There are 15 districts in the mid-west development region of Nepal. The regional headquarters is Birendranagar in Surkhet district. However, most of the regional activities are carried out at the Nepalgunj, which is also the regional trade hub for the region. In the whole region, an ENT consultant is deputed at the Bheri Zonal Hospital by the government since last 14 years. He also serves the far-west development region as well. The past 14 year's records of the ENT department of Bheri Zonal Hospital shows that around 60% [2] of the total cases visited the department were seeking ear services. Of them 36.32% were of 0-15 year's age group. Out of total ear cases 36% had COM (Chronic Otitis Media); which is the number one ear disease causing deafness in developing countries.

Since last 5 years the Nepalgunj Medical College is service patients for ENT care at their teaching hospital in Kohalpur. Now the hospital is also one of the referral centres for the far-mid west development regions.

The most regular and very popular ear health service provided in this area is surgical Ear Camps conducted by BRINOS. This programme was started from 1996 at Fateh-Bal Eye Hospital with an initiation and coordination of Swiss Red Cross. Later this collaboration was shifted with Nepalgunj Medical College, Swiss/Nepal Red Cross Society and Bheri Zonal hospital, as the new medical college developed provisions of ENT doctors and physical facilities at their teaching hospital in Kohalpur (Banke). Although this is an extremely popular and fortunate provision for the people of this area, it serves people only for a few days in a year.

However, those people residing in remote areas, having little money and no access of even the most basic services cannot even dream of this sort of services. Therefore, the only way to reach the unreached, poor and needy people could be through the community ear care strategy, which promotes community members to take actions themselves. This approach/concept has been fully agreed by the all collaborators involved in this programme and its implementation continues since year 2000.

CEHP (earlier known as PBL-CHIP [3] ) is a programme of Nepal Red Cross Society (NRCS) implemented with the support of Swiss Red Cross. CEHP coordinates supports and facilitates for the implementation of development activities through the Red Cross district chapters, the Red Cross volunteer networks and CBOs in the Mid West Development Region. CEHP possess public health professionals who provides necessary input and support to the other members of the programme team and district chapters to ensure proper implementation of community programmes. The main financial and technical contribution comes to the programme from the Swiss Red Cross.

The community ear care programme falls within the health promotion component of the CEHP programme, which is mainly supported by the BRINOS (Britain Nepal Otology Services) - UK. The other collaborators to CEHP for community ear care programme are Nepalgunj Medical College and Bheri Zonal Hospital.

CEHP envisions improving the health status of the most vulnerable and disadvantaged people of the Mid West Development Region.

Guided by fundamental principles of Red Cross, CEHP is committed to improve health status of the vulnerable and disadvantaged people of Mid West Development Region by mobilizing and capacity building of volunteers, NRC network and CBOs and collaborating with GOs/NGOs for prevention of blindness and health promotion.

1. To reduce prevalence of avoidable blindness with preventative and curative eye care provisions.

2. To improve the health status of the people through dissemination of primary health care messages.

4. To increase awareness among youth about transmission and prevention of HIV/AIDS.

5. To strengthen NRCS network to address emerging health needs of the local communities and to empower them for achieving greater sustainability of programs.

These are the general objectives of the programme, which is covered by the number 2 objective.

Specific Objectives of Community Ear Care Programme

· To introduce into the community the knowledge that prevention is better then cure – many of the ear diseases are preventable or curable.

· To utilise the existing community resources using their interest and resources by transferring skill and knowledge to promote sustainable improved ear health.

· To promote concept of Community Ear Assistant, and develop them as primary ear care trainer/clinician to bring the ear care services to the unreached.

· To provide basic services on hearing rehabilitation.

Primary Ear Care Activities

Hearing impairment inhibits proper mental development and academic performances of the children. Thus, the programme focuses its input to young children as they are the major risk groups, especially below 10 years of age. The activities under community ear care are basically aimed to promote self-care and awareness on importance of good hearing, and the measures to prevent and control deafness utilising local resources and the prevailing health services network. The key actors in the ear care programme are Community Ear Assistants (CEA) and the Ear Care Volunteers developed by the programme.

Major activities

· Primary ear care training to the volunteers (FCHVs and others)

· Primary ear care training to the health post staffs

· Primary ear care camps (mobile camps)

· School health activities (training and ear health screening)

· Ear health education and referral activities

· Hearing rehabilitation (assessment and hearing aid support)

· IEC (information, education, communication) dissemination

· Coordination and collaboration

Collaborators for Community Ear Care

CEHP is implementing the community ear care programme with the support of following collaborators:

Britain Nepal Otology Services (BRINOS)

BRINOS is a UK-based charity organisation solely devoted to provide services to the Nepalese people in the area of deafness control. This institution comprises board of directors from UK and Nepal. The main authority of the organisation is Mr. Neil Weir, renowned ENT surgeon in UK. BRINOS started their cooperation and services in the mid-west since 1996 with ear surgery camp.

Nepalgunj Medical College (NGMC)

This is the only medical college in the mid-west development region. Since last 6 years, the college hospital provides clinical service on ear care. The college also provides support to the NRCS Bardia to manage the community programme by bearing salary of a CEA. The main authority of the college is Dr. Suresh Kumar Kanodia, Managing Director. The college has its teaching hospital at Kohalpur, which is the base for the BRINOS supported ear surgery camps and referral centre for the patients with ear diseases.

Bheri Zonal Hospital (BZH)

BZH provides its active technical support through its ENT consultant, Dr. Ramesh Kumar Shrestha, who used to be the only doctor in the far and mid west regions for several years. The ENT department is the referral base for the patients referred from the regions. The department is fully equipped with necessary instruments and equipments for the ENT services.

Programme area and coverage

The community ear care programme was started in year 2000 from the Banke district. Now it has been expanded to total of 4 districts of Bheri zone. The additional districts are Bardia, Surkhet and Dailekh. Coverage of the VDCs is following:

VDCs in Banke district		VDCs in Bardia district
1. Naubasta	2. Kusum	1. Dhadhawar	2. Suryapatwa
3. Titihiriya	4. Kachanapur	3. Magragadi	4. Khairichandan
5. Rajhena	6. Mahadevpuri	5. Padanaha	6. Patabhar
7. Samsergunj	8. Kamdi	7. Baniyabhar	8. Daulatpur
9. Bankatwa	10. Basudevpur	9. Bagnaha	10. Naiyagaun
11. Kohalpur	12. Sitapur	11. Dhodari	12. Pashupatinagar
13. Chisapani	14. Udhrapur	13. Sanosri	14. Badalpur
15. Ganapur	16. Bagesowari	15. Taratal	16. Rajapur
17. Manikapur	18. Khajurakhurd	17. Gola	18. Bhimmapur
19. Belhari	20. Indrapur	19. Manau	20. Thakurdwara
20 VDCs in Banke 32 VDCs in Bardia (whole district)		21. Manpurtapara	22. Shivapur
		23. Sorahwa	24. Kalika
		25. Naulapur	26. Gulahariya
		27. Mainapokhar	28. Mohammadpur
		29. Jamuni	30. Deudakala
		31. Motipur	32. Belawa

VDCs in Surkhet district	VDCs in Dailekh district
1. Latikoili	1. Gamaudi
2. Uttarganga	2. Badakhola
3. Chhinchu	3. Kalbhairab
4. Jarbuta	4. Belpata
5. Gadhi	5. Dandaprajul
	6. Narayan municipality (some wards)

Community Ear Care activities in Banke district

The programme in Banke district is supported mainly by the BRINOS. The programme covers total of 20 VDCs, with recent expansion in 5 VDCs. The new VDCs are Sitapur, Udhrapur, Bagesowari, Khajurakhurd and Indrapur.

CEHP organised a programme introductory meeting in the newly expanded area with the participation from NGMC, BZH, Red Cross Banke chapter, district public health office, education office, DDC, HP in charge of new 5 VDC, Red Cross volunteers and related organization. The Coordinator of steering committee of CEHP, Dr. Ramesh Kumar Shrestha, Mr. Kamal Baral and CEAs described the programme objective, service delivery model and activities of the community ear care programme. The health post in charge of new 5 VDCs were very much impressed from it, and they expressed their commitment to provide full support for the programme to be started in their VDCs.

During this period, CEHP carried out a series of primary ear care camps in 35 locations in Banke district collaborating with VDC, Health Posts, schools and local Red Cross units. Total of 2,766 (1,120 with COM) patients were screened and 293 patients were referred to Bheri Zone Hospitals and Nepalgunj Medical College Teaching Hospital for medical and surgical interventions.

The CEAs carried out refresher training on primary ear care for 66 volunteers from 5 VDCs -Kamdi, Basudevpur, Mahadevpuri, Kachanapur and Kusum to update their skills and knowledge to identify the COM, provide primary care, educate and refer the patients to the appropriate health care centres.

The CEAs also carried out basic primary ear car training for 80 volunteers of the 5 new VDCs to give them skills and knowledge to identify the COM, provide primary care, educate and refer the patients to the appropriate health care centres.

Basic primary ear care training was provided to primary level teacher in Banke. Following the training the CEAs visited 12 schools and examined 4,011 students. Out of them 1,078 had Wax, 254 COM, and 94 had OME. 305 students were referred to hospitals in Nepalgunj.

The ear care volunteers carried out community ear health education sessions in 16 locations for total of 386 community people, with the support of CEAs.

Community Ear Care activities in Bardia district

The community ear care activities in Bardia district is implemented by Bardia Red Cross with the support of Nepalgunj Medical College (NGMC) for 32 VDCs in the district, and the equipments, IEC materials and logistics are supported by the BRINOS and CEHP.

During this period, Bardia Red Cross carried out 7 primary ear care camps and screened 1,033 cases (461 COM). 92 cases were referred to the hospitals for further management.

Mr. Dipak BC, CEA carried out primary ear care orientation in 5 VDCs for 85 ear care volunteers, 47 Red Cross volunteers and 33 students of Junior Red Cross Circles. The CEAs also carried out primary ear care training for 35 teacher sponsor in Bardia district collaborating with district education office.

Mr. Dipak BC supported ear screening of the patients in a health camp at Jumla organised by Ministry of Health. Total of 1,178 ear patients examined in that camp and 92 patients referred to NGMC for further management and ear surgery.

NRCS Bardia operates a weekly ear clinic at Gularia town at primary eye care centre on every Sunday. During this period total of 455 (157 COM) ear patients were treated and 64 were referred to the hospital in Nepalgunj for further management.

Community Ear Care activities in Surkhet district

The community ear care activities in Surkhet district is implemented by Surkhet Red Cross with the support of BRINOS in 5 VDCs of the district. It was started from July 2003.

A series of primary ear care camps in 14 locations were carried out and total of 1,016 patients (458 COM) were examined. 39 patients required further management were referred to the hospitals in Nepalgunj.

The CEAs also carried out primary ear care training for 17 primary grade school teachers collaborating with district education office. They also visited 12 schools and screened 2,007 students. Out of them 551 had Wax, 139 COM, and 45 had OME and 7 students were referred to hospitals in Nepalgunj for further management.

With the help of CEA, the ear care volunteers carried out community ear health education session in 33 locations for 1,050 community people.

NRCS Surkhet also operates a weekly ear clinic at Birendranagar town on every Sunday. During this period total of 180 (79 COM) ear patients were treated and 14 were referred to the hospital for further management.

Community Ear Care activities in Dailekh district

The community ear care activities in Dailekh district is implemented by Dailekh Red Cross with the support of BRINOS. It was started from July 2004.

A series of primary ear care camps were conducted in 12 locations in Dailekh and total of 1,163 (448 COM) ear patients were examined. 532 required further management were referred to Dailekh district hospital and hospitals in Nepalgunj.

The CEA carried out basic primary ear training for 63 volunteers to give their skills and knowledge for identify the COM, provide primary care, educate and refer the patients to the appropriate service centres.

The CEAs also carried out primary ear care training for 20 teacher of primary level of programme collaborating with district education office. 20 schools were also visited and 4,299 students were screened for ear disease. Out of them 1,250 had Wax, 1,076 COM, and 230 had OME. 839 students were referred to Dailekh district hospital and hospitals in Nepalgunj for further management.

With the help of CEA, the ear care volunteers carried out community ear health education session in 38 locations in the VDC for 937 community people.

NRCS Dailekh also operates a weekly ear clinic at Nayabazar town on every Sunday at primary eye care centre. During this period total of 400 (282 COM) ear patients were treated and 218 were referred to Dailekh district hospital and hospitals in Nepalgunj for further management.

Hearing rehabilitation

This has become one of the important activities of the programme. CEHP has got most of the basic provisions to support rehabilitation of hearing impairment. Basic equipment for assessment is provided by BRINOS and Cubex. Regular supplies of hearing aids have been received since year 2002 from Mr. Adam Shulberg, who is the head of Cubex-UK. Mr. Adam is the expert audiologist and has trained the CEHP team members for hearing assessment, rehabilitation, hearing aid fitting, repairing, etc.

CEHP organises hearing assessment and support activity 2 days a month (i.e. 10^th and 25^th day of each month as per Nepali calendar). During these days the patients referred from the field come to CEHP for hearing assessment, and as per requirement patients are provided hearing aid in subsidised cost. A hearing aid with 12 extra batteries cost only Rs. 550, if the patient is referred by a volunteers or CEA from the programme VDCs. If a patient is from out of programme VDCs they are charged Rs. 1,050.

During hearing assessment days, the patients revisit also get services on repairing of the hearing aids and supply of additional batteries with nominal cost, i.e. Rs. 50 for 12 numbers of batteries. Irreparable hearing aids replaced with small charges, i.e. Rs. 100.

During this period 112 patients were served; 44 with new hearing aids, 23 got replacement of hearing aids; 6 got their hearing aids repaired and 38 patients received new batteries.

Ear Surgery Camp

BRINOS provides technical support to Nepalgunj Medical College to conduct ear surgery camps 2 times (March and November) a year. These camps are held at teaching hospital of Nepalgunj Medical Collage at Kohalpur. The surgical camps mainly aimed serving the patients identified and referred by the ear care volunteers from the programme area in 4 districts stated above.

The camp held in March 2005 provided services for 485 patients as out patients; out of them 66 had major and 2 had minor surgeries. Around 90% of the patients operated at the camps were referred by the CEAs and volunteers from the programme areas.

IEC (information, education and communication) dissemination

The IEC material produced by the CEHP has become very popular. At the moment the programme has got following IEC materials on ear health:

· Poster on “Primary ear care education to prevent COM”

· Poster on “Early signs/symptoms of hearing impairment in children”

· Booklet on "Primary ear-care" (targeted for volunteers)

· Booklet on "ENT manual for paramedical"

· Brochure on "Prevention of COM"

Development of a Flip Chart for community health workers like – FCHVs, Red Cross and other volunteers is going on. This will soon be finalised and produced with the support of Cubex, UK.

During this period, 465 number of primary ear care (yellow) books, 474 number of posters about COM, 474 number of posters about early sign/symptom of hearing in children and 3,810 number of brochures about prevention of COM were supplied mainly to the ear care volunteers, teachers and health personnel. 107 ENT books for paramedics were also provided to the health post staffs.

Coordination and Sustainability

Coordination is vital part for sustainability of the programme. In principle, CEHP supports/implements community ear care activities in a particular VDC for 2 years, and transfers the responsibility to the Health posts in order to sustain the programme. This year, 5 more VDC – i.e. Kohalpur, Ganapur, Manikapur, Belhari and Chisapani were phased out transferring the responsibilities to the HPs. Prior to this process CEHP imparted necessary knowledge and skills to the health post staffs to ensure continuation of primary care and referral services to the patients attending the HPs. Skill development of HP staffs was done with the support of ENT department of Bheri Zonal Hospital.

The handover workshops were carried out in the said VDCs with the participation of FCHVs, HP staffs and staffs from the District Public Health Office (DPHO). 76 ear volunteers participated in the workshop. During the workshop low cost very basic ear care equipment – i.e. Otoscope, head mirror, jobson horn probe, aural forceps and tuning forks were also provided to the health post staffs of the 5 VDCs through DPHO. The volunteers and health post staffs attended the workshop requested to continue primary ear care camps in a regular basis for a certain period in the phased out VDCs, though direct support from CEHP is phased out; so that the clinical skills of the health post staffs remains updated.

Considering sustainability aspects of the programme, the chapter in Bardia, Surkhet and Dailekh are supported only with nominal external support. A significant part of the programme is organised at the local level by the chapter. This has been successfully demonstrated by the Bardia chapter mobilising various institutions at the local level and also expanding its coverage in the district. Similar success is expected in the other programme districts as well.

Human Resource Development

Human resource development is an important part of the programme as skilled and trained human resources enhances possibilities to reach more and more unserved locations. This is also a main part of program's sustainability. Thus, the programme provided basic ear care training to HP in charge and medicine seller in collaboration with Bheri Zonal Hospital. Dr. Ramesh Shrestha and the CEAs from CEHP facilitated them.

During this period, 10 health post in-charge from Banke and 1 from Jumla received ear care training at Nepalgunj. 3 CEAs from Banke, 1 from Bardia and 1 from Dailekh also received refresher training on ear care at Bheri Zonal hospital from Dr. Ramesh Shrestha.

Mr. Adam Shulberg, audiologist from UK has recommended start of developing ear moulds at CEHP. This provision is to ensure quality hearing to the people/patients using hearing aid. Thus a community ear assistant from CEHP will soon be sent to Kathmandu for training in the guidance of Dr. Kanshi Raj Gyawali, an ENT consultant. The dates for the training was planned for June 2005, but shifted for August because of unavoidable mission of trainers in Kathmandu.

Challenges and Constraints

The conflict situation in the country has provided big obstacle for the operation for all sorts of development activities. Despite of such situation, the community ear care programme has been going on in all programme districts. In some instances the staff had to face unnecessary difficulties and interrogations from conflicting parties. The community people take this programme very positively and provide their very good cooperation.

In the present context, the local development bodies are also inactive or not in presence because of security reason. This has led to a threat to the sustenance of the programme. Even in the presence of obvious benefit from the programme, at present, the health related NGOs and government institutions have put further low priority to the deafness control programme. In such context, it has given greater challenge for NRCS for its expansion and sustainability.

Administration

Dr. Neil Weir – the Director from BRINOS, Mr. Adam Shulberg, head of the Cubex-U.K, Mr. Joseph, Ms. Sue Astly and Mr. Richard visited the CEHP office while they were for an ear surgery camp. They visited the ear care unit and got detailed information on community ear care programme. They have provided valuable suggestions for the improvement of provisions on hearing aid support. Need for further development of IEC materials was discussed and Mr. Adam Shulberg provided his assurance to generate UKL 500 for CEHP to develop ear health education Flip-Chart to be used by the volunteers.

Report compiled by:

Kamal Baral

Programme Manager

NRCS CEHP, Nepalgunj

With the support of:

Mr. Puran Tharu

Community Ear Assistant Supervisor

NRCS CEHP, Nepalgunj

Mailing Address:

Sadarline Road, near post-office

Nepalgunj 12, NEPAL

Tel +977 81 520255

Fax +977 81 520589

Email: nrcscehp@ntc.net.np

Annex-1: CEAs in the programme

Name	Institution
1. Mr. Dipak B.C.	CEA Nepal Red Cross Society, Bardia
2. Mr. Ganga Bahadur Gyawali	CEA Nepal Red Cross Society, Surkhet
3. Mr. Indra K.C.	CEA Nepal Red Cross Society, Dailekh
4. Mr. Suraj Chaudhary	CEA Nepal Red Cross Society, CEHP, Nepalgunj
5. Mr. Ram Bahadur Bohara	CEA Nepal Red Cross Society, CEHP, Nepalgunj
6. Mr. Puran Tharu	CEAS Nepal Red Cross Society, CEHP, Nepalgunj

Annex-2: Community Ear Care Volunteers

District	Total VDC	No. of volunteers	Remarks
Banke	20	328	Started in 2000
Bardia	32	235	Started in 2002
Surkhet	5	64	Started in 2003
Dailekh	5	63	Started in 2004
Total	62	690

Annex-3: Equipments and instruments related to ear care programme

CEHP, Nepalgunj

a. The following equipments/instruments are donated by BRINOS.

SN	Particular	Quantity	Purpose
1.	Field audiometer	3	To carry out audiometry in the field
2.	Head mirror	1	Light reflector
3.	Jobson probe	1	Ear cleaning
4.	Otoscope	3	To examine ear drum
5.	Suction machine	3	Cleaning pus, wax, etc. from the ear
6.	Tuning fork	3	To assess hearing loss
7.	Aural forceps	3	For removing foreign body

b) The following equipments/instruments are donated by Cubex to CEHP.

SN	Particular	Quantity	Purpose
1.	Audiometer (desktop)	1	To carry out audiometry in the clinic
2.	Battery (zinc)	714	For hearing aids
3.	Hearing aid analyser	1	To calibrate/set hearing aid
4.	Hearing aids	111	Devices to improve hearing

Nepal Red Cross Society, Bardia (donated by BRINOS)

SN	Particular	Quantity	Purpose
1.	Aural forceps	1	For removing foreign body
2.	Field audiometer	1	To carry out audiometry in the field
3.	Head mirror	1	Light reflector
4.	Jobson probe	1	Ear cleaning
5.	Otoscope	1	To examine ear drum
6.	Suction machine	1	Cleaning pus, wax, etc. from the ear
7.	Tuning fork	1	To assess hearing loss

Nepal Red Cross Society, Surkhet (donated by BRINOS)

SN	Particular		Quantity	Purpose
1.		Aural forceps	1	For removing foreign body
2.	Field audiometer		1	To carry out audiometry in the field
3.	Head mirror		1	Light reflector
4.	Jobson probe		1	Ear cleaning
5.	Otoscope		1	To examine ear drum
6.	Suction machine		1	Cleaning pus, wax, etc. from the ear
7.	Tuning fork		1	To assess hearing loss

Nepal Red Cross Society, Dailekh (donated by BRINOS)

SN	Particular		Quantity	Purpose
1.		Aural forceps	1	For removing foreign body
2.	Head mirror		1	Light reflector
3.	Jobson probe		1	Ear cleaning
4.	Otoscope		1	To examine ear drum
5.	Tuning fork		1	To assess hearing loss

Annex-4: Summary of the clinical statistics on ear care services

a. Primary ear care camp (screening and education)

Districts	Total camps	Total patients	COM	OME	WAX	Hearing Loss	Others
Banke	35	2,766	1,120	255	247	159	930
Bardia	7	1,033	462	97	91	52	310
Surkhet	14	1,016	458	92	85	61	301
Dailekh	12	1,163	448	95	79	69	448
Total	68	5,978	2,488	539	502	341	1,989

b. School ear health programme (schools visited and screening)

Districts	Total schools	Total patients	COM	OME	WAX	Hearing Loss	Others
Banke	12	4,011	254	94	1,078	2,585	305
Surkhet	12	2,007	139	45	551	1,272	7
Dailekh	20	4,299	1076	230	1,250	1,743	839
Total	44	10,317	1,469	369	2,879	5,600	1,151

Note: No school health activities in Bardia.

c. Weekly clinic OPD (examination and education)

Districts	Total patients	COM	OME	WAX	Hearing Loss	Others
Bardia	455	157	33	77	14	174
Surkhet	256	105	28	31	6	86
Dailekh	400	144	21	60	40	135
Total	1,111	406	82	168	60	395

[1] Survey carried out by TUTH - Department of Community Medicine of Institute of Medicine, Kathmandu and Britain Nepal Otology Services (BRINOS) in 1991.

[2] 40% of the patients were with nose, throat and other problems.

[3] Prevention of blindness and community health intervention programme.

Implemented by Nepal Red Cross Society

in collaboration with BRINOS, BZH and NGMC