Remote Area Initiative

In 2014, as part of the GGMS project, CRS through its promising community-based initiative, RAI has been promoting and creating demand for FP, Maternal and Child Health (MCH) services amidst the rural communities, in hard to reach districts of Jumla, Bardiya and Bajhang. During the inception year, RAI covered 41 selected VDCs in these three districts. In year two, RAI was scaled up to 28 new VDCs to cover 68 VDCs and one municipality through 47 CCAs.
At the core of this promising community initiative are the community based change agents (CCAs), who are local woman that are trained to conduct health promotion in their VDCs, disseminate important maternal and child health messages to community women, and also encourage them to adopt their preferred choice of FP method. The main messages disseminated by the CCAs are on: FP, importance of antenatal check-up/ institutional delivery, health and hygiene, prevention and treatment of uterine prolapse.
RAI’s focus on the hard to reach areas stems from the need to breach existing gaps with regard to the quality, demand, access and delivery of FP and maternal health services in rural Nepal.
Reasons for the gaps in these services includes: limited knowledge about FP/MCH issues, limited availability and access to contraceptives, concerns regarding the quality of FP services are all contributing factors for these existing gaps. Underlying complications such as the poor involvement of men in FP, poor participation by socially excluded population, particularly Dalits and Muslims, prevailing myths and misconceptions and lack of awareness about FP and safe sexual behaviour, further exacerbate these gaps. 

The main objectives of RAI are to: create demand for FP/MCH products and services and modern methods of contraception among marginalized and vulnerable groups through targeted BCC interventions; improve FP knowledge, attitude and practice among married women of reproductive age group (15-49) in hard to reach geographical areas; help increase ANC attendance and institutional deliveries; and increase awareness about uterine prolapse and service seeking behavior.
With guidance and oversight of the field team which includes the District Coordinators and the Social Mobilizers, the CCAs play a key role in health promotion by engaging the community women in interactive and participatory ‘women group meetings’ in the VDCs, reaching them with key BCC messages and empowering  them to make informed FP decisions. CCAs are selected on certain specific criteria such as their literacy levels and their influence and reputation in the communities. The selected CCA usually represent the predominant group in the community (for instance if the members are primarily Dalit, then the CCA should be from that community).
CRS staff trains the CCAs periodically, and provides them on-the job training and support to enable them to reach rural women with targeted messages. Generally, one CCA per VDC is selected to conduct women group meetings on the four components mentioned above. In the first year 41 VDCs were covered through 35 CCAs.  In the second year, RAI was scaled up to additional 28 VDCs through 24 CCAs.  In the first year, CCAs conducted separate women group meetings on each of the four components to hone in these key messages and raise awareness among the participants.
To ensure that the women from the community who participated in these meetings, actually retained these messages conveyed during the first year, CCAs in the second year, conducted refresher trainings in the previous VDCs.  CCAs use these refresher meetings to disseminate combined messages about the four key components. 15-20 women typically attend these women group meetings, though there are instances of higher attendance at sessions especially when they are conducted in busy, crowded places.  As a result RAI has often surpassed its targets of sessions conducted and women reached.
Instead of always re-inventing the wheel and establishing a parallel system, CCAs where possible, utilize the existing community based groups such as the mothers group in Bajhang; forestry groups in Bardiya and Poverty Alleviation Fund groups in Jumla to connect with female members of the community.  By building on these existing community structures, RAI helps create synergies and coordination with other services being offered in these districts. 
While, the pivotal focus of the project is to increase the use of modern spacing methods among young and low parity couples, RAI has also played a role in referring the community women to health facilities for different services such as FP, ANC checkups, institutional delivery and treatment of uterine prolapse. The key FP services that women are referred to include OCPs, IUDs, implants (Jadelle) and Injectables (Depo)
Apart from women group meetings, RAI also conducts orientation sessions for school students on HIV/AIDS in these three hard to reach districts, and conducts condom infotainment games for the transport workers and the general community.  It also trains NTOs on HIV prevention and condom usage, thereby motivating them to stock condoms.

A key contributing factor to RAI’s success is that it is truly a community initiative - run by community members, with participation of community members, and where possible, using existing community structures. 
In a short time, RAI has made considerable progress, reaching a total of 178,558 women with the messages on FP, ANC checkups/institutional delivery, uterine prolapses and health and hygiene through 11,141 sessions.
Apart from communication about key issues, CCAs also use the community meetings to identify women with health issues and refer the cases to nearby health facilities. At present RAI is working on formalizing the referral system, by creating a tracking mechanism for following up with health facilities in these districts to see how many women are actually availing of the services. The ‘Achievements of RAI Project’ infographics shows the total number of referrals made by RAI up-to-date.
Based on testimonies gathered from the RAI beneficiaries, these community meetings and interactions, and the referral linkages, have not only increased their knowledge about these issues, but also had a positive impact on the health seeking behavior of the rural women. RAI has also helped empower the CCAs and build their image as change agents and key influencers, and serve as role models amongst their own communities.
In spite of the considerable progress made by RAI, some of the key programmatic limitations include: difficulty finding CCAs in some VDCs, who can be change agents within their communities due to lack of basic education in most of the women of these rural districts. Another challenge is limited exposure of men to the key BCC messages, thus far the target population of all these community meetings have been women, which limits the involvement of men, who are often the decision makers in these communities. CRS is planning to incorporate community meetings with males in the days ahead. Referrals also has its share of challenges, since in these geographically remote areas, women are hesitant to travel long distances to visit health facilities and often don’t have the time to do these visits. CCAs also find it difficult to effectively track the women and determine if they actually availed of the referral services. Finally not all the health facilities have the services that the women are looking for. RAI is hoping to create a more effective tracking mechanism, whereby CCAs and RAI staff can directly follow up with the health facilities on a periodic basis to determine the referrals made.

Keeping in mind the dynamic evolving situation in these hard to reach areas, RAI will always remain highly flexible with unwavering focus and commitment to achieving its key objectives and the national development goals.
The next steps for RAI include geographic expansion of the program to additional VDCs in the current districts as well as other districts with low CPR, creating formal tracking systems for referrals made to the health facilities to determine actual number of referral visits, and creating strong linkages with service delivery initiatives. For instance, to avoid the voluminous uterine prolapse cases, the project shall organize regular health camps in close coordination with government on Uterine prolapses and other health related as per requirement of the local community by introducing new components like STI (Especially the problem suffering from white discharge among the women of reproductive age); Zinc supplement with ORS, and Adolescent in existing program VDCs. RAI will continue to look for ways to enhance its impact and will also look for effective ways to communicate key messages to the male community members who often are the decision makers in these communities.
The next steps for RAI to a great extent will be informed by the mid-line study that will be conducted by an independent research agency with technical assistance from the SHOPS Plus project. This study will help determine the impact of RAI activities which would justify its scale up in other districts and measure the extent of  improvement in knowledge, attitude and practices among the women of reproductive age regarding contraception, reproductive health and maternal and child health.
Building on RAI’s success is working with CCAs, in the future the program may also consider a rural retailer model, whereby CCAs could be trained as rural retailers. This is in line with the needs of rural communities in Nepal, and CRS’s priority to expand and deepen its reach in rural communities.  CRS could explore the feasibility of training the CCAs as rural entrepreneurs, and designing a product basket that would fit with rural health priorities and consumer demand as well as provide a viable income for rural entrepreneurs/CCAs willing to work 25- 30 hours per week.  In this scenario, the VHCs will not be limited to just creating awareness about public health issues and conducting health promotion, but will also sell related products to consumers in their villages to help sustain themselves and their families.

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