Project Goal:

To contribute to the overall goal of MoH in reducing fertility and under five mortality by assisting DHos in implementing activities to strengthen the delivery and use of high impact FP/MCH services ar household and community levels.

Background
In Nepal the child and maternal mortality rates are very high. For every 100,000 births 539 women die, and 91 out of every 1,000 children under five years of age die each year of preventable diseases such as malnutrition, respiratory problems and diarrhoeal diseases. In the more remote districts of the country the people's knowledge about how to keep themselves and their children healthy is very low.

Nepal Family Health Programme (NFHP)
NFHP is programme managed by a consortium of organisations led by John Snow Inc. (JSI). Other managing partners of NFHP are Engender Health, Johns Hopkins University/Centre for Communication Program (JHU/CCP), and Johns Hopkins International Education and Training in Reproductive Health (JHPIEGO). The collaborative partners of the NFHP are CARE Nepal, Save the Children US, MASS, ADRA, NTAG and NFCC.

NFHP supports HMG/N's goal of reducing fertility and under-five mortality within the context of the current HMG National Health Policy and Second Long-Term Health Plan 1997-2017. Activities include increasing the use of quality family planning (FP) services and selected maternal and child health (MCH) services at different levels of health care delivery system, especially at household and community levels. To maximize the long-term impact, technical assistance and complementary activities are planned and implemented in close collaboration with the MOH, its divisions, centres, and district health offices.

Making Health Care Accessible to All
CARE Nepal is helping the District (Public) Health Office, Nepal ensure a basic package of FP/MCH services are available at each level of the health care system, particularly at household and community level. This will be achieved through:

Improving the Quality and Quantity of family planning and maternal and child health services provided by health facilities and community health workers through regular on the job training, supervision and monitoring.

Strengthening Management and Coordination of Community-based Services by ensuring that local Health Facilities Operation and Management Committee Meetings are held regularly and relevant family planning and mother and child health service issues are addressed at the health facility level.

Improving Sustainability of family planning and maternal and child health service improvements by increasing financial and in-kind support provided to FCHVs by local management committees.

Strengthening the Capacity of Community Level Health Care Providers (Village Health Workers, Maternal and Child Health Workers and Female Community Health Volunteers) to deliver better quality and sustainable family planning and maternal and child health services.

Promoting Behaviour Change in FP/MCH through community based communication strategies, health education and training.

Piloting Innovative Strategies to improve access, quality and utilization of FP/MCH services and improve accountability and responsibility among the service providers for sustainable impact at the community levels.

Serving the Community, District and Nation
In the community - here, at household and community level, clients meet providers and behaviour changes can be clearly seen and here is where greater opportunities for protecting the health of Nepali families lie. Aiming to strengthen the community health facilities, NFHP is also strengthening the role of Female Community Health Volunteers (FCHVs), Maternal Child Heath Workers (MCHWs) and Village Health Workers (VHWs), to whom communities look to for advice and guidance on health issues. Indeed, FCHVs will become capable focal persons for health information services in their communities; well placed to refer patients to other health services such as those provided by MCHWs, VHWs and at health facilities.

In the district - CARE Nepal's contribution to the NFHP is developing the technical capacity and the management systems of the District (Public) Health Office (D(P)HO) in the core programme districts and provide limited support to monitor and supervise in all the project districts. One key element is the strengthening of supervision and support systems at community level by the DPHO. Programme Officers provide orientation on how to better support community health workers with the expected outcome of improved performance of community workers and better quality services. Programme Officers will
also provide in-service training, technical support and advice on organisation systems that will contribute positively to the provision of services at health facilities within the districts. Training will be conducted at hospitals and systems will be assessed and improved.

The community and district level activities of NFHP are focused on 17 high-population core-programme districts (CPDs): Bajura, Banke, Bara, Bardiya, Chitwan, Dhanusha, Jhapa, Kailali, Kanchanpur, Mahottari, Morang, Nawalparasi, Parsa, Rasuwa, Rautahat, Siraha, and Sunsari. Other districts receiving limited technical assistance are Bhaktapur, Dang, Gorkha, Kaski, Kathmandu, Lalitpur, Makwanpur, Rupandehi, Saptari, and Sarlahi.

As a collaborating partner of NFHP, CARE Nepal is responsible to implement activities to strengthen the delivery and use of high impact FP/MCH services at household and community levels in seven core programme districts: Dhanusa, Mahottari, Kanchanpur, Parsa, Chitwan, Nawalparasi and Bajura.

The ultimate beneficiaries of the project are over 1.3 million mothers and children coming from 414 Village Development Committees (VDCs) and seven municipalities. The health facilities covered by the project include 23 primary health care centres, 57 health posts, 346 sub-health posts and 1,940 outreach clinics. In addition over 4,000 Female Community Health Volunteers will be involved.

Interventions
CARE Nepal will implement selected high impact approach methods such as whole site training, partnership defined quality and REFLECT in selected priority areas of the districts, with intense follow-up, support and monitoring. In addition the following interventions will take place in all the project areas:

· Support DPHOs to hand over health facilities to local bodies;
· Capacity assessment and strengthening of Health Facility Operation and Management Committee (HFOMC);
· Capacity building of Village Health Workers (VHW) and Maternal and Child Health Workers (MCHW) to deliver family planning services;
· Promoting practices of waste disposal and safety measures at health facilities;
· Regularisation and strengthening Primary Health Care/Out Reach Clinics (PHC/ORC);
· Periodic programme review and reflection at district and health facilities;
· Mobilizing communities to support FCHVs; and
· Technical support to manage malaria control programme in Kanchanpur.

Sustainable, higher quality services
It is expected that as a result of the programme, health facilities and community health workers will provide higher quality and more sustainable FP/MCH services to meet the increased community demand. An increased sense of accountability will be developed by the Health Facility Operation and Management Committees. In selected districts such as Kanchanpur, improved malaria case management is taking place. Further, the programme is encouraging the inclusion of Dalits and disadvantaged groups in overall programming through community empowerment.