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Community Ear Care Programme .... Go to Page 2
In collaboration with
BRINOS, CUBEX and NGMC
QUARTERLY REPORT
July - September 2006
Background
Nepal Red Cross Society (NRCS) has been implementing
Community Eye Care and Health Promotion Programme (CEHP) with the financial
and technical support of Swiss Red Cross (SRC) since March 2001. This
programme was called Prevention of Blindness and Community Health Intervention
Programme (PBL-CHIP) during 2001-2004 (first and second phases).
The main programme components of the CEHP are
prevention of blindness, that is guided by the Vision 2020: The Right
to Sight, the global initiatives against blindness. This project also
addresses other important health priorities through health promotion
component. This includes promotion of important segment of primary heath
care - as improvement on access to water and sanitation, promotion of
safe-motherhood practices, prevention of encephalitis, HIV/AIDS and
community ear care.
CEHP facilitates implementation of these activities
within the districts of Mid-Western Development Region of Nepal that
consists of 3 zones (Bheri, Karnali and Rapti), and 15 districts in
them. CEHP has its base office in Nepalgunj.
The community ear care
programme is supported by BRINOS, CUBEX and Nepalgunj Medical College
and implemented by Nepal Red Cross Society in 4 districts - i.e. Banke,
Bardia, Surkhet and Dailekh in Bheri zone. The key actors of the programme
are mid- level paramedical called community ear care assistant (CEA)
and the ear care volunteers who are trained by CEAs.
Ear Health Situation in Nepal
Deafness is not only a personal problem but also
a hindrance to national development, as hearing loss or impairment especially
in the children inhibit their potential for education and learning performances;
and weakens their over all academic and mental development.
Deafness is number one single disability for
Nepal and its prevalence is very high (16.6%1 in age
5 and over) in comparison to India (10.4%) and Great Britain (2% in
16-45 years). Out of 16.6% of prevalence 35% (one-third) deafness is
preventable. Every 5th case of deafness is caused by Otitis
media or its sequel in all age group. But in case of school going age
group (5-15 years) every second case of deafness is caused by Otitis
media.
In Nepal, for many years to come, the first contact
between the public and ENT health service will be the traditional healers,
medicine sellers, the nurses or paramedics rather than a doctor. In
context of Mid and Far-west region to have a contact with an ENT doctor
is a matter of a chance as only one ENT doctor was providing services
for the both regions; nearly 4 million population.
Later, a medical college emerged with more ENT doctors in Nepalgunj,
which was also limiting its services to the city, and the real needy
living in the rural communities still remained unserved.
Therefore, the community ear care programme was
necessary to make people aware to take care of their own and their families
ear health utilizing local resources and seeking services from the Health
Posts.
Existing Ear Health Services in Mid West Region
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-years 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 years 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 6 years the Nepalgunj Medical College
has been providing service to the patients for ENT care at their teaching
hospital in Kohalpur. Now the hospital is also one of the referral centers
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.
Community Eye Care and Health Promotion Programme (CEHP)
CEHP (earlier known as PBL-CHIP) is a project
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, mobilizing
Red Cross volunteer networks and Community Based Organizations (CBO)
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 programme.
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, Cubex and Bheri Zonal Hospital.
The above mentioned are the general objectives
of the CEHP programme; the specific objectives of the community ear
care are following:
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 utilize 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
in children 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 utilizing
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)
activities
Coordination and collaboration
Collaborators for Community Ear Care
CEHP is implementing community ear care programme
with the support of following collaborators:
Britain Nepal Otology Services (BRINOS):
BRINOS is a UK-based charity organization solely
devoted to provide services to the Nepalese people in the area of deafness
prevention and control. This institution comprises board of directors
from UK and Nepal. The main authority of the organization is Mr. Neil
Weir, renowned ENT surgeon in UK. BRINOS started their cooperation and
services in the mid-west since 1996 organizing ear surgery camp.
CUBEX: BRINOS has also helped
establishing cooperation with CUBEX; a private firm serves for hearing
rehabilitation. Mr. Adam Shulberg is the head of the firm. The CUBEX
is supporting CEHP to promote hearing aid related activities.
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)
Though Dr. Ramesh Shrestha left the services
from the BZH, the ENT department continued to be a referral base for
the patients referred from the regions. The department is fully equipped
with necessary instruments and equipments for the ENT services.
Technical Support
Community ear care programme receives technical support from
the Senior ENT consultant, Dr. Ramesh Shrestha, who trains CEAs and
HP in-charge and also provided continuous input to update and enhance
CEAs' skills and knowledge. Now Dr. Ramesh is the advisor for the ear
care programme implemented by CEHP.
Community Ear Care and CEA (Community Ear-care
Assistant):
Lack of sufficient and appropriate human resources for
service delivery is the primary reason for inadequate access to ear
care services to the people living in the rural and remote areas, who
are the neediest population. The ENT specialist population is very low
in Nepal and is mainly concentrated in Kathmandu and other big cities,
like other specialties. Therefore, CEHP and its collaborators initiated
development of a mid-level human resource on ear care. Nepal has a successful
eye care programme and one of the main reasons for this achievement
is through extensive mobilization of paramedics called ophthalmic assistant.
In order to meet out need for intermediate level ear care worker, this
programme took initiation to develop Community Ear Assistant (CEA) for
the first time in Nepal. The service delivery model mentioned later
in this report has obvious explanation that the implementation of community
ear care programme is led by the CEAs; who are primarily Community Medical
Auxiliary (1 year training after high-school), and intensive additional
3 months course in a period of 1 year in ear care. The training curriculum
is designed by Dr. Ramesh Kumar Shrestha. The CEAs are also provided
various other inputs from collaborators. The community management skills
are continuously promoted in the CEAs by the CEHP programme through
public health professionals; the technical and clinical skills on ear
health is provided by the ENT consultant Dr. Ramesh Kumar Shrestha from
Bheri Zonal hospital and BRINOS, hearing aid rehabilitation skills are
provided by Cubex. Thus, the CEAs are multipurpose community health
workers in the programme.
A community ear care programme also needs regular
availability of a team-leader having understanding on public health
management, an ENT specialist with an interest to contribute time for
the community ear care and an institution base with strong commitment
to serve the needy residing in the rural and remote areas.
At the community level the CEAs develop network
of volunteers transferring ear care and health education skills on them
through primary eye care training. The volunteers are mainly the Female
Community Health Volunteers (FCHV), school teachers, health post staffs,
Red Cross volunteers and volunteers from other development agencies.
They are the person who make direct linkages with the community members
and support them with education and referral advices. Out of them the
FCHVs receive greater input, as they are the permanent resident of a
village responsible to help community members for all sorts of health
problems. They also have direct linkages with the near by health post
and are known figure in the community/villages. Thus, the FCHVs (volunteers)
are the main agent in the community who are serving as bridge between
community and health service providers like, health posts, District
and Zonal hospital and so on. The model service delivery below illustrates
this system.
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 other districts are Bardia, Surkhet
and Dailekh. Name of the Village Development Committees (VDC) covered
by the programme are listed in the tables below.
Community Ear Care activities in Banke district
The programme in Banke district is supported mainly by the
BRINOS. It covers total of 25 VDCs (out of 46), with recent expansion
in 5 VDCs. The new VDCs where the programme was started this year are
Hirminiya, Holiya, Betahani, Bankatti and Udayapur.
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