed below. Eight SAP steps 1. Overview of context 2. System boundaries 3. Consensus on vision of sustainability 4. Selection of sustainability indicators (SI) in each of the six SF components 5. Measurement of SIs 6. Reference system for sustainability 7. Illustrating the indicators on radar diagrams 8. Analysis of sustainability levels Details about these eight steps and their related tools, are available in the practical guide, The Sustainability Analysis Process: the case of physical rehabilitation8. Additionally, please refer to the Sustaining Ability website9 which contains detailed information about the joint study, the SAP methodology and ongoing global SAP coordination and development, including useful resources and country level case studies. 8 Blanchet, Karl, Boggs, Dorothy (2012) “The Sustainability Analysis Process: the case of physical rehabilitation” Lyon: Handicap International 9 Sustaining Ability http://www.sustainingability.org 9 II. Sustainability analysis process in Nepal’s rehabilitation sector Nepal’s rehabiltiation sector has been a key stakeholder in the development of SAP. As one of the five post-conflict countries selected for the Sustainability Study, Nepal’s rehabilition sector participated in two SAP workshops during the study, an international Sustainability seminar and the third SAP workshop held August 2014. The timeline in Figure 2 outlines key moments when Nepal’s rehabilitation sector has directly been invovled in using the SAP towards developing a more sustainable sector. Specific annual details about Nepal’s rehabilitation sector SAP actvities are provided in the following sections from 2010 to 2014. A. 2010 SAP activities Researchers from ICED at the LSHTM were commissioned by Handicap International to facilitate workshops on Planning for Sustainability in the Physical Rehabilitation Sector in Nepal as one of the five countries selected for the Sustainability Study. During this initial SAP workshop, key rehabilitation actors in the sector were invited and were introduced to the Sustainability Analysis Process (SAP), which was used to discuss issues related to sustainability in rehabilitation. By the end of the workshop, participants had (i) agreed on a vision of sustainability for their country, (ii) chosen relevant indicators which would allow stakeholders to measure progress towards that vision and (iii) created a list of recommendations that needed to be implemented in order to achieve this vision. The vision, indicators and recommendations were documented in a workshop report and circulated to participants in 2010. The report also includes a background to the national context of disability services provision, including a summary of the main actors involved in provision and analysis of the main challenges and opportunities for sustainability in the sector at that time. B. 2011 SAP activities After the first workshop, the outcome of this planning activity was followed up through a consultancy to collect baseline measurements the SAP indicators between July and September 2011. The measurement activity was supported by various rehabilitation actors through consultation and the data collection activities, led by two consultants. A report titled “Assessment of the Physical Rehabilitation Sector in Nepal” was also produced. C. 2012 SAP activities The principal LSHTM researcher and the author of this report, who works in Handicap International’s Knowledge Management team, returned to Nepal to follow-up progress that had been made in the sector regarding the use of sustainability indicators. This was accomplished by holding a second workshop in the capital, Kathmandu, in August 2012. Participants were reminded of the components of the SAP, asked to revisit the 2011 indicators and recommendations previously made, and discussed progress on these in relation to events that had occurred over the previous two years. Through this second workshop, the results of the sustainability measures were analysed and the list of sustainability indicators were reviewed and revised. The report from the 2012 follow-up study in Nepal10 summarises an analysis of the main findings with an updated sustainability indicator list. D. 2013 SAP activities 10 Blanchet, Karl, Palmer, Jennifer (2012) “Planning for Sustainability in the Physical Rehabilitation Sector : Report of a 2-year follow-up study in Nepal” London: LSHTM ICED. 10 Upon completion of the study and analysis of the findings, Nepal’s rehabilitation sector emerged as the ‘sustainability champion’ of the five countries who participated in the joint four year study. This is due to a few key factors including: the rehabilitation sector’s dense decentralised network; the increased participation of the state actors for financing the services; the existence of coordinated umbrella bodies for DPOs, such as NFDN, and for service providers, such as NASPIR; the actors’ proactive involvement in the workshop and their ability to follow up the results of the workshop, especially the integration and use of the sustainability indicators. The successful results from Nepal’s involvement in the Sustainability Study were presented at an international “Challenges of sustainability of physical rehabilitation sector” seminar held in Kathmandu, Nepal from 24-29 of January 201311 and recently in a peer-reviewed publication.12 E. 2014 SAP activities Just over two years following the second workshop, a third SAP workshop was indicated to follow up the 2012 sustainability indicators for re-measurements and further analysis and revision to see the progress in the rehabilitation sector. This workshop was held once again in the capital city, Kathmandu, on 21st and 22nd of August 2014. Participants were reminded of the components of the SAP, reflected on events that had occurred in the previous two year and revisited the 2012 indicators to re-measure, analyse progress and revise as necessary. This process is particularly meaningful given the changing rehabilitation context. At the policy level, there is more awareness of the need for coordinated actions to plan and respond to gaps in access to specific services. This increased awareness is due to the advocacy contributions of main actors and new actors, including professional associations, health institutions and service providers. 11 12 HI Seminar website Blanchet K, Palmer J, Palanchoke R, Boggs D, Jama A and Girois S. (2014) “Advancing the application of systems thinking in health: the contextual and social network factors influencing the use of sustainability indicators in a health system - a comparative study in Nepal and Somaliland.” Health Research Policy and Systems 12:46 DOI information: 10.1186/1478-4505-12-46 11 Figure 2: Key SAP moments in Nepal’s rehabilitation sector August 2012 April 2010 2 workshop organised by LSHTM and HI to follow up progress 1st SAP Workshop organised by LSHTM and HI December 2009 Initial field trip by researcher from LSHTM August 2014 nd 3rd SAP Workshop organised by HI June/July 2011 January 2013 Assessment of physical rehabilitation sector organised by consultants International Sustainability Seminar in Nepal III. Objectives of the SAP workshop III The specific objectives of this SAP workshop III in Nepal were to: 1. 2. 3. 4. 5. IV. Identify events that affected sustainability in the rehabilitation sector Re-measure 2012 indicators and analyse progress and challenges Revise the 2012 list of sustainability indicator definitions and standards Measure the revised 2014 sustainability indicators Illustrate the 2014 measures on Star diagrams Workshop activities conducted In order to collect information for the above objectives, a participatory two-day SAP workshop was held in Kathmandu, covering the topics and activities listed in the agenda below (Table 2). Group activities were observed, any group outputs, such as diagrams and tables that were produced, were documented and notes were taken from all relevant discussions. Table 2: SAP Workshop III Agenda Day 1 10.00-10.15 Welcome to participants and introductions 10:15-10:30 Opening remarks from NFDN, PHCR Division, NHRC and MOWCSW 10:30-10:45 Objectives , Expected results of the workshop , schedule for the 2 days 10:45-11:30 Background information on the multi-country sustainability research ( LSHTM-HI 20092012) on physical rehabilitation and tools developed (HI) Sustainability of physical rehabilitation services in Nepal: the way so far (NASPIR) 11.30-11:45 Tea break 11:45-13:15 Construction of time-line changes with impact on the rehab sector (Group work) 13.15-14:15 Lunch break 14:15-15:45 Re-measurement of indicators of 2012 (Group work) 15:45-16:45 Group presentations (Plenary) 16:45-17:00 Wrap up Day 2 10:00-10:15 Welcome and presentation of objectives of day 2 and schedule 10:15-11:00 Warm up and review of Day 1 11:00-11:30 Analysis of change: Explain indicators changes since 2012 (Group work) 11:30-11:45 Tea break 11:45-12:45 Revision of indicators and sustainability standards ( redefine, rephrase, delete, omit, or create new indicators) (Group work) 12:45-13:45 Lunch 13:45-14:45 Presentation of revisions and validation by whole group (Plenary) 14:45-15:15 Way forward and action points (Plenary) V. Key findings Objective 1: Identify events that affected sustainability in the rehabilitation sector Events and activities that affected the rehabilitation sector since the last workshop were listed by the participants and mapped on a timeline. Events that had a beneficial impact on the sector were categorised as positive and events that created constraints were categorised as negative events. Table 3 summarises these events from August 2012, when the second SAP workshop was held, until August 2014 when the third SAP workshop was conducted. 14 Table 3: Timeline of positive & negative events affecting sustainability in the physical rehabilitation sector in Nepal between August 2012 and August 2014 Month AugDec 2012 Positive events Jan-Dec 2013 Negative events International Wheelchair Day, Association of International NGOs (AIN) disability working group formed Nepal Census report MOHP allocated budget for 5 districts Inclusion of disability in Community Based Disaster Risk Management Drafting of Accessibility Guidelines Funding through District Public Health Office for PR services from MOHP (PHCRD) 2,000Rs given to leprosy patient after treatment (MOHP) Practical implementation of District Project Advisory Committee (HI partners) to Central Project Advisory Committee (HI-STRIDE) platform for sharing Implementation of integrated Public Health camps (PRCs and Primary Health Care and Revitalisation Division) Nov 2012 report by GIZ on access to health & rehab services AIN Career Expo for people with disabilities (AIN)December CSPO scholarship 2012-2013 (Prosthetics and Orthotics Society-Nepal) AIN disability working group-monthly meetings • Supreme court decision on support for people with disability (2000-5000rps) • National Accessibility guideline passed (early 2013) (MOWCSW) • Ministry of Youth and Sports (MOYS) budget allocation for physical rehabilitation Annual Para Olympics (MOYS) • National wheelchair working group formed • 1 CAT I Prosthetist &Orthotist studying in Thailand • Budget allocation for wheelchair production to the National Association of Physically Disabled, Centre for Independent Living, Wheelchair Club to from Ministry of Women Children and Social Welfare • 3 CAT II Prosthetist &Orthotist (P & O) graduates returned from Cambodia School of Prosthetics and Orthotics (ICRC and POSNepal) • The National Planning Commission coordinated the development of a three year plan for disability (2013-2016) ,under the coordination of the MOWCSW • Policy implementation of District Disability Coordination Committee (DDCC) revised by MOWCSW • Physiotherapy conferences, seminars, workshops, camps, awareness raising activities annually (Nepal Physiotherapy Association-NEPTA) • AIN disability working group continued • Approval of Accessibility Guidelines (September) • Partial implementation of supreme court order • MOHP not budgeting for 5 Districts • DDC not continue (DPAD) 15 • October 2013 : International CP conference (Hospital & Rehabilitation for Disabled Children) • Spinal Cord Injury patient received financial support 1 lakh, policy changed through networking & advocacy (MOHP) • Medical Community Based Rehabilitation training at regional/central level (MOHP) • Annual regional review workshop included PR service providers/disability sector (MOHP) • National Health Training Center + SIRC started training health worker on neuro-rehab + SCI • AIN carrier Expo for people with disabilities (AIN)-December • MOYS support to NDF • MCBR training started by Leprosy Control Division • Disability Act approved process has been on hold (MOWCSW) • No representation of people with disabilities in constitution assembly JanAugust 2014 • 5 CTEVT recognition of P & O (POS-Nepal, NASPIR) • 2 CAT I P&O graduates returned from Thailand • Leprosy Control Division ( LCD) at MoHP to work beyond Leprosy for development of rehabilitation centres • Drafting of Day care services for people with disabilities • Drafting of personal assistance guidelines • Drafting of LCD Rehabilitation guideline • MCBR Guideline formed (MOHP) • National Action Plan of Disability under revision by MOWCSW • PA guidelines - ongoing process • UNCRPD country report sent by government • AIN-DWG support to construction of accessible public toilet • MOWCSW increased funding support to 5 rehab centres • National Health Training Center + HI training of health professionals on emergency trauma • New Education Act (MOE) • New Health policy released (MOE)Endorsement of the Global Disability Action Plan by WHO (April) • A community of practice on Cerebral Palsy is created under the leadership of Handicap International and HRDC • Disability and Rehabilitation Services are being discussed in the thematic group of Non Communicable Diseases within the NHSP III ( preliminary meetings )CAPAD project extension (July) • CBR Guidelines for Nepal – revised draft in process, final stages (MOWCSW) • Physiotherapy conferences, seminars, workshops, camps, awareness raising activities annually (NEPTA) • National health Policy includes rehabilitation services in priority action (August) Poor implementation of available policies (ongoing) Lack of employment policy for qualified P & O and rehab professionals (OT, PT) P&O human resource analysis not done Lack of coordination among line agencies Insufficient funds Domestication of UNCRPD stopped due to New Constitution Assembly (MOWCSW) Funding through DPHOs for PR services discontinued 16 Authorities: Ministry of Women, Children and Social Welfare (MOWCSW) is the focal ministry for disability and responsible for preparing the overall plan and policies on disability. The ministry has been providing funds (around 20% of the annual operating cost) for 3 rehabilitation centres since 2011, and added funds for 2 more centres in 2013 and 2014. Funds have been allocated in a pilot initiative to support the production of wheelchairs in Nepal (2013). In 2014 the Ministry started the revision of the national Action Plan on Disability that was on hold since 2006. Ministry of Peace and Reconstruction (MOPR) was established as a Governmental body responsible for promoting the peace process, reconstruction of infrastructures damaged during the recent conflict and for the rehabilitation services (including orthopaedic devices, corrective surgeries and physiotherapy) of people affected/injured during the conflict. The support provided through NDF to 5 other collaborative rehabilitation centres in 2011 has been extended until end of 2015. Ministry of Federal Affair and Local Development (MOFALD) is the governmental body responsible for the planning and implementation of the development initiations at the village and district levels being the line agency for the District Development Committees (DDC) and Village Development Committees (VDC). The DDC and VDC are authorised to register, maintain records of all the persons with disabilities in order to distribute compensation allowance and provide financial support to enhance livelihood options for marginalised communities including the persons with disabilities. Each DDC and VCD allocates the 15% of budget provided by MOFALD to deprived groups, including persons with disabilities and women. National Planning Commission (NPC) is the central Governmental body responsible for preparing the overall national strategy of the Government of Nepal, including mainstreaming disability into the national development process. NPC coordinated the development of their three-year plan (2013-2016) for disability, under the responsibility of MWCSW. The eight objectives are 1)strengthened CBR in 75 districts according to the WHO guidelines ;2) access to devices; 3) protect and promote rights of people with disabilities (UNCRPD?); 4) accessible roads, renovation, universal design and enabling environment ; 5) establishment of rehabilitation centres for isolated individuals; 6) recreational activities; 7) access to employment, self -employment and vocational training for livelihoods; 8) sign language promotion Ministry of Health and Population (MOHP) has no defined responsibility in the field of disability, however through its separate divisions (the Primary Health Care and Revitalization Division, the Child Health Division, the Leprosy Control Division) contributes towards the preventative, promotional and curative services for persons with disabilities; rehabilitation services are sometimes contracted out to few facilities in the private sector. In 2012 some PRCs participated in integrated public health camps organised by the PHCR Division where screening and identification of impairments was added to routine health interventions. The Leprosy control Division has become proactive in advocating for an improved access to physical rehabilitation centres within the MoHP at both national (policy planning) and local level through CBR services. In August 2014 the new national health policy was endorsed with a first mention to rehabilitation services. Policy planning for the next 5 years (2015-2020) is under process with emerging themes such as non-communicable diseases and injuries. Ministry of Youth and Sport (MOYS) started allocating budget to support NDF in Kathmandu in 2013 in the frame of their policy of support to the disadvantaged youth, including young people with disabilities. This Ministry is also supporting the National Para Olympics with allocation of annual budget. Users and DPOs: User groups and local coordination committees: Village disability groups/committees are coordinating for the support mechanism for persons living with disabilities in communities. They 17 help in generating resources from local authorities and other community sources and mobilise it for the physical as well as economic rehabilitation of persons with disabilities. Likewise in districts, a District Disability Coordination Committees (DDCC) - consisting of representatives from the service providers, local Government authorities, disabled people organisations and other stakeholders, have been working for the development of district level coordination for generating resources and mobilising it for rehabilitation and other disability service provisions. Disabled People Organisations (DPOs): The National Federation of the Disabled – Nepal (NFDN) and other national DPOs are the main organisations in advocating for the persons with disabilities. Service Providers: HI-supported physical rehabilitation centres and satellite units: Community Based Rehabilitation Biratnagar (CBRB) is working in Morang district in the eastern region Prerana is a Non-Governmental Organisation (NGO) working in Sarlahi district in the central region National Disabled Fund (NDF) is an semi-Government organisation based in Kathmandu in the central region Nepalgunj Medical College (NGMC) is a private hospital located in Banke district in the midwestern region Nepal National Social Welfare Association (NNSWA) is a NGO working in Kanchanpur district in the far-western region ICRC-supported centres: Sainik Punastahpan Kenfrs (SPK) is a Government owned centre located in Kathmandu district (central region) and managed by the Nepal Army Department, runs a physical rehabilitation centre with the technical support of the International Committee of the Red Cross (ICRC) Green Pastures Hospital (GPH), which is managed by the International Nepal Fellowship, is located in Pokhara district in the western region. With technical assistance of ICRC, this hospital is providing medical treatment and rehabilitation services to persons with disabilities in the western region of Nepal. Other service providers: Hospital & Rehabilitation Centre for Disabled Children (HRDC) is an NGO-run hospital with a rehabilitation centre in Kavre district (central region) and providing specialised medical and rehabilitation services for children, outreach rehabilitation services, conducting outreach mobile camps and CBR activities. Spinal Injury Rehabilitation Centre (SIRC) has developed a range of facilities to support the spinally injured of Nepal, who tend to come from the most marginalized bracket of society. The Center offers rehabilitation services to patients so that they are able to rebuild their lives within the limits of their ability. In recent times, the Center has had to significantly expand its services because of the widespread awareness of the services provided by the Center as well as a dramatic rise in road traffic and other accidents. Anandban Leprosy Hospital in Kathmandu provides medical, surgical and rehabilitation services for people affected by leprosy and other impairments. Associations, Professional groups and communities of practice: National Association of Service Providers in Physical Rehabilitation (NASPIR) was established in 2010, is umbrella organization of the physical rehabilitation service providers in the country. Currently twelve organizations providing physical rehabilitation services are the core members of this network. NASPIR aims to create a conducive and sustainable environment for the quality 18 services to the persons with disabilities by strengthening the existing services with technical and institutional aspects. Prosthetic and Orthotic Society (POS) Nepal is a group of national P&O professionals working for promotion of P&O profession in Nepal. Nepal Physiotherapists Association (NEPTA) is an association of Physiotherapists working in Nepal. ANOT is the association of Nepal Occupational Therapists The Wheelchair working group is an advocacy group created in the frame of a programme funded by international donors and made of rehabilitation stakeholders and user groups, working for the development of national policies on mobility devices Cerebral Palsy in Nepal is a community of practice that gathers several service providers and academic institutions specialized or involved in the delivery of services for children with Cerebral Palsy International Agencies: Handicap International (HI) is supporting 5 rehabilitation centres across the country for service provisions and technical and institutional sustainability of service providers. HI is also promoting the development of policies on disability and rehabilitation services working alongside civil society ( NASPIR, NFDN) and relevant Ministries ( MOHP, MWCSW) International Committee of the Red Cross (ICRC) is supporting 2 rehabilitation centres in Nepal. Figure 3: Location of rehabilitation centres in Nepal - 2014 Main developments in the sector: 19 The actors highlighted very impressive and significant actions that occurred in the rehabilitation sector throughout the two years in between Sustainability workshops. There was an increase in professional association and ministerial participation compared to 2012 workshop and additional ministries were present, such as the Ministry of Youth and Sport, which highlighted further disability and rehabilitation activities. Besides the increased support to two more rehabilitation centers by the MOWCSW, and the new support to national Para Olympic by the MYS, the government continued its supported as in 2012 with no remarkable changes from the financial point of view. Within the Ministry of Health, the Leprosy Control Division started to promote links with rehabilitation services, especially through CBR programmes, but coordination and leadership on such services by this ministry is still unclear. However, an increased engagement on disability and rehabilitation is shown by the availability of new data on disability (Census) and the planning for more accurate data at the national level, that includes the CBR survey by the MOWCSW, the planning for a new national survey on disability by MoHP and the inclusion of rehabilitation services in the new national health policy. These changes are encouraging and represent initial steps towards the future development of comprehensive policies for rehabilitation services that are still missing in Nepal. The MOWCSW together with the civil society started to lead the development of guidelines to increase access and quality and services for people with disabilities, for example on accessibility and on personal assistance, and more are planned The engagement of civil society and service providers has been particularly important in 2012-2014. The Disability working group met regularly, and new events were successfully organised, such as Career expo and disability. These events contributed to create new opportunities and visibility for the disability movement. In the absence of and until the establishment of a leading Government authority for the overall rehabilitation sector, NASPIR has continued being active in awareness-raising at the national level. The organisation has continued to gather comprehensive information on available services and gaps in access. Following the consultative workshops in 2010 and 2011, NASPIR drafted strategic recommendations for the development of rehabilitation services in Nepal in 2012 with the support of HI and all national stakeholders. This document is available for further revision with authorities. The Prosthetics and Orthotics Society (POS) Nepal and NASPIR have developed a working group to advocate/lobby with Nepal Health Professional Council (NHPC) and Council for Technical Education and Vocational Training (CTEVT) for their official recognition and affiliation by the government of Nepal. In November 2010, NASPIR and POS Nepal, with close support from HI, jointly organized consultative meetings with the CTEVT. In 2012 and 2013, a series of follow up meetings were organised with CTEVT, and both NASPIR and POS- Nepal were assisted by the HI team for providing required technical information and documents to support this recognition process. Recently in September and October 2014, the CTEVT has provided equivalent certificate to the Nepali P&Os, who were trained in Mobility India and Cambodia. Rehabilitation providers were engaged in several initiatives to increase sharing of practices, such as organising the first national conference on Cerebral Palsy and the creation of community of practice. These initiatives not only contributed to strengthening links among providers, expanding the network and highlighting the availability of services, but also further emphasised the need for a better referral system and coverage. Trainings for rehabilitation professionals have continued and were supported by project-related funds and initiatives of the professional associations, especially NEPTA. Further, physiotherapists working in rural areas joined the association for the first time. 20 Objective 2: Re-measure 2012 indicators and analyse progress and challenges At the second SAP workshop in 2012, a number of the 2010 sustainability indicators were revised and selected by rehabilitation actors to indicate and measure progress towards sustainable development of the rehabilitation sector. The following table presents the 2012 sustainability indicators initially re-measured during the 2014 workshop, compared to the measurement in 2012 and their sustainability standard or ‘ideal’ that the sector should be working towards (also chosen by participants in 2012). The two right-hand columns of the table indicate the participants’ analysis of the indicators progress and their related comments about challenges met during the workshop remeasurement activity. Throughout the remainder of this report, ‘*’ is used to mark information that is further specified in Appendix III, and ? indicates that more information and/or data is needed. Table 4: Sustainability indicators chosen at the 2012 workshop, their measurements in 2012 and their initial measurements and analysis during 2014 workshop Component C1: Health outputs C2: Health Service delivery Sustainability Indicator Sustainability standard 2012 measurement 2014 initial measurement Progress Y/N Comments/Analysis Number of wheelchairs, tricycles and mobility aids distributed per year 266,178 3,398 2068 No Number of treatment sessions per year 140,000 226,701 205, 379 No Number of prosthetics and orthotics distributed per year 12,000 items 11,942 10,230 No Number of disability-related surgeries per year Further research needed ---- 3,147 --- Incomplete data compiled; WHO estimates (1% of pop needs w/c) + proportional need of MA Incomplete data compiled; Suggestion to change standard Incomplete data compiled; based upon WHO/ISPO estimate (0.5% need devices) First time data compiled; Difficult to predict standard; Suggestion to change defn and specify type of surgeries Number of physiotherapists working in rehabilitation centres and Hospitals at Regional + Zonal levels 70 54 168 Yes Number of CAT I P&O working in rehabilitation 6 (5+1) 0 2 Yes 92 are working in RC and remaining will plan to be recruit in Govt. hospital; SSDRC-1, SIRC8,HRDC-4, Anandaban-6, SPK-2, MWRH-1, ORTHO Plast-3, RCRD-1, Rehab partners-9, Lalgadh-2, Nepal Matri Griha-1 (Government Regional-1, Sub Regional-3, Zonal Hospitals-11and District 68 in process to recruit PT); Suggestion to change standard to 170 One is working in his own workshop; NGOs Rehab 21 centres Centre required 5, Possibility to recruit other hospital based rehabilitation centres; Suggestion to change standard to 10 as required to be calculation of P& O numbers as per ISPO/WHO standard Number of CAT II P&O working in rehabilitation centres (20 centres) Number of bench workers (non-clinical workers) CAT III Number of OT working in rehabilitation centres 60 22 25 Yes 3 P&O returned from CSPO study 60 24 41 Yes HRDC-4 Added SPK-2 Added, Lalgadh-4 20 1 2 Yes Number of PTA working in rehabilitation centres 140 28 35* Yes Nepali OT are 2- one in Tnasen and one in Pokhara; there are 4 expatriate OT as well in the country, not counted in this table. HRDC -4, SIRC-2, SPK-2 Number of counsellors working in rehabilitation centres Number of medical officers working in rehabilitation centres Number of Rehab Community Workers in Rehab Centre 20 13 18 Yes HRDC-1, GPHRC-1, SIRC-2 Added, SHDRC-1 40 18 18 No Same as 2012 100 87 98 Yes Anandaban-20, Lalgadh10, HRDC-2 added, Rehab partner-1 Added, all VDC of Nepal to be cover; Suggestion for all VDCs of Nepal to be covered so change standard to 1300 (around 4000 VDCs are covered by 1300 CDW) C2: Health Services Training & capacity building Number of rehabilitation centres have CPE plan (PT, P&O, OT, Counselling, CBR and Medical) per year 18 0 5 Yes C3&4: Organisationa l Capacity & viability Existence of national disability commission in Nepal % of District Disability Rehabilitation Committee (DDRC) on disability maintain database on PRS Existence of the commission 100% (75, existence and wellfunctioning ) No No No 0% ? ? More data needed; Within HI supported 5 Rehab centres in practices but need to ask others; suggestion to change standard to all 25 centres Disability commission does not exist Need more data; not possible to calculate percentage right now 22 % of rehab centres that receive at least 50% of funding from the Government % FCHV trained on disability C5: Community capacity C6: Enabling environment 50% 0% ? ? 100% 2% ? Yes Existence of centrally managed database system on rehabilitation Yes No No No Number of government hospitals up to Zonal level or hospital above 50 beds 17 2 5 Yes % of districts with Village Disability Rehabilitation Committee (VDRC) % of Disabled People Organisations (DPOs) that have action plans 100% 47% ? ? 100% 70% ? ? Formation of a coordinating committee, Existence of the plan Guidelines and standards available from NASPIR No DPPAD NPPAD Yes Yes No -- 4 per year No No No Certification available No No Yes 75 13 18 Yes 7% 3.5% ? Yes Existence of a national action plan on rehabilitation National guidelines and standards regarding rehabilitation services are elaborated Number of meetings organised by the subcommission on rehabilitation Recognition and certification of P&O and OT by NHPC Number of districts that have an action plan on disability % of annual budgets of local development committees allocated to disability Need data from rehabilitation centres; not possible to calculate percentage right now Data needs to be compiled but 24 districts training HRDC; suggestion to change to health staff Only database at individual level; need standard format for central database 5 government and private hospitals Need more data; not possible to calculate percentage right now Need more data; not possible to calculate percentage right now MOWCSW + NFDN Policy already were available in 2012 but was not recorded during last review NASPIR guideline is available which can be considered as a guideline but awaiting Government of Nepal revision and recognition Different consultation held but no subcommittee formed; Rec to refer to UNCRPD recommendations on committees Work in progress (CSPO & MI) for recognition to be done NFDN reported additional 5 districts have action plan Not enough information available but increase in budget allocation observed at local level The 2014 sustainability workshop aimed to measure the sustainability indicators, two years after the 2012 measurements, to confirm the relevance of indicators and identify progress between 2012 and 2014. Prior to the workshop, Handicap International Nepal team coordinated the collection of 23 rehabilitation sector data and the results were distributed to each working group during day 1 of the workshop for the re-measurement activity. However, even with this additional source of data, the workshop participants encountered difficulties with the re-measurement activity due to a number of challenges and contextual changes. Specific 2012 indicator re-measurement challenges are listed in the comments section of Table 4 as discussed by the participants during group work and in plenary. A thematic analysis of overall challenges includes a few key factors as highlighted below: Changes in the sector due to various contextual factors: As highlighted in the timeline activity, significant events occurred throughout the two years in the rehabilitation sector that positively and negatively impacted the rehabilitation sector. Some of these changes affected the relevancy of the indicators and/or the standards were no longer relevant. Incomplete data: Though all actors were encouraged to provide data, the data collection was incomplete due to several factors. Among the rehabilitation actors there is limited capacity to collect data. More importantly, there is still no mandate among government bodies to collect data, so as a consequence information and processes remains fragmented. For certain indicators, especially on component 3&4, it was clearly felt that more data and time for data collection activities was needed to be able to be accurate in the measurement, especially given it is necessary to include different kinds of sources/actors. Sustainability indicator and/or standard information unclear: Though the 2012 indicators had useful in-depth information including definitions, assumptions, source of data and sustainability standard information, gaps still existed when the participants revisited the indicators for measurements. This recognition reinforced the importance of being thorough in documenting future indicator metadata. Further, it is important to remember that aspects of global standards and definitions for rehabilitation services are still being defined, so therefore are not available for reference. Moreover, rehabilitation service providers do not have sufficient links yet with the Nepali health system including information on health needs, facilities, coverage of health services and management of human resources .This is an ongoing process that will require time, creation of communication channels, functional links and policy support. Therefore, instead of objectively measuring progress on sustainability in the sector via indicators during the workshop, the 2014 sustainability workshop was similar to the 2012 where emphasis was placed on revising the list of sustainability indicators to ensure that they would be most relevant and more easily monitored by rehabilitation actors in the future. This was mainly due to the contextual changes and the challenges encountered with the re-measurement activity. Therefore, the initial remeasurement and analysis activities provided a current updated detailed analysis of the 2012 indicators which directly enriched and fed into the subsequent indicator revision workshop activities. Objective 3: Revise the list of 2012 sustainability indicators & standards Several major and minor revisions to the 2012 list of sustainability indicators and standards were made by the 2014 workshop participants, as listed in Table 5 below. Table 5: List of sustainability indicators deleted, revised and added to the 2012 list 24 Sustainability Component C 1: Health Outputs Sustainability Indicator Action Number of wheelchairs, tricycles and mobility aids distributed per year Source of data and standard redefined Number of treatment sessions per year Assumption, source of data and standard redefined Number of prosthetics and orthotics distributed per year Assumption, source of data and standard redefined Number of disability-related surgeries per year Assumption and source of data redefined Number of physiotherapists working in rehabilitation centres/(sub)regional and zonal and district hospitals Title, definition and standard redefined Number of CAT I P&O working in rehabilitation centres Standard redefined Number of CAT II P&O working in rehabilitation centres (20 centres) No change Number of bench workers (non-clinical workers) CAT III No change Number of OT working in rehabilitation centres No change Number of PTA working in rehabilitation centres No change Number of counsellors working in rehabilitation centres No change Number of medical officers working in rehabilitation centres No change Number of Rehab Community Workers in Rehab Centre Standard redefined C2: Health Services - Training & capacity building Number of rehabilitation centres have CPE plan (PT, P&O, OT, Counselling, CBR and Medical) per year Standard redefined C3&4: Organisational capacity & viability Existence of national disability commission in Nepal / In line with NPPAD and CRPD, an Inclusive National Coordination Committee (INCC) for PRS is required Title and standard redefined % of District Inclusion Disability Rehabilitation Committee (DIDRC) on disability maintain database on PRS % of rehab centres that receive at least 80% of funding from the Government annually Title and definition refined % of FCHVs + HWs trained on disability Title, definition and assumption redefined Existence of central database system on rehabilitation Title and source of data redefined No of government hospitals up to District level or hospital above 50* beds with orthopaedic surgeons, operate or develop linkage with existing rehab centres for services % of districts with Village Disability rehabilitation Committee (VDRC)* / VDC / Municipality level committee in Disability Title, assumption and standard redefined C2: Health Service delivery C5: Community capacity Title, definition, assumption, source of data and standard redefined Title redefined 25 C6: Enabling environment % of Disabled People Organisations (DPOs) that have action plans Definition, assumption and source of data redefined Existence of a national action plan on rehabilitation No change National guidelines and standards regarding rehabilitation services are elaborated Standard redefined Number of meetings organised by the sub-commission on rehabilitation Definition defined Recognition and certification of P&O and OT by NHPC No change Code of Ethics for rehab professionals including licensing (Counsellors/OT/P&O/PT/SLP) New indicator A Rehab council for professional (Counsellors/OT/P&O/PT/SLP) New indicator Number of districts that have an action plan on disability Assumption and source of data redefined % of annual budgets of local development committees allocated to disability Assumption, source of data and standard redefined Of the 28 sustainability indicators originally selected in 2012, only eight remained unchanged. No indicators were deleted during this workshop; however, eight had changes to their title to provide further clarity and focus. A further twenty-three indicator definitions, assumptions underlying definitions, sustainability standards or sources of data were revised to improve clarity or to better reflect the context of current service provision in Nepal. For example, as illustrated in Table 6 below, the participants revised the assumption and sustainability standard of component 1’s second indicator. Table 6: Example of revisions made to the indicator “number of treatment sessions per year” Sustainability Indicator Definition Assumptions Source of Data Sustainability Standard Number of treatment sessions per year The total number of treatment sessions relating to rehabilitation in one year, including physiotherapy representing 8 10 sessions a day per physio Rehabilitation centres record and disseminate information to NASPIR; session include service provided by any level of professional (assistants/PT/Specialized PT) NASPIR 250 days/year/physio – 140000 75,00,000 sessions/year This represents the annual output of 3000 PTs (no of PT; 1 PT per 10,00 population, 10 session in a day) Note: Words in red were inserted into the original text, while text crossed out was deleted. Finally, two new indicators were added to the list, to improve the enabling environment for the rehabilitation sector specifically related to rehabilitation professionals, such as the formation of a rehabilitation council for professionals. The participants felt that enhancing the environment for the rehabilitation sector was one of the most important factors for sustainability, and the two new indicators selected reflect concepts that the participants viewed as essential to understanding and improving sustainability of rehabilitation in Nepal. 26 Details on the definitions, assumptions and sources of data for the revised 2014 list of sustainability indicators can be found in the Appendix II. 27 Objective 4: Measure the new sustainability indicators chosen in 2014 The 2014 indicators and their measurements are listed below with updated sustainability standards as available and relevant (Table 7). After the workshop in August 2014, it is anticipated that the multi-stakeholder committee, which formed as a participatory action point at the conclusion of the seminar, will coordinate outstanding sustainability indicator data collection and measurement activities. Table 7: Measures of sustainability indicators in 2014 and their sustainability standard Component C1: Health outputs Sustainability Indicator Sustainability standard 2014 final measurement 300,000 2068 75,00,000 205, 379 40000 10,230 Further research needed 3,147 1) Number of physiotherapists working in rehabilitation centres/(sub)regional and zonal and district hospitals 170 168 2) Number of CAT I P&O working in rehabilitation centres 10 2 3) Number of CAT II P&O working in rehabilitation centres (20 centres) 60 25 4) Number of bench workers (non-clinical workers) CAT III 60 41 5) Number of OT working in rehabilitation centres 20 2 6) Number of PTA working in rehabilitation centres 140 35* 7) Number of counsellors working in rehabilitation centres 20 18 8) Number of medical officers working in rehabilitation centres 40 18 1300 98 20 5 Existence of the commission No 1) Number of wheelchairs, tricycles and mobility aids distributed per year 2) Number of treatment sessions per year 3) Number of prosthetics and orthotics distributed per year 4) Number of disability related surgeries per year C2: Service delivery 9) Number of Rehab Community Workers in Rehab Centre C2: Health Services - Training & capacity building 10) Number of rehabilitation centres that have CPE plan (PT, P&O, OT, Counselling, CBR and Medical) per year C3&4: Organisational Capacity & 1) Existence of national disability commission in Nepal / In line with NPPAD and CRPD, an Inclusive National Coordination Committee 28 viability C5: Community capacity C6: Enabling environment (INCC) for PRS is required 2) % of District Inclusion Disability Rehabilitation Committee (DDRC) on disability maintain database on PRS 100% (75, existence and wellfunctioning) ? 3) % of rehab centres that receive at least 80% of funding from the Government annually 80% ? 4) % of FCHVs + HWs trained on disability 100% ? 5) Existence of central database system on rehabilitation Yes No 6) No of government hospitals up to District level or hospital above 50* beds with orthopaedic surgeons, operate or develop linkage with existing rehab centres for services 1) % of districts with Village Disability rehabilitation Committee (VDRC)* / VDC / Municipality level committee in Disability 2) % of Disabled People Organisations (DPOs) that have action plans 75 5 100% ? 100% 70%* Formation of a coordinating committee, Existence of the plan Yes Guidelines and standards available from NASPIR and recognised by GON 4 per year No Certification available No Approved code of ethics available for individual professions Council exists under the organogram of MoHP 75 1/5 10% ? 1) Existence of a national action plan on rehabilitation 2) National guidelines and standards regarding rehabilitation services are elaborated 3) Number of meetings organised by the subcommission on rehabilitation 4) Recognition and certification of P&O and OT by NHPC 5) Code of Ethics for rehab professionals including licensing (Counsellors/OT/P&O/PT/SLP) 6) A Rehab council for professional (Counsellors/OT/P&O/PT/SLP) 7) Number of districts that have an action plan on disability 8) % of annual budgets of local development committees allocated to disability 0 No 18 29 Objective 5: Illustrate 2012 sustainability indicators with star diagrams In order to visualise the contribution of indicators to each component of sustainability, star diagrams of their measurements were built. A star diagram is built for every component of the sustainability framework. On a star diagram, each indicator is represented by a branch. Every measurement of sustainability is spotted on the branch with the sustainability standard illustrated in red and the 2014 indicator measurement in blue. Note all indicators with and without measurements at the time of the 2014 SAP III workshop are indicated on the star diagrams. Component 1: Health and Rehabilitation Outcomes Number of wheelchairs, tricycles and mobility aids distributed per year Number of disability related surgeries per year 300,000 August 2014 Sustainability Reference ? 3,147 2068 205,379 10,230 40,000 Number of treatment sessions per year 750,000 Number of prosthetics and orthotics distributed per year Component 2: Rehabilitation Services Number of physiotherapists working in rehabilitation centres and Hospitals at Regional + Zonal + District levels 170 Number of rehabilitation centres that have CPE plan Number of CAT I P&O working in rehabilitation centres 10 168 Number of CAT II P&O working in rehabilitation centres 60 20 5 Number of Rehab Community Workers in Rehab Centre 2 25 41 98 60 1300 2 18 Number of medical officers working in rehabilitation centres Number of bench workers CAT III 35 40 Number of counsellors working in rehabilitation centres 20 18 140 Number of PTA working in rehabilitation centres 20 Number of OT working in rehabilitation centres 30 Component 3&4: Organisational Capacity and Viability of the Sector Existence of national disability commission in Nepal/ in line with NPPAD and CRPD, an inclusive Natl Coordination Committee (INCC) for PRS is required 100% % of District Inclusion Disability Rehabilitation Yes Committee (DDRC) on disability maintain % of FCHV and HW trained on database on PRS disability ? 100% No ? No 5 80% ? % of rehab centres that receive at least 80% of funding from the govt annually Yes Existence of central database system on rehabilitation 75 No of govt hospitals up to District level or hospital level above 50* beds with orthopaedic surgeons, operate or develop linkage with existing rehab centres for services Component 5: Community Capacity % of districts with Village Disability rehabilitation Committee (VDRC)* / VDC / Municipality level committee in Disability 100% ? 70%* % of Disabled People Organizations that have action plans 100% 31 Component 6: Environment Existence of a national action plan on rehabilitation Yes Code of ethics for rehab professionals including licensing (counsellors/OT/P&O/PT/SLP) Yes National guidelines and standards regarding rehabilitation services are elaborated Yes 5 % of annual budgets of local development committees allocated to disability No 1 10% ? A Rehab council for professional (counsellors/OT/P&O/PT/SLP) No No 0 Yes 18 4 Number of meetings organized by the sub commission on rehabilitation 75 Number of districts that have an action plan on disability Yes Recognition and certification of P&O and OT by ministries 32 VI. The next steps A. National context The actors in Nepal agreed that the cohesion between themselves has facilitated the ongoing analysis of sustainability indicators and the systemic approach to planning in the sector. Limitations and challenges continue to exist in the systematic collection and provision of accurate data and in the definition of the indicators given the dynamic sector context. Given this recognition, one of the most important outcomes of the workshop was the participatory decision to set-up a core committee inclusively representing relevant rehabilitation stakeholders in order to ensure more efficiency and continuity in the definition and measurement of the indicators. All participants felt that this is the most appropriate way to fill the gaps in the definition of the rehabilitation services system in Nepal. This set of new sustainability indicators reflects the current priorities of the sector and provides important information that can be used by all rehabilitation actors groups to strategically plan and make decisions moving forward. The next step will be to continue to integrate the measurement of these indicators in the management of the sector by all the Ministries concerned, in particular the MOWCSW but also the MoHP for indicators that are more related to service delivery and human resources. This experience could also be shared with other health and social sectors in Nepal and with rehabilitation actors in other countries. 2015 or 2016 will be the right time to measure these indicators again and analyse progress made. This measurement activity and subsequent analysis will constitute a crucial step for all actors of the rehabilitation sector in Nepal. B. Global context In addition to the national level rehabilitation sector analysis, the findings as detailed in this report will directly feed into a broader cross-country SAP analysis by using both the results and lessons learned from the workshop and indicators. To date, HI has supported nine SAP workshops in the following countries: Cambodia, Liberia, Nepal (x3), Sierra Leone, Somaliland(x2) and Burundi. Nepal’s rehabilitation sector continues to be a ‘sustainability champion’ for the wider SAP initiatives given the strong results obtained in this third workshop; the proactive participatory stakeholders; the dense sector with exisiting umbrella bodies for disabled people oranisations, service providers and professional associations; and the diverse and increased representation of the Ministries. Globally, it is anticipated that Nepal’s SAP in country findings and the broader cross-country SAP analysis will be shared widely to inform and sensitise global rehabilitation sectors and UN cluster systems in emergencies through ongoing publications and international conferences, such as recent conference abstract submissions to the upcoming 2015 WCPT and ISPO conferences. Further, the SAP compliments WHO’s health system blocks and contributes to broader global disability and health initiaitives such as vulnerability, disability-related services, human resources for health and universal healthcare. This report and additional SAP information is publically available through Handicap International’s Sustaining Ability website (http://www.sustainingability.org/). 33 VII. Appendix I List of Participants at Sustainability Analysis Process workshop III, 21 & 22 August, 2014, Kathmandu, Nepal SN 21st 22nd 1 X X 2 X 3 X X 4 X X 5 X 6 X 7 X 8 X 9 X X 10 X X 11 X 12 X X 13 X X 14 X X 15 X X 16 X X 17 X X 18 X X 19 X X 20 X X 21 X 22 X X 23 X X 24 X X 25 X X X Name of participants Ms Ishowri Devi Shrestha Mr Shankar Pathak Mr. Resham Kumar Khatri Mr. Maheswar Sharma Mr. Krishna Prasad Subedi Dr. K.P. Dhakal Dr. Khem B. Karki Dr. Krishna Aryal Ms. Esha Thapa Dr. Menu Acharya Mr. Shovakhar Kandel Mr. Bishnu Dhungana Mr. Rajendra Yadav Mr. Kapil Pokharel Mr. Ramesh Baral Mr. Neeraj Dhungana Mr. Nitesh Kumar Gupta Mr. Ashish Dhungana Mr. Amit Ratna Bajracharya Mr. Ashok Bikram Jairu Dr. Naresh Giri Maj. Navin Raut Mr. Pralahad Prasad Parajuli Mr. Krishna Prasad Bhattrai Mr. Surya Bhakta Prajapati Designation Chief Nurse Joint Secretaty Section Officer Under Secretary Section Officer Country Director Member Secretary Research Officer Director Health consultant Country Representative Manager Centre Manager Project Coordinator Centre Manager Administrator President Rehab Centre Manager Advisor President Brigadier General (surgeon) P&O Head P&O Head Advisor Executive Director Organisation Curative Division, MOHP MOWCSW Disability Section, MOWCSW MOYS PHC Revitaiization /DoHs NLR NHRC NHRC SIRC CTEVT TLMN Aanandaban Hospital CBRB Prerana Prerana NGMC NDF NDF NASPIR NASPIR SPK SPK HRDC NASPIR RCRD 26 X 27 X X 28 X X 29 X X 30 X X 31 X X 32 X X 33 X X 34 X X 35 X X 36 X 37 X 38 X X 39 X X 40 X X 41 X X 42 X X 43 X X 44 X X 45 X 46 X X 47 X X 48 X 49 X Ms. Goma Chetri Ms. Rita Gautam Mr. Prakash Wagle Mr. Jagadish Shrestha Mr. Bedraj Dhungana Mr. Mukunda Hari Dahal Mr. Kiran Shilpakar Ms. Rebika Rai Mr. Nishchal Shakya Mr. Pushpa Ratna Bajracharya Ms. Pragya Shrestha Ms. Sangay Amina Bomzan Ms. Chiara Retis Mr. Raju Palanchoke Ms. Sita Paudel Mr. Pushpak Newar Mr. Hari Prasad Khanal Mr. Ritesh Rajbhandari Ms. Dorothy Boggs Ms Sarah Blin Mr. Deepak Raj Subedi Ms. Reena Shakya Mr. Kirshna Duwal Nitra Basnet Education Section Senior program officer (CBR) Country Coordinator Head of Health Department Chief of Health department Secretary Chairperson Vice-President President President Head of Operation RTC RPM DPM(P&S) RTM P&SO RPA Knowledge Management-HI UK CD TSU Coordinator PME officer Driver Driver Save the Children Karuna Foundation CBM ICRC, Health Dpt. NFDN NFDN NAPD ANOT NEPTA POS-N USAID/Nepal Handicap International Nepal Handicap International Nepal Handicap International Nepal Handicap International Nepal Handicap International Nepal Handicap International Nepal Handicap International Nepal Handicap International-HQ Handicap International-HQ Handicap International Nepal Handicap International Nepal Handicap International Nepal HRDC 35 VIII. Appendix II Final list of sustainability indicators developed in 2014, by component Component 1: Health and Rehabilitation Outcomes (4 indicators) Sustainability Indicator Definition Assumptions Source of data 1) Number of wheelchairs, tricycles and mobility aids distributed per year The total number of wheelchairs, tricycles and mobility aids (including crutches and walking frames) distributed in one year All data from free wheelchair distribution outside of the rehabilitation centres will be reported to NASPIR MOWCSW/WCO/NASPIR Sustainability standard Sustainability Indicator Definition Assumptions Source of data Sustainability standard Sustainability Indicator Definition Assumptions Source of data 300000 this represents the estimated annual requirement 1% of the total population in Nepal -> 266178 (WHO 2011); proportional number of mobility aids estimated 2) Number of treatment sessions per year The total number of treatment sessions relating to rehabilitation in one year, including physiotherapy representing 8 10 sessions a day per physio Rehabilitation centres record and disseminate information to NASPIR; session include service provided by any level of professional (assistants/PT/Specialized PT) NASPIR and MOWCSW 250 days/year/physio – 750,000 sessions/year This represents the annual output of 3000 PTs (no of PT; 1 PT per 10,00 population, 10 session in a day) 3) Number of prosthetics and orthotics distributed per year The total number of prosthetics and orthotics, both locally produced and imported, distributed per year Rehabilitation centres record and disseminate information to NASPIR & POS Nepal NASPIR & POS Nepal 40,000 items: This represents the annual output of 200 P&Os (200/P&O/year); ISPO calculation 4) Number of disability related surgeries per year The total number of disability related surgeries in one year This includes surgeries related to disability performed in the surgical camps/hospitals MOHP/MOWCSW/NASPIR Sustainability standard Needs further research. Sustainability Indicator Definition Assumptions Source of data* Sustainability standard 36 Component 2: Health Services – Human Resources (9 indicators) Sustainability Indicator Definition Assumptions Source of data 1) Number of physiotherapists working in rehabilitation centres/(sub)regional and zonal and district hospitals Total number of physiotherapists working in rehabilitation centres/ hospitals providing rehab services Both NHPC registered CPT and BPT are considered to be physiotherapists Rehabilitation service providers Sustainability standard* Sustainability Indicator Definition Assumptions Source of data Sustainability standard 170 (40 in 20 centres/ + 24 in regional/sub regional /zonal hospitals + 6 backup + District) 2) Number of cat I P&O working in rehabilitation centres Total number of cat I P&O working in rehabilitation centres All P&Os will be NHPC registered Rehabilitation service providers 10 (one in each region, 2 in the central region, sustainability standard required to be calculation of P& O numbers as per ISPO/WHO standard) 3) Number of cat II P&O working in rehabilitation centres Total number of cat II P&O working in rehabilitation centres NHPC registered and non-registered to be included Rehabilitation service providers 60 ( 3 persons Cat II per centre; requirement of centre 20) 4) Number of bench workers Total number of bench workers working in rehabilitation centres; helping P&Os Each centre required 3 bench workers Rehabilitation service providers 60 (3 in each centre) 5) Number of occupational therapists working in rehabilitation centres Total number of occupational therapists working in rehabilitation centres NHPC registered staff only to be included Rehabilitation service providers 20 (1 per centre) 6) Number of physiotherapy assistants working in rehabilitation centres Total number of physiotherapy assistants working in rehabilitation centres NHPC registered staff only to be included Rehabilitation service providers 140 (80 in 20 centres/ + 48 in regional/sub regional /zonal hospitals + 12backup) 7) Number of counsellors/social advisor working in rehabilitation centres Sustainability Indicator Definition Assumptions Source of data Sustainability standard Sustainability Indicator Definition Assumptions Source of data Sustainability standard Sustainability Indicator Definition Assumptions* Source of data Sustainability standard Sustainability Indicator Definition Assumptions Source of data Sustainability standard Sustainability Indicator 37 Definition Assumptions Source of data Sustainability standard Sustainability Indicator Definition Assumptions Source of data Sustainability standard Sustainability Indicator Definition Assumptions Source of data Sustainability standard Centre-based counsellors providing referral services to other socio-economic and educational services; providing information on rights and benefits to persons with disabilities; disseminating information. S/he should be with at least 3 months basic trainings on PRT or counselling NHPC registered staff only to be included Rehabilitation service providers 20 (one each centre) 8) Number of medical officers working/liaising in rehabilitation centres Total number of medical officers working in/or liaising with rehabilitation centres Medical coverage from a linked institution also to be included Rehabilitation Service providers 40 (2 per centre) 9) Number of Rehab Community Workers in rehabilitation centres Total number of rehab community workers with at least 3 month PRT courses associated with rehabilitation centres and working in communities 5 RCWs required pers centre Rehabilitation Service providers 1300 (around 4000 VDCs are covered by 1300 CDW) Component 2: Health Services – Training and Capacity Building (1 indicator) Sustainability Indicator Definition Assumptions Source of data Sustainability standard 10) Number of rehabilitation centres that have CPE plan (PT, P&O, OT, Counselling, CBR and Medical) per year Total Number of rehabilitation centres have CPE plan (PT, P&O, OT, Counselling, CBR and Medical) per year Rehabilitation Service providers 20 Number of rehab centres in Nepal Component 3&4: Organisational Capacity and Viability (6 indicators) Sustainability Indicator Definition 1) Existence of national disability commission in Nepal / In line with NPPAD and CRPD, an Inclusive National Coordination Committee (INCC) for PRS is required Define Policy on disability preventions, identification and management it define the strategy for implementation 38 Assumptions Source of data Autonomous body having authority to direct government for resource mobilization Sustainability standard Sustainability Indicator Definition Assumptions Source of data Sustainability standard Sustainability Indicator Definition Assumptions Source of data Sustainability standard Sustainability Indicator Definition Assumptions Source of data Sustainability standard Sustainability Indicator Definition Assumptions Source of data Sustainability standard Sustainability Indicator Existence of the a Commission INCC 2) % of District Inclusion Disability Rehabilitation Committee (DDRC) on disability maintain database on PRS DIDRC collects, classify, disseminate information and manage disability in the district District level disability information are easily accessed through central database system MOWCSW and MOHP 75 districts, existence and well-functioning 3) % of rehab centres that receive at least 80% of funding from the Government annually Amount of funding received from government compare to the total budget of the annual centres Increase capacity, continuity of the service Budget of centres/financial report/other contributors / and MOF 80% 4) % of FCHVs + HWs trained on disability No. of FCHV + HWs trained on disability All existing and newly recruited FCHVs + HWs are trained in the identification of disability and appropriate onwards referral MOHP 100% 5) Existence of central database system on rehabilitation Statistics of every centres is available at the central level Access to date can help make strategic decision for the sector Ministry of MWCSW + MOHP Yes 6) No of government hospitals up to District level or hospital above 50* beds with orthopaedic surgeons, operate or develop linkage with existing rehab centres for services Hospitals providing prevention of the disability and rehabilitation services within the health care system Disability rehabilitation becomes as part of health care system MOHP and rehab centres 75 Definition Assumptions Source of data Sustainability standard Component 5: Community Capacity (2 indicators) Sustainability Indicator 1) % of districts with Village Disability rehabilitation Committee (VDRC)* / VDC / Municipality level committee in Disability 39 Definition Assumptions Source of data Promotion of rights, support in cross referral mechanism Data is collected and disseminated by the MOWCSW MOWCSW Sustainability standard Sustainability Indicator Definition Assumptions Source of data Sustainability standard 100% 2) % of Disabled People Organizations (DPOs) that have action plans % of total number of DPOs affiliated with National Association of Physical Disabled (NAPD)-Nepal Action plans relate to the DPO work including rehab service provision NFDN + NAPD 100% Component 6: Enabling Environment (8 indicators) Sustainability Indicator Definition Assumptions Source of data 1) Existence of a national action plan on rehabilitation National plan as outlined in the NPPAD, in compliance with CRPD and WHO guidelines The national plan will be formulated and implemented by the central co-ordinating committee Coordinating Committee Sustainability standard Sustainability Indicator Formation of a coordinating committee Existence of the plan 2) National guidelines and standards regarding rehabilitation services are elaborated Definition Assumptions Source of data Sustainability standard Sustainability Indicator Definition Assumptions Source of data Sustainability standard Sustainability Indicator Definition Assumptions Source of data There are existing guidelines and standards regarding rehabilitation services NASPIR Guidelines and standards available from NASPIR; recognized by GoN 3) Number of meetings organised by the sub commission on rehabilitation Subcommittee as recommended by UNCRPD Consensus between Ministries on the lead ministry the sub-commission 4 per year 4) Recognition and certification of P&O and OT (to be checked) by NHPC Data is held and disseminated by the NHPC NHPC 40 Sustainability standard Sustainability Indicator Definition Assumptions Source of data Sustainability standard Sustainability Indicator Definition Assumptions Source of data Sustainability standard Sustainability Indicator Definition Assumptions Source of data Sustainability standard Sustainability Indicator Definition Assumptions Source of data Sustainability standard Certification available 5) Code of Ethics for rehab professionals including licensing (Counselors/OT/P&O/PT/SLP) Code of ethics including job description for different level of professionals Govt recognizes the above mentioned professions and their levels NHPC Approved code of ethics available for individual profession; currently available only for the PTs 6) A Rehab council for professional (Counselors/OT/P&O/PT/SLP) A council representing rehabilitation professionals governing their work in Nepal MoHP A structure under the organogram of MoHP; currently none, professional associations exists but not recognized by GoN 7) Number of districts that have an action plan on disability Data is held and disseminated by the MOWCSW MOWCSW 75 8) % of annual budget of local development committees allocated to disability Data is held and disseminated by the MOLD/MoE/MOWCSW MOLD/MOE/MOWCSW 10%, The existing % of VDC budget for disability sector is around 3.5%. The sustainability standard was previously perceived as 7% 41 IX. Appendix III ? Data collection and measurement activities to be discussed by the committee *Key points to be discussed and verified with the committee: Component 1, #2, Source of data: Notes from the discussion had the MOWCSW as well as NASPIR so the Ministry was added to the source of data. To be confirmed with the committee. Component 2, #1, Sustainability standard: Committee to confirm how this number is calculated. Note from workshop regarding District measurement is that 92 are working in RC and remaining will plan to be recruit in Govt. hospital. Component 2, #5, Sustainability assumption: Committee to verify notes that it is assumed that for NGOs Rehab Centre required 5, possibility to recruit other hospital based rehabilitation centres. Component 2, #6, Sustainability 2014 measurement: Committee to verify 2014 measurement. Measurement is listed as 35, but previous 2012 measurement was 28 + 8 new PTAs were noted in SAP III workshop (see Table 4) which would total 36. Component 3&4, #6, Title and sustainability standard: 2012 indicator ‘No of government hospitals up to Zonal level or hospital above 50 beds with orthopaedic surgeons, operate or develop linkage with existing rehab centres for services’ had note to devolve this to district hospitals, specifically by the number 50. Committee to verify new 2014 indicator title and sustainability standard. Component 5, #1, Title: Village Disability rehabilitation committee with note ‘Committee rehabilitation committee.’ Indicator title needs to be verified with committee. Component 5, #2, 2014 measurement: Measurement from 2012 however it was mentioned in notes that all DPOs have action plans now. Committee to verify measurement and update as needed. It is anticipated that the committee will discuss data collection and measurement activities with the MOWCSW and MOHP in order to verify and/or provide accurate measurements for sustainability indicators. 42