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