The challenge of people with disabilities in Nepal is complex: Persons with a disability in Nepal are stigmatised, considered a burden for the family and society and often hidden in houses. Politically the topic of disability is on the agenda, a legal framework exists, but implementation of rehabilitation programs is characterised by few fragmented practices around the country. The provision of ‘disability identity cards’ has assured the right to healthcare and social security allowances in Nepal, but an estimated 60% of persons with a disability are deprived of benefits as they are unaware/not capable to get this card.
To prevent disabilities and early death, concerted efforts have been made to improve maternal and child health over the past decade in Nepal. However, figures on neonatal deaths, rates of disability at birth and stunted growth remain high. Major reasons are insufficient quality of health care, important gaps in existing programs, compounded by poor access to good care especially in remote rural areas.
In the past 12 years Karuna Foundation has developed a new model for community based healthcare in a pilot district in a remote area of east Nepal that addresses the root causes of above-described challenges encourage collaboration between different levels of government, and other organisations and provides a platform for co-funding.
In 2019 the program has been transformed in a formal government program (Disability Prevention and Rehabilitation Program (DPRP). A Public Private Partnership between Provincial government, municipalities and Karuna Foundation Nepal provides for cost sharing mechanism between provincial government, municipalities and Karuna Foundation. Special guidelines for implementation have been developed and a steering committee at provincial level has been formed. More specifically over the past 12 years the Karuna Foundation followed the following practices:
- In system diagnosis: research and appraisal by team of experts; developing the program in pilot villages; action learning with all stakeholders, adaptive management; external evaluations and adaptation of the program; research on evidence-based interventions; interactive policy development with local government and stakeholders; “system thinking” to diagnose the social dynamics among all stakeholders
- On strategy design: the Karuna Foundation worked together with the local government in municipalities from the start. The scaling principles include for example: show good and tangible results creating visible changes; develop a cost-effective program, affordable for the local government; development of Theory of Change (logical framework) to make sure all inputs and outputs lead to desired outcomes and impact; the announced exit of Karuna in each municipality after 3 years of funding from the start and hence the management of expectations of the government to continue the program at their own costs afterwards; lobby with and support to the government to let them take ownership of the program; involvement of crucial stakeholders in the program
- On Adaptive Management, Learning and Evaluation: Karuna Foundation is a learning organisation applying adaptive management via regular M&E reports and review meetings on lessons learnt and sharing output and achievements with all stakeholders. An impact study has been assigned to an independent research institute (KIT Royal Tropical Institute Amsterdam). They will implement a quasi-experimental mixed methods evaluation which allows for triangulation between its three key components: a quantitative epidemiological study, a qualitative study and a costing. It consists of a baseline, midterm and end line study. The midterm study will show the room for further improvement of the program.
- On collaboration: Our principles of building alliances are based on the principles of building a good name as reliable partner and strong collaboration with the Government at federal, provincial and local level. Also, networking and offering opportunities to other NGO’s (win wins); giving them access to local communities and the government strengthen the health care system; KarunaNL Foundation in the Netherlands has brought a group of funders together, who committed themselves to the implementation of the first half of the province for a total of €7 million over a period of 5 years. One reporting format is used for all funders and regular meetings with all partners involved are held.
- Leadership: characterised by strongly developed values in the organisation; culture of learning (review meetings, PDP,.) and trust; complementarity and co-leadership director; well defined structure and systems in place (HR, Financial Management).
All 10 municipalities in the pilot district of Ilam have continued the implementation of the program at their own costs starting July 15th, 2021.
Insights / Advice to Peers
Major reasons for our achievements and positive results so far include: the agility of the team in Nepal to keep the program running even in times of lock down; strong leadership of the directors in Nepal; good collaboration with the government; the assigned priority to the program by the government, (100% funding the program despite 25% cuts in budgets); strong network of collaborating partners. Some of our major challenges are described below:
- As the COVID lockdowns slowed down our progress in implementation, the first tangible results were only seen this summer. We decided to slow down the pace of scaling.
- Collaboration with the public partners compromises on the flexibility in implementation (following their fiscal years, reporting schedule and political interests).
- Support to the local government in managing the program.
- Keep funders committed in times of Covid.
Three pieces of advice:
- Fully delegate strategy and implementation of your program to a strong local team who lobby and collaborate with the government.
- Organise a group of committed funders around a shared objective for multiple years
- Implement evidence-based interventions and organise rigorous impact study by an external party.
Dr. Annet van den Hoek, Director, Karuna Foundation NL