Nepal – the country of the Buddha and the Mt. Everest

Peace comes from within. Do not seek it without – Buddha


Posted by Ram Kumar Shrestha on August 15, 2011

By Prabha Shrestha

1.         BACKGROUND

 Cases of HIV (Human Immunodeficiency Virus) are growing rapidly in the world. According to the UNAIDS report in December 1998, 33.4 million people were HIV positive with eleven people infected every minute (JICA brochure).

 HIV/AIDS is recognized as an emerging public health problem in Nepal too.  NCASC (National Control for AIDS and STD Centre) reported 842 cases of AIDS and 3,600 HIV infections as of November 2004.  However, this data could be the tip of the iceberg due to a lack of surveillance data. UNAIDS/WHO estimated approximately 60,018 people in Nepal are living with HIV/AIDS with 2,958 AIDS related deaths in 2002.  It is possible that most of the people (60,018) living with HIV/AIDS do not know they are infected and many of them maybe engaging in unsafe sexual practices.  It is considered that there is a low disease prevalence in the general population, with a higher prevalence in various sub sets of population such as 68% in IDUs (Intravenous Drug Users) approximately 17% in Sex Workers and 4% in Sexually Transmitted Infection (STI) cases (NCASC/MOH, 2003).  The consequence of inaction is that AIDS could become the leading cause of death in Nepal over coming years with a serious impact on poverty and vulnerability of the population.  Besides the negative impact on socio economic development through loss of productivity, the burden of diseases would put further stress on the health sector.

STI form a significant component of the AIDS/HIV epidemic in Nepal. Unsafe sexual behaviour contributes to a large number of HIV infections.  It is estimated that 200,000 cases of STI’s occurs annually and its prevalence in women is about 5%.  STI cases among sex workers are considerably high.  Syphilis prevalence among Sex Workers (SW) is reported to be 19% in Terai and Kathmandu with a rate of 14% in Pokhara. Similarly, syphilis prevalence is about 5% in the clients of SW (NCASC/MOH, 2004). The provision of early, correct diagnosis and effective STI treatment can not only prevent serious complications but also decrease the chance of HIV spread.  However, it is not easy to access services that provide early diagnosis and treatment in a resource poor country such as Nepal.

In order to address the above situation, HMG/Nepal adopted a National Policy for AIDS prevention with 12 key policy statements in 1995.  HIV/AIDS and STI prevention program is one of the 12 policy statements.  This policy guided NCASC to form the “National AIDS Coordination Committee” and “National AIDS Council” with participation from the government, non-government, private sector and civil society. This helps to operationalise the national policy and advocate for multisectoral participation in the fight against HIV/AIDS.  The government is committed to deliver the STI control program with the support of the External Development Partners (EDPs).

Despite the commitment of the government and support of EDPs to ensuring a STI case management program, it is still a major challenge faced by the health sector because the government lacks resources and essential drugs (MOH, 2004) even to manage primary health services.   Therefore, it is quite difficult to expect the provision of STI drugs and blood testing kits limited by the stringent financial resources of the government.

To overcome the situation, NCASC explored the availability of STI drugs and equipment from donors.  The JICA “Equipment Supply Program for AIDS Control and Blood Test” program (later on this will be replaced by “program”) is one such valuable program that has assisted HMG in the control of STI and prevention of HIV/AIDS. JICA supported the STI drugs, equipments and HIV test kits to NCASC (recipient country, consignee)/Department of Health Services (DOHS), Ministry of Health (MOH).  During the participatory needs assessment of STI drugs, NCASC and FHI Nepal agreed to utilize part of STI drugs among partner NGOs which are primarily working in the area of STI care and treatment in the communities. This understanding was made with the intention of contributing to meet the objectives of Ministry of Health in prevention and control of STIs including HIV/AIDS.

Under this supply program, JICA works together with UNICEF (United Nations Children’s Fund) to supply the necessary commodities and equipments to recipient countries.  According to the agreement between JICA headquarters and UNICEF headquarters, UNICEF procures the drugs, equipments and HIV testing kits from different parts of the world.  This sort of program was the first in Nepal when it happened in 2003. Thus, in this evaluation NCASC and UNICEF are identified as the primary stakeholders of JICA and other key informants the secondary stakeholders.

This is the evaluation of the program that is commissioned by JICA to assess the effectiveness and efficiency of the program.  Similar evaluations have been carried out in other countries.

2.         OBJECTIVES

The following were the main objectives of this evaluation:

  • To assess the efficiency and effectiveness of the program
  • To propose possible new procedures or solutions to improve the efficiency and the effectiveness of the program.
  • To provide evidence or collect requests from the concerning parties for JICA on the plan for further cooperation for the program in the FY 2005.

 3.         SCOPES

As per JICA guidelines, the scope of this evaluation was as follows:

  • General issues in JICA health program.
  • Procedure of official request by the recipient country
  • Procurement work under the medical equipment supply
  • Delivery and distribution of the program
  • Reporting of the program
  • Monitoring and evaluating of the program

 4.         METHODOLOGY

 This was a qualitative, process evaluation, with a descriptive design, as this design is comparatively simple and quick to collect data.  The main source of information was primary data with some secondary sources of information complementing the primary data.  Secondary data consisted of gathering and analyzing policy, program documents, reports, letters and proposals that also generated ideas for interaction during interviews with relevant persons.  JICA developed questionnaires were used for guiding the interview with NCASC and multilateral cooperation.

This evaluation process was divided into three phases.  Firstly, several meetings were held with JICA in order to finalize the evaluation design and brief out on the program. Then all the HMG policy and program documents were collected and reviewed.

 Secondly, data was collected through face-to-face interviews and interaction with the primary and secondary stakeholders respectively at national and district levels.  Field trip was done to two districts (Makawanpur and Banke) to undertake district interviews and observe the clinics at the FHI/Nepal project areas.  Finally, report was prepared based on the format provided by JICA.

 5.         LIMITATIONS

There are few limitations with this evaluation output:

  • Lack of users’ perspective to triangulate the information collected from the providers.
  • Due to the lack of participation of the primary stakeholders in the entire process of the evaluation, it is difficult to prepare specific future plan for the program.

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