Research


My Research Projects


A] Ongoing Projects

2015-            Towards Inclusive Higher Education: Diversity, Equity, Access, and Learning (DEAL) in Christian Institutions
2015-            Complex Adaptive Systems (CAS): Strengthening Community-University Economic Development Approaches

B] Completed Projects

2008-2013    Experiences of the 1996-2006 Civil Conflict in Nepal: Narratives of Engagement of Tamangs (Indigenous People) and Bahun-Chhetris (Non-Indigenous People)
2008-2010    The Practice and Meanings of Spiritual Healing in Nepal
2001-2009    Community Intervention Study to Promote Rational Treatment of Acute Respiratory Infection (ARI) in Rural Nepal
2005-2008    Impact of NGOs on Empowering People Living with HIV Positive
1997-2008    Community Financing Drug Schemes
2006-2007    Using Health Rights of Women Assessment Instrument (HeRWAI)
2005-2007    Assessing Linkages between HIV Service Sites and TB Service Sites
2005-2006    HIV/AIDS Vulnerability Assessment on the Returning Migrant Communities
2003-2006    Operational Research to Improve TB Control Program
2003-2006    Assessment of Health Situation in Eastern Development Region of Nepal
1999-2001    Socio-economic Status and Use of Primary Health Care Services
1997-2000    Hill Drug Scheme and its New Approach: a Brief Report of Thirty Years 1969-1999

C] Research Summaries/ Abstracts

2008-2013    Experiences of the 1996-2006 Civil Conflict in Nepal: Narratives of Engagement of Tamangs (Indigenous People) and Bahun-Chhetris (Non-Indigenous People)

Funded by: AusAID and University of Newcastle, Australia

Memoir: I came to Australia to do PhD with my research proposal titled ‘The Excluded Groups and Civil Conflict in Nepal: Implications of Insurgencies for Everyday Life’. Working with my supervisors, I revised my research proposal and finalized the title as ‘The Experiences of Civil Conflict in Nepal’. As per the University’s requirement I attended candidature confirmation meeting. Before the confirmation meeting I was shocked when my supervisors said to me, “You do only qualitative study. We will help you. If you want to do both qualitative and quantitative we are not interested in supervising you. You can go to another University or you can join Master’s Degree here.” I thought that was a good opportunity for me to enhance my qualitative skills and decided to continue as per their advice. I am grateful to my Principal Supervisor Professor Pam Nilan who led me from the beginning to the end of my PhD journey. I also thank Dr Terry Leahy, Dr Alex Broom, Russell Hancock and Professor John Germov for their contributions during my doctoral study. I presented my doctoral research in 10 academic forums in Australia, Canada and United States (the presentations are listed in this blog in 'publications' page.

Abstract:

This thesis explores people’s experiences of the recent political insurgency in Nepal that impinged upon, and transformed everyday life in rural communities. Since 1996, the civil conflict has killed more than 13,000 people, injured thousands, displaced many others, and damaged innumerable properties. Employing qualitative techniques: focus group discussions, in-depth interviews and extended family case studies - the study has generated knowledge from two groups: a marginalized indigenous people - the Tamangs; and the dominant non-indigenous people - the Bahun-Chhetris.

Findings imply that poor governance and injustice was the root cause of the conflict, and that was fueled by pervasive discrimination and low socio-economic status, especially for those in rural areas, and for members of marginal groups. The civil conflict severely affected livelihoods and national development. Access to basic social services, especially health and education, was restricted. Overall, livelihood opportunities were reduced. Rural people adopted various coping strategies to maintain their survival; among them: silence, avoidance and adaptation. The impact of the conflict was different for Tamangs and Bahun-Chhetris, and so were some of the coping strategies. The higher socio-economic status and better networking skills of the Bahun-Chhetris gave them a distinct advantage.

Both men and women participated in the civil conflict. The bravery of female rebels convinced the government to recruit women into the national military forces. Through the Maoist rhetoric and promises, the civil conflict raised the people’s awareness overall and increased expectations, leading to the post-conflict emergence of some intensified ‘identity politics’ based on ethnicity, religion and geographical differences.

Neither the Maoists nor the government gained an ultimate victory in the war. Nonetheless, post-conflict, Nepal became a 'Federal Democratic Republic' with the Maoist Party in control. The main leaders of the new government in the New Nepal came from among the Bahun-Chhetris with the inclusion of a few ethnic elites. Post-conflict transformation in the New Nepal has been very slow, particularly in establishing peace and security, and institutionalizing democracy and human rights. Indigenous groups and marginalized minorities feel that their needs and demands have not been met, despite the promises of Maoist rhetoric during the civil war, and continuing policy initiatives of the current government. There is still a risk of local and perhaps widespread civil insurgency, especially if people’s expectations and the post-conflict issues are not addressed appropriately as the years go by.

Beyond the contribution to knowledge about contemporary Nepal, this thesis makes a contribution to our knowledge about the experience of ordinary people in civil insurgencies in South Asia. It also contributes to the epistemology of people’s movements, political insurgencies and violent events that have impacted on and transformed the society of developing countries. Most importantly, the thesis has made visible the roles played by rural people in the process of making histories or bringing changes in a state governance system, an area of enquiry that has suffered from under-acknowledgement, and a lack of research.

Key words:
Tamangs, Bahun-Chhetris, ethnic groups, civil conflict, civil war, political insurgency, violence, access,  social services, health, education, livelihood opportunities, coping, survival strategies, post-conflict, transformation, peace, security, social development, wellbeing.

Online at:
http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:13212?queryType=vitalDismax&query=tamang

2008-2010    The Practice and Meanings of Spiritual Healing in Nepal

Memoir: While doing my PhD, one of my supervisors Dr Alex Broom asked me if I were interested in carrying out a research on traditional healing system in Nepal as a part of his global research on traditional medicine. He funded the research and supported me to participate in an international workshop. I presented the research in the workshop and eventually, we published a paper in an academic journal.

Abstract:

Most of the Nepalese populations use various forms of traditional medicine (TM) as their primary form of health care. Biomedical health-care services are currently extremely limited and are largely situated in urban settings. Despite widespread reliance on TM in contemporary Nepal, we know relatively little about the roles and uses of traditional medicine and the socio-cultural impacts of a diverse therapeutic landscape. Drawing on a series of in-depth interviews with eight Nepalese spiritual healers, this article explores the character of spiritual healing; processes of training and knowledge transfer and the interplay of biomedicine and spiritual healing. The results illustrate the importance of metaphysical referencing and the master–disciple tradition in securing the socio-medical authority of spiritual healers and the protection of ‘the art’ of healing. Furthermore, their accounts reflect the impact of recent bio-medically driven development programs on the contemporary practice of spiritual healing in Nepal. We use this data to argue for further research to examine interplay of different forms of TM and biomedicine in Nepal, and to illustrate the importance of such an understanding for health development projects in the region.

2001-2009    Community Intervention Study to Promote Rational Treatment of Acute Respiratory Infection (ARI) in Rural Nepal

Funded by: Applied Research on Child Health (ARCH) Project Centre for International Health Boston University, USA

Policy, Access and Rational Use, Essential Drugs and Medicines Policy, World Health Organization (WHO), Geneva

Rational Pharmaceutical Management (RPM) Plus Program, Management Sciences for Health, Arlington, USA

The Britain Nepal Medical Trust (BNMT), UK

Memoir: We received an email from an international collaboration of WHO, INRUD, MSH, Boston University and others that called for proposals on applied health research. We submitted a proposal because ARI was a common cause of morbidity and mortality among children in Nepal. Our study design was “Pre-Post and Control Model” with two districts ‘control’ and two districts ‘intervention’. Interventions were carried out at the community level involving students, community leaders and drug vendor/retailer. We presented papers in International Conference on Improving Use of Medicines and published a paper in an academic journal (abstracts ‘a’ and ‘b’ below).

a. Tamang, AL, Karkee, SB, Gurung, YB, Rai, C, Holloway, K; Kafle, KK 2004, ‘Assessing Community Members’ Understanding and Practices in Treating ARI in Rural Nepal (Conference Abstract)’, International Conference on Improving Use of Medicines, 30 March - 2 April, 2004, Bangkok, Thailand

Abstract:

Problem Statement: Acute respiratory infection (ARI) is one of the top ten diseases in Nepal and causes about 45,000 deaths annually in children under five years. A high death rate from ARI indicates that antibiotics are not properly used or that there is lack of access to antibiotics. There are few data available regarding community understanding and practices in treating ARI in rural Nepal.

Objectives: To investigate consumers’ knowledge and treatment-seeking practices regarding ARI and to recommend appropriate strategies for intervention in managing ARI.

Design: Descriptive cross-sectional study with focus on qualitative information. This was the formative stage of a currently-underway randomized pre-post intervention study with control.

Setting and Population: The study was carried out in eastern Nepal in 2002. Forty-two in-depth interviews with opinion leaders, 12 focus group discussions with mothers, community members, and students, and 282 interviews with mothers of hospital/health post patients were performed.

Outcome Measures: Concepts of ARI among community members, local terms used for ARI, types of treatment practices, approach to be adopted in bringing change.

Results: Mothers were the main caretakers of sick children. Most people recognized ARI in local terms (e.g., “rudhi” or “cold” for mild cases and “sannipat” or “pneumonia” for severe cases). Concepts used by the community to distinguish severe from mild ARI included high fever, fast/difficult breathing, chest in-drawing, inability to play/drink/eat, lethargy, and irritability. Usually, treatment seeking and care are done as per the instruction of old and respected members of the community. Fifty-six percent of caretakers of hospital/health post patients stated that the first place they sought treatment was a health institution, 32 % at a traditional healer, and 10% at a drug shop. Many informants were unable to recognize antibiotics correctly. Various terms (e.g., “drug for pneumonia,” “fever-reducing drug,” and “powder-like drug”) were used. Some people gave raw extracts of various plants to a sick child. Most people gave soup of “tulsi patta’” (ocimum leaves). A few people gave “gaiko gobar” (cow dung) to a severely sick child. Most students were unaware of ARI. Most informants recommended educating parents, especially mothers, in the appropriate care of a sick child.

Conclusions: Most people recognize ARI and can distinguish severe disease. Both good and poor home treatment practices exist. However, a large proportion of community members do not use the health facilities, even for severe ARI in young children, and have a poor understanding of antibiotics. Therefore, there is an urgent need to educate communities, especially the mothers of young children, in how to treat severe ARI in children under five years.

b. Holloway, KA, Karkee, SB, Tamang, AL, Gurung, YB, Kafle, KK, Pradhan, R & Reeves, BC 2009, ‘Community intervention to promote rational treatment of acute respiratory infection in rural Nepal’, Tropical Medicine and International Health, vol. 14, no. 1, pp. 101–110.

Abstract:

Background: Acute respiratory infection (ARI) in children under-five years (under-fives) is often inadequately treated in rural Nepal. This study evaluated a community education program about treatment of ARI.

Objective: To evaluate a community education program about treatment of acute respiratory infection (ARI).

Methods: First, community case definitions for severe and mild ARI were developed. The intervention was then evaluated using a controlled before-and-after design. Household surveys collected data about ARI treatment in 20 clusters, each based around a school and health facility. Treatment indicators included percentages of cases attending health facilities and receiving antibiotics. The intervention consisted of an education program in schools culminating in street theater performances, discussions with mothers after performances and training for community leaders and drug retailers by paramedics. The intervention was conducted in mid-2003. Indicators were measured before the intervention in Nov ⁄ Dec 2002 and again in Dec 2003 ⁄ Jan 2004.

Results: Two thousand and seven hundred and nineteen households were surveyed and 3654 under-fives were identified, of whom 377 had severe ARI. After implementing the intervention, health post (HP) attendance rose by 13% in under-fives with severe ARI and fell by 9% in under-fives with mild ARI (test of interaction, P = 0.01). Use of prescribed antibiotics increased in under-fives with severe ARI by 21% but only by 1% in under-fives with mild ARI (test of interaction, P = 0.38). Irrespective of ARI severity, the use of non-prescribed antibiotics dropped by 5% (P = 0.002), and consultation with female community health volunteers (FCHVs) and use of safe home remedies increased by 6.7% (P not estimated) and 5.7% (P = 0.008) respectively.

Conclusion: The intervention was implemented using local structures and in difficult circumstances, yet had a moderate impact. Thus it has the potential to effect large scale changes in behavior and merits replication elsewhere.

2005-2008    Impact of NGOs on Empowering People Living with HIV Positive

Funded by: Self-Funded

Memoir: This was Dimpal’s Thesis project for her Master’s Degree. I advised her to do research on HIV. Later we co-authored an abstract (abstract ‘a’ below).

a. Yonjan-Lama, D & Tamang, AL 2008, 'Impact of NGOs on Empowering People Living with HIV Positive (PLHP) (Conference Abstract)’, XVII International AIDS Conference, 3-8 August 2008, Mexico City, Mexico.

Abstract:

Background: HIV/AIDS in Nepal, with a prevalence rate of 0.5%, is emerging as a major threat to cause death in age group 15-49 years. Many non-governmental organizations (NGOs) are working to enable the empowerment of ‘People Living with HIV Positive (PLHP)’. This study was carried out to identify the impact of their work.

Methods: A descriptive and analytical study was carried out collecting information from 33 male and 25 female PLHP in Kathmandu valley during 2006. About half of the informants came from outside the valley. The researcher observed them over a six months period in different NGOs. Semi-structured interviews and group discussions were also held.

Results: Although one-fourth of the informants were illiterate, half of the informants were job-holders because of the support from NGOs. Similarly, 86.2% had disclosed their HIV status to their family members; and 76% of the disclosed got positive behavior of family members. In health institution, 87.2% medical persons treated PLHP with positive behavior. Only 17.2% respondents had taken financial support from NGOs for the expenses of health checkup, medicines, food, clothes and transport; 91.4 % received counselling and education service and 96% of them increased their self-confidence to live normal life. The study found that 85.7% PLHP were able to promote the philosophy of positive living; 69.6% to identify their needs, and 16.1% to design initiatives to address their problems. Cent percent informants agreed that they were in need of good working NGOs.

Conclusions: The study concludes that the PLHP are benefited by the services of NGOs but their services are insufficient. Beside Kathmandu valley, many PLHP are living in different parts of the country. As the services provided by NGOs were mainly limited in urban areas, the informants who came from remote areas were in need of more support.

1997-2008    Community Financing Drug Schemes

Funded by: Big Lottery Fund (BLF), UK

Inter-Church Organization for Development Co-operation (ICCO), the Netherlands

Kadoorie Charitable Foundation (KCF), Hong Kong

Australian Agency for International Development (AusAID), Nepal

The Britain Nepal Medical Trust (BNMT), UK

Memoir: I joined BNMT as a Junior Program Officer in 1997 and left the organizations as the Program Director in 2007. Over a decade, I worked for different projects and enhanced my knowledge and skills in the fields of health, social development and research. One of the important projects was community drug financing schemes. This was not just a project but a big program. We worked from community level to national level involving disadvantaged groups, health committees, volunteers, students, teachers, people’s representatives, health workers, government officials and others. Although we had generated lots of knowledge, we could not document appropriately and disseminate them adequately. Summaries of disseminated information are presented below (abstracts ‘a’ to ‘f’ below).

a. Karkee, SB, Tamang, AL, Gurung, YB, Dahal, S & Saunders, P 2000, ‘Cost Sharing Drug Scheme (CSDS): an experience from Chhyangthapu Health Post’, Journal of Institute of Medicine, Nepal, vol. 22, no. 1 & 2, pp. 32-40.

Abstract:

This paper describes a community organized Cost Sharing Drug Scheme (CSDS) in a remote Health Post (HP) of eastern Nepal. The inadequate annual supply of drugs from the government was supplemented by an additional supply from Britain Nepal Medical Trust (BNMT) in 80 % of the cost price. The prescribed drugs were dispensed at 40 % of the cost price. The local Village Development Committees (VDCs) also made financial contribution. Thus, the government supply, BNMT subsidy, the local VDCs contribution and the patient fee helped to generate a revolving fund which was managed by the Local Health Support Committee (LHSC). The District Health Office (DHO) carried out the supervision / monitoring and the BNMT staff facilitated the process of Drug Scheme Program (DSP) implementation. The result showed that unit item fee improves the quality of care and the local community can be involved in drug schemes management. 

b. Tamang, AL & Karkee, SB 2002, Terhathum Community Drug Program: Annual Report 2001/2002, the Britain Nepal Medical Trust, submitted to AusAID Country Office, Kathmandu, Nepal.

Abstract:

The Britain Nepal Medical Trust (BNMT) has been able to carry out about all of the planned Terhathum Drug Scheme (ThDS) activities in 2001 in spite of the difficult security situation throughout the year, culminating in the government imposing an emergency state throughout the country, which has been in place since 26 November 2001. By the end of 2001, community drug scheme/ program (CDP) is operational in 16 health HIs in Terhathum. BNMT was able to facilitate the district health and drug management committee (DHDMC) to implement the CDP at Terhathum district hospital (DH), which is an innovative approach to strengthen the referral system through the CDP strategy reaching between 10-15 thousand patients each year. The most common characteristic of the scheme is ‘partnership and cooperation’ with different partners e.g. community people and village/district development committee (VDC/DDC). To commit the partners in playing active roles, BNMT has worked as a facilitator at different levels such as village and district levels. Another common characteristic of the scheme is operating a revolving drug fund (RDF). The partners contribute to the fund: patients pay for drugs, government supplies drugs, VDC/DDC provides money, and BNMT supplies drugs at a cheaper rate (50-300% cheaper than in the local market). The funds are being regularly monitored by CHMCs and district health offices (DHOs). Most of the HIs have sufficient money in the RDF. At the end of 2001, the fund balance was about Rs 642,978 and a drug stock valued about Rs. 624,408 in 16 HIs. BNMT supplied quality essential drugs and medical items worth about Rs 475,070 to the supplier from which HIs bought drugs worth about Rs 292,006. BNMT managed drug transportation cost up to the district supplier that was managed by CHMCs up to their HIs. 37,307 patients received CDP service after the program implementation (patient per day, last year= 7.3 and this year= 9.4).

c. Tamang, AL & Karkee, SB 2002, an Evaluation of Drug Schemes Program in Eastern Nepal: Final Report 2002, the Britain Nepal Medical Trust, Nepal.

Abstract:

Since 1969 BNMT has been supporting community managed drug schemes (DSs) in eastern hills of Nepal. By December 2002, the schemes were implemented in 124 health institutions in five districts. A participatory cross sectional study was carried out using SWOT analysis, Focus Group Discussions (FGDs), Social Mappings and Household Rankings, Mood Meter Analysis, Time Trend Analysis (Mortality Trend Analysis) and household interviews. The findings showed that the choice of the first place of treatment was health institutions (71%) followed by traditional healers (24%), drug retailers (2%) and private health workers (2%). About 19 % of the households expressed that the poor were most benefited from the program whereas 80% of the households reported that all people were equally benefited. A revolving drug fund (RDF) is operating in each HI. Financial contributions are available from VDCs, government (as annual supplies of drugs), patients (as fee for dispensed drugs) and BNMT (subsidy on drugs). About 90% of the informants were willing to pay for drugs dispensed at HIs. The result shows that there is an active participation of management committees, district managers, community health workers, VDC members, schoolteachers, FCHVs and women groups in running the program. As the community members control the financial and managerial aspects of the program, the ownership of the program remains in the community. The results also indicate that since the program is appreciated and managed by the community and is also supported by the district health office, the providers at health care services are motivated to provide better services.

d. Tamang, AL & Karkee, SB 2005, Sankhuwasabha Drug Scheme Project: End of Project Report (July 2001 - June 2004), the Britain Nepal Medical Trust, submitted to Kadoorie Charitable Foundation, Hong Kong.

Abstract:

The Kadoorie Charitable foundation funded the project “BNMT Drug Scheme Sankhuwasabha”. The project period duration was July 2001 to June 2004. During the period BNMT assisted the District Health Office, local health institutions, local health committees and local suppliers in the management and implementation of the community organized drug scheme in Sankhuwasabha District of eastern Nepal. It appears to be one of the most successful drugs financing schemes implemented in the health sector of developing countries. This scheme has addressed the needs of the local people and mobilized them in developing a better quality health system for the poor and disadvantaged people in the remote district. At the end of the project all 39 health institutions in Sankhuwasabha have drug schemes. Resources are available and managed at the implementation level. Responsibilities of health institutions and the Community have been agreed. Now, every health institution has sufficient revolving fund to cover about one year’s need of essential drugs and medical supplies.

e. Karkee, SB, Tamang, AL, Gurung, YB, Mishra, G, Banez-Ockelford, J, Saunders, P & Rai, C 2005, ‘Improving access of drugs to poor households in a cost sharing drug scheme: wealth ranking approach’, Nepal Medical College Journal, Nepal, vol. 7, no. 1, pp. 26-31.

Abstract:

In Nepal lack of drugs in government health institutions has markedly reduced access to essential drugs by poor patients. Despite the implementation of a drug scheme with adequate availability of drugs and with provision of fee exemption for the poor, the poorest people still had no access to drugs. We carried out a wealth ranking process to identify poorest of the poor households in a village. Each of the poor household was provided with a free treatment card and information about the availability of free service at the local health post. Baseline and post intervention data on service utilization and prescribing practices were collected using carbon copies of prescriptions. Data were also collected about the attitude of patients, using qualitative interviews. About 1.8% of the total annual patient visits to the Health were from cardholder households. The annual health post utilization rate for the poor patients was 1.18, whereas among other patients it was 0.69. On average, about 2.4 drugs were prescribed to any of the cardholder patients. Among the prescriptions to cardholders about 51% included at least one antibiotic drug. No injection was prescribed to any cardholder. Within 18 months, the total fee exemption provided to the poorest among the poor households was equivalent to about US$ 1.6. Since the method is valued by local people, and is also feasible to implement through the communities' efforts, it is recommended to initiate it in other drug scheme areas as well.

f. Holloway, KA, Karkee, SB, Tamang, AL, Gurung, YB, Pradhan, R & Reeves, BC 2008, ‘The effect of user fees on prescribing quality in rural Nepal: two controlled pre-post studies to compare a fee per drug unit vs. a fee per drug item’, Tropical Medicine and International Health, vol. 13, no. 4, pp. 1-7.

Abstract:

Objective: To compare prescribing quality with a fee per drug unit vs. a fee per drug item. Methods: Prescribing data were collected prospectively over 10 years from 21 health facilities in two districts of rural eastern Nepal. In 1995, both districts charged a fee per drug item. By 2000, one district was charging a fee per drug unit, and the second district continued to charge a fee per drug item (control group). By 2002, the second district was also charging a fee per drug unit. These fee changes allowed two pre-post ‘cohort’ with control analyses to compare INRUD⁄WHO drug use indicators for a fee per drug unit vs. a fee per drug item.

Results: Charging a fee per drug unit increased the percentage of antibiotics prescribed in under-dosage by 11–12% (P = 0.02 and 0.02), decreased the percentage of patients prescribed injections by 4–6% (P = 0.002 and 0.02), reduced the units per drug item prescribed by 1.7 (P = 0.02 and 0.03), and decreased compliance with standard treatment guidelines by 11–15% (P = 0.02 and 0.06).

Conclusion: A fee per unit was associated with prescription of fewer units of drugs and fewer expensive drugs (such as injections), resulting in significantly poorer compliance with standard treatment guidelines. This finding is of great concern for public health in countries where patients are charged a fee per unit of drug.

2006-2007    Using Health Rights of Women Assessment Instrument (HeRWAI)

Funded by: Aim for Human Rights (AHR), the Netherlands

The Britain Nepal Medical Trust (BNMT), UK

Memoir: We were implementing a health project with rights-based approach. The donor who was funding the project linked us to a Dutch organization, Aims for Human Rights (AHR). Two experts from AHR facilitated a training for us. We applied the knowledge and skills that we acquired from the training in this project (abstract ‘a’ below).

a. Tamang, AL, Mishra, G & Chaudhary, R 2007, Safe Motherhood Plan 2002 -2017 and Post-Partum Hemorrhage (PPH) in Nepal: an Assessment of Policy, Its Implementation and Implications Using Health Rights of Women Assessment Instrument (HeRWAI), the Britain Nepal Medical Trust, submitted to Aim for Human Rights, the Netherlands.

Abstract:

Britain Nepal Medical Trust (BNMT) has adopted rights-based approach to health since 2005 for the purpose of promoting the health rights of the right holders and strengthening the capacity of the duty bearers. In November 2006, a workshop on Health Rights of Women Assessment Instrument (HeRWAI) was organized for BNMT staff members. After the workshop, the participants decided to analyze Nepal’s “safe motherhood plan 2002 -2017” with focus on post-partum hemorrhage, one of the major causes of maternal deaths in Nepal. The analysis found that the safe motherhood plan was developed as a strategic instrument for reducing maternal deaths due to post-partum hemorrhage and many other preventable causes; and has included various services needed during pregnancy, during child birth, and after the child birth. The plan directly affects woman’s right to life, right to work, and right to human dignity. There are also numerous factors which limit the government in fulfilling its commitments e.g. early marriage, majority of deliveries at home, majority deliveries without any skilled medical help, traditional Nepali society taking a woman as polluted and impure for the first 11 days after giving birth, political transition, staff transfers and restricted support from development partners. Despite the limitations, the policy on women’s health rights has brought some positive effects such as more women have started to decide to take the health services from the health institutions; comprehensive essential obstetric care implemented in 28 districts and basic essential obstetric care in 63 sites in 47 districts; more than 50,000 women benefited with the maternity incentive scheme in 2006; the percent of births delivered in a health facility has doubled since 2001, and assistance at birth by a skilled birth attendant has increased by over 70 percent in the past five years.

2005-2007    Assessing Linkages between HIV Service Sites and TB Service Sites

Funded by: United States Agency for International Development (USAID) through Family Health International (FHI), Nepal

Memoir: We carried out an assessment regarding access to TB/HIV services. I presented the findings in a national conference and published the paper in the NMA Souvenir (abstracts ‘a’ to ‘c’ below).

a. Tamang, AL & Shrestha, S 2005, Assessing Linkages between HIV Service Sites and TB Service Sites in order to Access TB Services for People Living with HIV Positive (PLHP), the Britain Nepal Medical Trust, submitted to Family Health International (FHI), Kathmandu.

Abstract:

The HIV/AIDS epidemic is an enormous threat to health and wellbeing in the South and South East Asian Region including Nepal. It is estimated that at least 60,000 Nepali people are infected. Tuberculosis (TB) is the most common infection and a major cause of death for people living with HIV positive (PLHP). A Rapid Appraisal Study (Exploratory Study) carried out to assess linkages between HIV service sites and TB service sites in Nepal to ensure access to TB services for PLHP.

Sixty four males and 33 females were interviewed from 97 service sites (85 DOTS sub/centers and 12 VCT centers). According to the DOTS service providers, the best counsellor would be health workers (85.8%) followed by family members (52.9%). Likewise, VCT service providers felt counsellors (58.3%) and friends (33.3%) would be the best people to provide counselling. About 98% of informants from DOTS centers had received TB basic training, while only 16.6% of VCT service providers had attended this training. Similarly, only 25.8% of DOTS service providers had participated in HIV related training compared to 66.6% of the VCT service providers. TB diagnostic services were available in all TB service sites, as were HIV diagnostic services in all HIV service sites. The service of diagnosing both HIV infection and TB infection in the same place was not available at any HIV or TB service site except central level hospitals (Patan, Bir and Teku Hospitals) in Kathmandu.

The assessment data gathered from service users (PLHP) involved interviews with 306 PLHP (218 males and 88 females). Both PLHP and the organizations serving them were reluctant to disclose their status. Some VCT centers demanded financial support for their organizations but suggested not to give money to PLHP directly. Some informants objected to be called “PLHA”, “PLWHA” or “PLWA” – the commonly used acronyms used to refer to them - as the terms were discriminatory and embarrassing. About 82% of the informants had been aware of their HIV positive status for more than one year; and 26% of the informants were living for more than five years even after they knew they were HIV positive. A female informant (40-49 years) had been living with the status for 14 years and was still healthy.

In conclusion, the study did not find existing direct or formal mechanism of linking the TB service sites and HIV service sites. However such linkage mechanism seems possible.

b. Tamang, AL 2007, ‘Linkages between TB Service Sites and HIV Service Sites to Access TB Services by People Living with HIV Positive (PLHP)’, Souvenir: 23rd All Nepal Medical Conference, 1-7 November 2007, Nepal Medical Association, Nepal, pp. 8-19.

Abstract:

Nepal’s concentrated human immunodeficiency virus (HIV) epidemic is spreading rapidly among its most-at-risk populations and evidences suggest that the epidemic will become more generalized in the near future. Tuberculosis (TB) is the most common infection and a major cause of death for people living with HIV-positive (PLHP). In this regard, a rapid appraisal study was carried out in Kathmandu valley and five districts of eastern Nepal to assess linkages between HIV service sites and TB service sites so that access to TB services by the PLHP could be ensured. The study incorporated the perspectives of both service providers and service users by collecting data from 85 TB and 12 HIV service sites using site mapping, non-participant observation and semi-structured interviews. The study found that 80% of the TB service providers understood sputum test as a method of TB diagnosis which was only 33.3% among HIV service providers. During the last year, most of the informants (74.1%) from TB service sites were not aware of any TB/HIV co-infected patients but two third of the informants (66.7%) from HIV service sites had encountered at least one co-infected patient. The co-infected patients were reportedly referred (83.3%) to higher level hospital for treatment. Informants reported that they were reluctant to work with the co-infected patients because of fear of infection, patients’ demand for financial aid, lack of facilities for providing services, difficulty to motivate for behavior change and patients’ reluctance to disclose their status publicly. It was difficult for service providers to identify the co-infected patients because about half of the 306 PLHP (43%) who were interviewed had not disclosed their status to others. The reason given for this was fear of loss of love and social prestige; and they wanted to avoid being discriminated against or having to live in deprived conditions. The study did not find existence of any direct or formal mechanism that linked the TB service sites and HIV service sites although there is a possibility of such mechanisms for collaboration between the service sites in future. The study clearly demonstrated that large populations of the PLHP do not have access to available services. Therefore, future interventions should include collaboration between TB and HIV service sites by upgrading knowledge and skills of service providers, monitoring and evaluation, logistics and commodity supplies, meaningful participation of service users as service providers, awareness raising, advocacy and policy reforms.

c. Tamang, AL, Rai, C, Bhattarai, L, Mishra, G, Paudel, H, Aryal, T, Dahal, R & Shah, CN 2006, ‘What is in a name? People living with HIV-positive diagnosis in Nepal object to the terms used to describe them (Conference Abstract)’, XVI International AIDS Conference, 13-18 August 2006, Toronto, Canada.

Abstract:

Background: The Kingdom of Nepal is not immune to the South East Asian HIV epidemic. Over 60,000 Nepalis are infected and the disease is spreading rapidly among most-at-risk populations. A variety HIV/AIDS programs are available, but seldom engage the views of intended beneficiaries. An assessment of linkages between TB and HIV services found some surprising service user perspectives.

Methods: A semi-structured interviews were conducted to evoke views of 306 people living with HIV-positive diagnosis regarding local HIV and TB services in 2005. This was part of a larger study incorporating observations and interviews with service providers and users across 97 HIV or TB service sites in 8 of Nepal’s 75 districts.

Results: Some interviewees objected the prevailing terms - “PLHA” or “PLWHA” - finding them to be discriminatory and embarrassing. Some argued that although all AIDS patients are HIV positive, not all people living with HIV-positive diagnosis have AIDS. They preferred the term “People Living with HIV Positive” (PLHP). The interviews further revealed high levels of stigma and discrimination from families (50%), friends (58%) and relatives (67%) of PLHP. About 43% had not disclosed their status to others as a result. Only 39% reported receiving HIV/AIDS related training; and described more positive outlooks, healthier and safer lifestyles as the impacts of training. Almost all interviewees, however, felt income generating opportunities would be more valuable to them.

Conclusions: The study demonstrated that the common terms used to describe PLHP can be interpreted in a variety of ways and may offend some. Services like counseling, social support, ART and income generating programs are likely to be well received if available in Nepal; and would be better used if discrimination and stigma are reduced. Researchers and service providers are reminded to be cautious about assuming how terms and services are received by PLHP.

2005-2006    HIV/AIDS Vulnerability Assessment on the Returning Migrant Communities

Funded by: Global Fund (GF) through the United Nations Development Program (UNDP), Kathmandu

Memoir: UNDP Nepal called proposals for carrying out different projects. I submitted a proposal for carrying out qualitative study in a district. Interestingly, they offered us to carry out the study in six districts that covered all developmental regions of Nepal. We negotiated to carry out the study in two districts that best represented the study population. We successfully completed the study. The following abstracts ‘a’ and ‘b’ provides information about the study.

a. Tamang, AL 2005, HIV/AIDS Vulnerability Assessment on the Returning Migrant Communities: a Study for the Global Fund (GF), the Britain Nepal Medical Trust, submitted to United Nations Development Program (UNDP), Kathmandu.

Abstract:

A migrant’s chance of being exposed with high-risk behavior groups seem to be higher. Therefore, a vulnerability assessment was carried out in Jhapa and Banke Districts. Both Jhapa and Banke border India to the south and are accessible by modern means of transportation. An open border has allowed people from both districts to migrate to and from India seeking work without proper records. As a result, it was felt a rapid appraisal study with focus on qualitative information should be carried out in coordination with various partners. Sites for data collection were selected after discussion with concerned people in the district. Nine FGDs in Jhapa and seven FGDs in Banke were conducted with a total of 87 males (nine groups) and 72 females (seven groups). Mobility charts and case studies were carried out among 20 people. Discussions with organizations related to migration and HIV/AIDS programs were also held.

In general, males of economically active age, but unemployed in their home areas, migrate to India to seek jobs. The number of female migrants was negligible. The major destinations were Delhi, Gujarat, Kanpur, Rajasthan, Mumbai and other areas of Maharastra, Punjanb, Silang, Surath, Himanchal and Ahmadabad in India. Some also migrated to Malaysia and Qatar. Most of the unskilled and semi-skilled migrates worked as factory manual workers, farm laborers, waiters/stewards and watchmen or gate-keepers. There were no caste/ethnicity barriers or discrimination involved in getting jobs in India or overseas. Working hours ranged from 10 to16 per day.

Poverty, unemployment in home country, landlessness, big family size, inability to send the children to schools, lack of money for marriage, family disputes and, political instability within home country were the push factors of migration. The pull factors of migration were observation of better living standard, inspiring stories told by the friends about comfortable and luxurious (sexual life also included) life, greater freedom than in home places, more amount of money than in home country and, opportunity of visiting different places.

Common leisure activities were visiting different places, watching television, drinking alcohol, gambling, talking, discussing sexual issues, and sharing sex experiences. Visits to brothels, masturbation, watching pornographic videos, and group sex were commonly practiced. Uncommon sexual practices were also found among the migrants such as the use HIV/AIDS Vulnerability Assessment on the Returning Migrant Communities, 2005 of artificial sex organs and anal sex with colleagues. The practice of sex with animals was also mentioned.

Common health problems in the workplace were malaria fever, jaundice, colds, allergies (skin), sore throats and tonsils, pain during urination and allergies on the penis. They visited health clinics or pharmacies to consult health professionals and take prescriptions for a quicker remedy. Most of them knew about blood tests, but did not visit hospitals or pathology lab for test because they did not want to `hear about HIV/AIDS due to social stigma. Educated youths responded more positively than the older migrants and general population. If people knew someone as People Living with HIV Positive (PLHP1), they did not behave well with him/her. Spouses of migrants were also suspected and stigmatized if they got any sexually transmitted infections.

Availability of health services and information to migrants were not institutionalized. Few organizations were contributing in the fields of HIV/AIDS. Almost all the migrant males were aware of condom and its use and most of the males and females who were aware of HIV/AIDS used condom during sex or stopped visiting brothels. Condom use was felt necessary while having sex with non-regular partners but there was low rate of use with regular partners. Females requested their husbands to use condom during sex but this request was usually denied as their husbands felt they did not get the same sexual satisfaction when using condoms.

Taking a loan from a bank and/or Saving/Credit Cooperation or selling their land or animals was common. Returnee migrants usually spent the money in food, clothing, rent and entertainment. Positive changes that came about when migrants returned were new skills, improved habits, respect from society, and the realization of the importance of money. The negative impacts of migration were being unable to care for their children's education, becoming ill and receiving no care, rude and offending behavior of employers and suspicion of HIV/AIDS.

The findings of the study concluded that unsafe sex was the main cause in making migrants and their families vulnerable to HIV/AIDS. The other factors such as unemployment, alcoholism, exploitation by employers, etc. contributed to making them more vulnerable. The term “PLHA” or “PLWHA” or “PLWA” is commonly used both for people living with HIV positive (PLHP) and people living with AIDS. A study carried out by BNMT during mid-2005 found that it was wrong to call all positives PLHA or PLWHA or PLWA because only few had developed AIDS.

b. Tamang, AL, Rai, C, Karkee, SB, Ghimire, CM & Thakali, P 2006, ‘Migrants, Sex and Vulnerability to HIV/AIDS (Conference Abstract)’, XVI International AIDS Conference, 13-18 August 2006, Toronto, Canada.

Abstract:

Background: The HIV/AIDS epidemic is a threat to health and wellbeing in South Asia. Nepal has concentrated HIV epidemic; and about 60,000 people are infected with it. Migration to India and other countries has contributed for the spread of HIV. A study was conducted to assess HIV vulnerability on returning migrants in Nepal.

Methods: Sixteen focused-group-discussions were conducted with 159 migrants or their spouses in two border districts of Nepal. Mobility-charts, case studies and in-depth interviews were taken from 20 informants. Relevant documents were also reviewed.

Results: Poverty and unemployment were the major reasons for migration. Migrant’s behavior was influenced by changes in social value systems, for example, taking alcohol before sex; use of drugs to enhance sexual excitement; and watching pornography. While staying outside home, most male-migrants (especially the youths) had sex with commercial-sex-workers. They also practiced group-sex with women. Sexual exploitations were done both by employer and migrant: a land-lady satisfied her sexual needs forcefully with her 17-year male-migrant; later, the migrant did it with her 14-year daughter. Employers and their guests had sex with some female-migrants and left them after being pregnant. Returnee-migrants, sometimes, used their skills to exploit females in home country: a 23-year male-migrant convinced a woman from a local market to have sex; and more than fifteen men satisfied their sexual desire with her. People suspected migrant-women of having sex-work. Wives of migrants were also blamed for such act. Most of the migrants used condom during sex. However, they usually did not use it with regular sex-partners.

Conclusions: Unsafe sex, whether forced or in consent, was common among migrants. The migrants are vulnerable to HIV/AIDS; and they can transmit it to their employers, families and communities. Poverty, unemployment, alcoholism, and exploitations are contributing factors. Therefore, plans have to be implemented targeting the migrants to halt the spread of HIV/AIDS.

2003-2006    Operational Research to Improve TB Control Program

Funded by: UK Department for International Development (DFID) through World Health Organization (WHO), Nepal

The Britain Nepal Medical Trust (BNMT), UK

Memoir: In the beginning, I was leading one of the three operational research projects (abstract ‘a’ below). Later, I became responsible for all of the projects and finalized the research reports (abstracts ‘a’ to ‘c’).

a. Tamang, AL 2006, an Operational Research Report on Mobilization of Satisfied Clients to Improve TB Control Program in Siraha District, National Tuberculosis Centre and the Britain Nepal Medical Trust, Nepal.

Abstract:

In Nepal, about 44,000 people develop active Tuberculosis (TB) every year, of whom 20,000 have infectious pulmonary TB; and 6,000 – 7,000 people continue to die every year from this disease. An operational research with control ‘mobilization of satisfied clients to increase case finding rate (CFR) of TB’ was designed and implemented in Siraha district during 2004- 2005. The satisfied clients included female community health volunteers (FCHVs), TB patients, cured TB patients and their family members. A baseline survey was carried out in September/ October 2004. An intervention package was developed and implemented from January to March 2005. The effect of the intervention was evaluated in September/ October 2005.

Results: This study found that informants saying tuberculosis is transmitted by air/respiration increased in the intervention sites (from 1.5% pre to 11.7% post). The informants’ choice of health institution as a place for seeking TB treatment was slightly increased in intervention sites during post intervention phase than in pre intervention phase (96.7% pre to 98.0% post). This was slightly decreased in control sites (99% pre to 98.5 post). All of the TB cases (100%) in the intervention sites during post intervention phase were diagnosed by testing patient’s sputum; and it was only 92.9% in the control sites. Likewise, use of health institutions was increased from 78.3% to 87.5 in the intervention sites. In contrast, it was decreased from 80% to 64.3% in the control sites. Furthermore, analysis of case finding rates showed that it was increased in the intervention sites immediately after the intervention than in the previous reporting period. On the basis of these findings it is concluded that mobilization of satisfied clients can improve case finding rate contributing to control and prevention of tuberculosis. Moreover, the study clearly showed that the case finding rate can be improved during the second quarter of the year if community members were mobilized. Hence, mobilization of satisfied clients can change the trend of case finding rates that are the lowest in the second quarters almost all the times. Therefore, policy makers, planners and program implementers are recommended to use ‘mobilization of satisfied clients’ as a strategy to improve TB control program.

b. Tamang, AL & Karkee SB 2006, an Operational Research Report on Promoting Public-Private Partnership for Improving Tuberculosis Control Program in Eastern Nepal, National Tuberculosis Centre and the Britain Nepal Medical Trust, Nepal.

Abstract:

Overall objective of the study was to promote public-private partnership for improving the TB control activities. The study design was a pre-post comparison. Biratnagar Sub-Metropolitan City of Morang District and Damak Municipality of Jhapa District were purposely selected as study areas. Baseline data were collected between November 2004 and February 2005. The intervention activities took place between March and September 2005. The intervention included motivational sessions/ meetings, workshops and trainings with different categories of service providers. TOR/Plan of action was agreed for each group of providers. The post intervention data were collected between November 2005 and January 2005 (about five months of initiating intervention). Data collection instruments included questionnaires for interviews, and observation checklists/formats.

Results: The project has successfully established/reactivated DOTS center in seven nursing homes/clinics in Morang and one nursing home and one private hospital in Jhapa. These outlets are being managed by the private sectors. DPHOs/DTLAs are supporting and monitoring the activities of those outlets. The study showed that private clinics and nursing homes are also the source of treatment for TB patients. It is evident that if training and awareness were provided then the private sectors are ready, willing and able to carry out the DOTS policy. The participants from different target groups believe that community awareness raising program can be key to improvement of the approach.

c. Karkee SB & Tamang, AL 2006, an Operational Research Report on Effectiveness of DOTS Committees in TB control in Jhapa and Morang districts, National Tuberculosis Centre and the Britain Nepal Medical Trust, Nepal.

Abstract:

The general objective of the study was to identify how DOTS committee can be mobilized to support TB control program. The study design was prospective with pre-post comparison. Baseline data were collected between October and November 2004. The DOTS committees were formed/ reformed. The intervention focused to support the DOTS committees to promote TB control activities at the community level. It consisted of implementation of TOR/ Plan of action prepared and agreed by each committee. The post intervention data were collected on December 2005. The data collection instruments included questionnaires and FGD guideline.

Results: DOTS Committee members managed and monitored the field level activities. Before the intervention, based on the practice, only two DOTS committees were formed by the government in each district. At the end of the study, DOTS committees were actively functioning at each treatment center/ sub-center included in the study. The study clearly outlined the process for activating or supporting the efforts of DOTS committee for community awareness and community mobilization. There is a need to plan participatory activities at district and community level at regular time interval through the support of National Tuberculosis program.

2003-2006    Assessment of Health Situation in Eastern Development Region of Nepal

Funded by: Big Lottery Fund (BLF), UK

UK Department for International Development (DFID) through World Health Organization (WHO), Nepal

Inter-Church Organization for Development Co-operation (ICCO), the Netherlands

Simavi, the Netherlands

The Britain Nepal Medical Trust (BNMT), UK

Memoir: Historically, BNMT changed its strategic plan from vertical programs to integrated programs. In 2003, an intensive assessment of health situation was carried out in 16 districts of eastern Nepal using participatory approaches. For a long period, the organization could not produce a detailed report. I managed to compile the report in 2006 (abstract ‘a’ below).

a. Tamang, AL, Karkee, SB, & Rai, C 2006, Assessment Report 2003: Health Improvement Program, the Britain Nepal Medical Trust, Nepal.

Abstract:

The study on Assessment of Health Status in Eastern Development Region (EDR) of Nepal was conducted with the joint effort of The Eastern Regional Health Directorate (ERHD) and Britain Nepal Medical Trust (BNMT). The objective of the survey was to support the Health Improvement Program of ERHD. The assessment study was conducted in all the 16 districts of the Eastern Region of Nepal. The study interviewed 8061 households (4,026 disadvantaged and 4,035 general), 48 traditional healers and 93 HI in-Charges. 6 FGDs each with health committee members and FCHVs/TBAs were conducted. Interview with 1,311 exiting patients was also conducted. Data were also collected from 59 nursing homes/ private clinics, 83 drug retailers, 84 NGOs and 75 CBOs using structured questionnaires.

Findings: About 5.7% of the household members had fallen sick within the last 15 days of the interview; the incidence was marginally higher in disadvantage segment. About 89% of respondents from the general segment and 73% from the disadvantaged segment had heard about Tuberculosis. Only 61% of the respondents had heard of HIV/AIDS and which was lower among disadvantaged segment (46% as compared to 75%). More females from general households had heard of HIV/AIDS as compared to females of disadvantaged households (70% as compared to 41%). About 66% of the respondents were aware of the danger signs of pregnancy. About 60% of the respondent (67% general and 53% disadvantaged) reported that a child suffering from diarrhea should be treated with ORS. To prevent from malaria, general household members were more likely to use mosquito net compared to disadvantaged households (58% as compared to 34%). The average time to reach the nearest health facility by walking was about 38 minutes (27 minutes in general segment and 49 minutes in disadvantaged segment). About 12% of households (5% general and 18% disadvantaged) reported that they have to walk more than 60 minutes to reach the nearest health facility.

1999-2001    Socio-economic Status and Use of Primary Health Care Services

Funded by: Self-funded

Memoir: This project was for my Master’s Degree Thesis. In the beginning I was interested to do a research about traditional healing. I interviewed 11 traditional healers. Later I dropped that interview and carried out this study (abstract ‘a’).

a. Tamang, AL 2001, Socio-economic Status and Use of Primary Health Care Services: a Sociological Study in Sankhuwasabha District, Master’s Degree Thesis, Tribhuvan University, Nepal.

Abstract:

Socio-economic status (SES) is an important determinant of primary health care practices (PHCP) of community people. This study was carried out to explain the rural people’s understanding about SES, and to show relationship between SES and PHCP. The design of this study was explorative in nature and fieldwork was carried out in four wards of four villages in Sankhuwasabha district in November/ December 1999. Participatory tools namely ward mapping, focus group discussion, ranking by card sorting and semi-structured interview were used. Thirty six informants who had got health checkup from health posts (HPs) within last three months provided information. Additional information was received from health workers of the concerned HPs and members of village development committees (VDC).

Results: The informants categorized the households in four groups and defined them as follows: 1) Rich: Have domestic animals; grows cereals, vegetables and fruits; runs retail shops; holds a job; have income from foreign country; and sells locally produced goods. 2) Middle: Have domestic animals; grows cereals, vegetables and fruits; runs retail shops; holds a job; and sells locally produced goods. 3) Poor: Have domestic animals; grows cereals, vegetables and fruits; earns from portering, fishing, carpentry and masonry; sells locally produced goods. 4) Very poor: Have domestic animals; grows cereals, vegetables and fruits; earns from portering, fishing, carpentry and masonry. Of the 402 households of four VDCs, 52 (13%) were categorized as rich, 144 (36%) as middle, 179 (45%) as poor and remaining 27 (7%) as very poor. The study found that the HPs were under-used by the poor and very poor groups than by the middle and rich groups of the community people.

1997-2000    Hill Drug Scheme and its New Approach: a Brief Report of Thirty Years 1969-1999

Funded by: The Britain Nepal Medical Trust

Memoir: We agreed to evaluate the program and change it to new program in the changed context (abstract ‘a’).

a. Karkee, SB, Tamang, AL & Gurung, YB 2000, Hill Drug Scheme and its New Approach: a Brief Report of Thirty Years 1969 – 1999, the Britain Nepal Medical Trust, Nepal.

Abstract:

In 1969, the Britain Nepal Medical Trust (BNMT) introduced Hill Drug Scheme (HDS) in the eastern hill districts of Nepal. The aim of the scheme was to make essential drugs available to the isolated local communities in remote areas where there were no other sources for getting drugs. During the last thirty years this scheme was implemented in nine hill districts, and more than 70 retailers participated in the program. In this program, BNMT supplies drugs to the HDS retailers at Biratnagar (a town in Terai) wholesale price plus 10% handling charge. The trained retailers sell drugs to customers for 15% mark-up.

During the 1970s the HDS system was very useful for isolated communities. At that time, there were no drug retailers in remote areas. But during the 1980s, a number of private retail shops started their business near the health institutions. Health personnel also started to keep drugs for their own private practice.

The 1996 evaluation and 1998 review showed different issues in the HDS system. Community had no ownership in the HDS system. At present this program has been modified into a community organized drug scheme for the Sub-Health Post (SHP) level. In the new system the ownership is based on local VDC/LHSC, and the drug fund is developed through the village development committee (VDC) contribution, government annual drugs and patient fees. In the initial year patient pay 100% of the drug cost (wholesale price) but in the second year or consecutive years the fee can be revised according to the community decision.

The HDS retailers, community people and district authorities have agreed that the HDS system has fulfilled its aim. The HDS system has developed the capacity of the participants to work independently. According to the DSP Plan, the existing HDS will be completely handed over to the retailers by 2000. Instead of HDS, Community Hill Drug Scheme was gradually introduced at the sub-health post level. In this system, the ownership was on the local VDC/ LHSC. The steps for implementation are similar to the Cost Sharing Drug Scheme.