Reestablishing Health Shelters in Quake-affected Areas in ... · Reestablishing Health Shelters in Quake-affected Areas in Gorkha and Sindhupalchok Districts PROJECT COMPLETION REPORT

Reestablishing Health Shelters in Quake-affected Areas in

Gorkha and Sindhupalchok Districts

PROJECT COMPLETION REPORT

(July 17, 015 - March 31, 016)

Submitted To:

Apotheker Ohne Grenzen (AoG)

action medeor (am)

Submitted by:

SOCIAL WELFARE ASSOCIATION OF NEPAL

KATHMANDU, NEPAL

(10 May, 2016)

SOCIAL WELFARE ASSOCIATION OF NEPAL

(SWAN)

Reestablishing Health Shelters in Quake-affected Areas in

Gorkha and Sindhupalchok Districts

PROJECT COMPLETION REPORT

(July 17, 015 - March 31, 016)

ACRONYMS

AoG - Apotheker Ohne Grenzen

am - action medeor

BC - Birthing Center

CGI - Corrugated Galvanized Iron

DHO - District Health Office

DPC - Damp Proof Course

DPHO - District Public Health Office

HDP - High Density Pipe

HF - Health Facility

HFOMC - Health Facility Operation and Management Committee

HP- Health Post

HWs - Health Workers

MoHP - Ministry of Health and Population

MoU - Memorandum of Understanding

PCC - Plain Cement Concrete

PHCC - Primary Health Care Center

PPICD - The Policy Planning and International Cooperation Division

RCHC - Rural Community Health Center

RRM - Reinforced Retaining Masonry

SHP - Sub Health Post

SWAN - Social Welfare Association of Nepal

VDC - Village Development Committee

WFP - World Food Program

ACKNOWLEDGEMENT

This project was implemented in financial support of action medeor and Apotheker Ohne Grenzen and in close coordination with Ministry of Health and Population, District Public Health Office, Gorkha, and District Health Office, Sindhupalchowk. SWAN sincerely acknowledges all of them for their valuable supports provided during the course of implementation of the project. We also express our sincere thanks to Ms Eliette Fischbach from AoG, Ms Margret Muller from action medeor, respective HPs, HFOMC members, community, SPHA Mr Mahendradhowj Adhikari from DPHO, Gorkha, SPHA Mr Sagar Rajbhandari from DHO Sindhupalchowk, technical teams from MoHP and SPHA Mr Sagar Dahal. We would also like to express our thanks to the SWAN board members for their continuous support and guidance throughout the project implementation.

Dhurba Shrestha

Program Manager

EXECUTIVE SUMMARY

This report is prepared to share the achievements of the project "Reestablishing Health Shelters in Quake affected Areas in Gorkha and Sindhupaclhowk Districts". The project was implemented in the financial support of action medeor and Apotheker Ohne Grenzen from 17 July, 2015 to 31 March, 2016 with an objective to "reestablish at least 15 health shelters at Gorkha and Sindhupalchowk districts so that the (earthquake) survivors have easy access to quality basic health care services".

Due to the fuel crisis (from October-December) and redesigning of the health shelter, there was rise in the unit cost of a semi permanent health center. In Jan, 2016 we agreed to extend the time period until 31st March and construct only 11 semi permanent health shelters.

SWAN constructed 8 semi permanent health shelters by the end of the 31st March, 2016. It also provided medical equipments and furniture in all these health shelters. Among them, 6 semi permanent health shelters in Gorkha have been handed over to the community. The reconstruction of these semi permanent health shelters along with the supply of furniture, medical equipments and the basic medicines was a crucial step in restoring the delivery of the basic health care services in the communities in a physically safe, clinically hygienic and technically equipment spaces. Approximately 38,400 people are receiving regular services from these 8 health shelters.

Project Completion Report on Reestablishing Health Shelters Page 1

CHAPTER: ONE

Initial Situation and Target Group Analysis

Background On 25 April, a 7.8 magnitude earthquake struck Nepal causing severe destruction in 14 out of the 75 districts in the country. Two weeks later, on 12 May, another quake of 7.3 magnitude hit, worsening the humanitarian situation. A total of 8,891 people were confirmed dead, 605,254 houses destroyed and 288,255 houses damaged. During the height of the emergency, some 188,900 people were temporarily displaced. In Sindupalchowk district, 70 out of 79 health facilities were destroyed by the earthquake. Among them 49 health facilities was damaged completely and 21 health facilities had become dysfunctional putting around 287,798 people at high risk of any kind of communicable diseases. Similarly in Gorkha 31 health organization buildings were destroyed completely. Moreover, a total of 44 buildings were in such a condition that health services could not be provided from there. Health facilities meant for providing health care to the locals and these health facilities (HP and PHCC) as frontline public medical facilities provide promotive, preventive and basic curative services to the locals. These health facilities provide basic health care services free of charge to the local people. The health care services they (Health Posts) deliver are outpatient services, maternity and emergency services round the clock. Besides this, they conduct relevant essential minor surgical interventions, drug and diagnostic services led by paramedical health workers. They also identify the referral need and referral services to primary or secondary level of health facility. In the case of primary health care center (PHCC), the services are delivered by medical doctor with paramedic team with laboratory and x ray facility. The earthquake of April 12, 015 not only destroyed and damaged health facilities but it also disrupted and paralyzed all these regular and normal health services to a great extent. In such situation, the establishment of damaged and destroyed health facilities and to resume health services in quake affected areas was considered prime priority to support the District Health Offices, Health Posts and community people to bring the health services towards normalization.

The Humanitarian Response from SWAN Immediately after the earthquake, SWAN Nepal decided to reach to the quake victims for providing immediate relief support. SWAN mobilized and coordinated and reached 560 households with relief packages including medicines in three districts mainly Gorkha, Nuwakot and Sindhupalchowk. SWAN visited Sindhupalchowk in the 4th day of the earth quake and carried out an assessment and coordinated with DHO Sindhupalchowk for the support. During the meeting with DHO Sindhupalchowk, it was found that many of the health facilities were running under the tents as an emergency response. During the field visit, it was found that the health facility that was running under the tent was very hot; it compelled to think us that is tent is not a good solution because the reconstruction of the health facilities would take years. So, it was very important that the semi permanent health facility is built for the transitional period that is physically safe, clinically hygienic and technically equipped. After the field visit, SWAN visited DHO Sindhupalchowk and put the issue in the meeting. SWAN argued that the semi permanent (can survive for at least 5 years) health facility that has safe physical infrastructure, has basic medical equipments, has essential furniture and has adequate medicine is necessary and this has to be done in a package. The concept was highly accepted. As its immediate response, SWAN reached out to 4 VDCs of Sindhupalchowk district and 2 VDCs of Nuwakot and constructed 4 temporary and 2 semi permanent health shelters. With the successful completion of construction of these six health shelters, SWAN further decided to collaborate with other partners to construct a similar type of health shelters in other quake affected areas and collaborate with Apotheker Ohne Grenzen (AoG) and action medeor (am) to construct additional 15 semi permanent health shelters with some modifications in design in Gorkha and Sindhupalchowk district.


Target Group for the Support: Almost 90 percentage of health facilities were damaged completely or were dysfunctional by the earthquake. At this point every health facilities were in dire need of the post recovery and reconstruction work. SWAN coordinated with District Health Offices (DHOs). 10 health facilities in Gorkha and 5 health facilities in Sindhupalchowk were allocated to SWAN for the post recovery and reconstruction work. The target health facilities allocated to us were of mixed type. Few of them were remotely situated and few of them were situated nearby the district headquarter and were easy for the access. For example, Gankhu is situated in a distance of 2 hours and can be reached by bus throughout the year where as Ranchowk at Saurpani, Dharapani at Jaubari are remotely situated and are accessible only through foot in monsoon and by jeep in winter season. Among the allocated health shelters, all were dysfunctional and were being operated under the tent except in Gankhu. The service at Gankhu was being delivered from a VDC building which was situated at 30 minutes walking distance from the health facility and had to climb the hill. Among the 8 constructed, 6 were completely damaged and 2 were partially damaged. However, the partially damaged health facilities were also in a state of collapse. Any time they could fall down and services from here were being given from the tents. The majority of the population (90%) receiving health care services are of Gurung in Ranchowk and Dharapani. In Gunsakot and Baruwa the majority of the population (90%) is of Tamang community. In Gankhu, the composition of dalits, janajatis (tamang) and others is almost of equal composition. In Borlang, Sera and Ratamata the majority of the population is of Brahmins and Chettries. The composition of female population is higher to the male in all VDCs.

S.No. VDC Name Total HHS

Total Population

Male Female Dalits Janajati Brahmin Chhetri

1 Borlang 1179 5044 2281 2763 837 2612 1595

2 Dhuwakot 1110 4259 1850 2409 1068 1477 1714

3 Gankhu 694 2986 1348 1638 743 1379 864

4 Jaubari 740 2987 1338 1649 628 1725 634

5 Saurpani 1125 5958 2614 3344 819 3499 1640

6 Baruwa 487 1831 932 899 66 1662 103

7 Gunsakot 449 1902 1000 902 49 1851 2


CHAPTER: TWO

PROJECT ACHIEVEMENTS

Objective of the Project:

The objective of the project is to reestablish at least 15 health shelters at Gorkha and Sindhupalchowk

districts so that the survivors have easy access to quality basic health care services.

Expected Outcome:

15 health shelters spaces of 80 square feet of 3 rooms will be constructed with water and

toilet facilities.

Each health shelter will have essential medical equipments and furniture including examination and dressing tables to deliver basic health services.

(On 26 Jan, 2016 SWAN and am-AoG revisited the project and did some amendments. Based on

these amendments, we revised the objective and the expected outcome.)

Revised Objective of the Project:

The objective of the project is to reestablish at least 11 health shelters at Gorkha and Sindhupalchowk

districts so that the survivors have easy access to quality basic health care services.

Revised Expected Outcome of the Project:

11 health shelters spaces of 80 square feet of 3 rooms will be constructed with electricity,

water and toilet facilities.

Each health shelter will have essential medical equipments and furniture including examination and dressing tables to deliver basic health services.

Achievements in relation to the Project Goal and Objectives:

By the end of March, 2016 construction of 8 semi permanent health shelters has been completed and

4 of them have been handed over to the community. 2 semi permanent health shelters in Gorkha and

2 semi permanent health shelters in Sindhupalchowk have not yet been handed over. The medical

equipments and furniture have already been supplied to all the health shelters.

The patient flow in the health facilities before and after the construction work is also observed high.

The total patient flow in the month of Nov-Dec, 2015 (before construction) was 1479 and the patient

flow of the month of April-May, 2016 was 1992. The increase of female patients was 881 to 1233

during the same period. For detail please see in the Annex 5.

Description of actual outputs compared to planned outputs:

SNo Activities Planned Output Actual output Remarks

1 Coordination with DHO and site assessment

Data collection of fifteen health facilities Letter of DHO to health facilities to support SWAN in reconstruction of HS

Data collection of twelve health facilities (10 in Gorkha and 2 in Sindhupalchowk) completed. DHO Gorkha has coordinated with health facilities for the reconstruction work.

2 Coordination with MoHP and signing of MoU

Signed MoU with MoHP Hand over a copy of signed contract agreement between SWAN

MoU signed between SWAN and MoHP on Sept 01, 015 DHO Sindhupalchowk and Gorkha handed over the MoU between SWAN and MoHP


with MoHP to respective DHOs

3 Hiring of construction team

Contract agreement

12 skilled man powers hired from Kathmandu during September-October, 2015 and 10 were hired during Jan-March, 2016.

4 Purchase of construction materials

All the construction materials are stock in SWAN office / Sites

Total 52 vendors; 6 vendors for electronic items, 6 vendors for aluminum sheet, 6 vendors for paintings, 4 vendors for sanitary items, 10 vendors for construction (hardware) materials, 6 vendors for metal works, 4 vendors for transportation, 3 vendors for medical equipment, and 4 vendors for plywood and 3 vendors for furniture items submitted the quotations. Construction material for Gorkha was purchased from Gorkha and construction material for sindhupalchowk was purchased from Banepa, Kavre.

5 Coordination with health facilities (in charge and health facility operational and management committee)

Availability of the site to construct Health Shelter

10 health facilities in Gorkha district and 2 health facilities in Sindhupalchowk have been coordinated and site has been fixed in these 12 health facilities.

Among the sites visited we constructed semi permanent health shelter in 8 sites.

6 Selection of the construction site

Availablility of adequate, safe, and accessible site for the health shelter

6 sites (Gankhu, Sera and Ratamata in Dhuwakot, Dharapani in Jaubari, Borlang and Suryapani) have been selected in Gorkha district. 2 sites (Baruwa and Gunsakot) have been selected in Sindhupalchowk district.

7 Reconstruction of health shelter

Health shelters (safe from excess cold and heat) with water and toilet facilities according to agreed design standards

Construction of 8 semi permanent health shelters completed by 31st March, 2016. Among them 6 health shelters are in Gorkha and 2 health shelters are in Sindhupalchowk.

In the first agreement we agreed to construct 15 semi permanent health shelters. In the revision of the agreement in Jan 26, 2016 we agreed to construct 11 semi permanent health shelters.

8 Supply of medical equipments, furniture and medicine

Availability of necessary medicines, equipments and furniture in the HSs

Medical equipments and furniture supplied to all 8 semi permanent health shelters.

We purchased 10 sets of medical equipments and furniture for Gorkha. Among


them, we used 2 sets from the same set to Sindhupalchowk. Still 2 sets of medical equipments and furniture are at Gorkha store.

9 Monitoring and Supervision

Approval letter from the DHO/MoHP Monitoring Visit after Handing over

The approval letter (handover certificate) from DPHO Gorkha has been obtained for 4 semi permanent health shelters. 2 approval letters (handover certificate) from Sindhupalchowk and 2 approval letters from Gorkha has to be obtained yet.

We could not handover 2 health shelters in Sindhupalchowk and 2 health shelters in Gorkha before 31st March, 2016.

10 Handover of the shelter to the HFOMC

Handing over of the operational health shelters to DHO representative and Health Workers

4 semi permanent health shelters in Gorkha handed over to health facility operation and management committee.

11 Reporting Interim Reports Project Completion Report

One interim report prepared.


CHAPTER: THREE

PROJECT PLANING

Coordination with DHO and MoHP: The Policy Planning and International Cooperation Division (PPICD) in Ministry of Health and Population (MoHP) was the responsible division at Ministry of Health and Population to handle all the post recovery and reconstruction work in the health sector. At district level, District Health Office had this authority. Social Welfare Association of Nepal (SWAN) coordinated with DHO at district level and PPICD at national level. There was a team of infrastructure at PPICD, who looked after and approved the design of the infrastructure. SWAN closely worked with District Health office Sindhupalchowk, District Public Health Office Gorkha, technical team of infrastructure at PPICD and the PPICD throughout the project completion. The district health offices assisted SWAN in selecting the health facilities, coordinated with health facility management committees and the health workers. They also participated in the monitoring process and hand over process. Similarly, the infrastructure team gave feedback in the proposed health shelter design and approved it. Based on this approved design of the health shelter, the PPICD signed the MoU with SWAN. The PPICD also organized monitoring visits at field, organized meetings and gave feedbacks to partners. These were very crucial steps in implementing the projects. Status of Health Facilities (Assessment of Health Facility): SWAN developed individual health facility assessment tool to identify the status of damages of health facilities made by the earthquake. The need assessment was done regards to types, accessibility, patient flow, damage made, availability of furniture, medical equipments, medicine and availability of the health workers. The allocated health facilities were situated close to district head quarter as well far from the district head quarter. All the health faculties had road access (Jeep/Bus) but only for the six months. During the monsoon, the access to these health facilities was only possible through foot. Transportation of construction materials was almost impossible in the monsoon. They were situated close to the road (Gankhu) and very far (Jaubari, Saurpani, Gunsakot and Baruwa). Among the 8 health facilities we reconstructed, 6 were completely damaged and 2 were partially damaged. However, the services were being delivered through tents. The partially damaged health facilities were also dysfunctional. The health workers were mentally suffered, medical equipments were damaged, and furniture was also damaged. Many of the medicines were out of stock. Despite these challenges, the health workers were serving the people.

SNo Name of the HF

Type of HF

Status of HF Access

Patient

Enro

lme

nt

No o

f H

Ws

Level of D

am

age

Availability

Befo

re E

art

hq

uake

After

eart

hq

uake

Furn

iture

Equ

ipm

ents

Med

icin

e

1 Baruwa Health Post HP Tent

Jeep/ Foot 188 302 3 1 2 3 2

2 Gunsakot Health Post HP Tent

Jeep/ Foot 200 347 3 1 2 3 2

3 Gankhu Health Post HP

VDC building

Jeep/ Foot 314 500 5 1 2 3 2


4 Borlang Health Post HP Tent

Jeep/ Foot 381 488 7 2 3 3 1

5 Dharapani, Jaubari RCHC Tent Jeep/ Foot 166 232 3 1 3 3 1

6 Ratamata, Dhuwakot HP/BC Tent

Jeep/ Foot 463 526 5 2 3 3 1

7 Sera, Dhuwakot RCHC Tent Jeep/ Foot 86 144 2 1 3 3 2

8 Ranchowk, Saurpani RCHC Tent

Jeep/ Foot 123 235 2 1 3 3 2

Note: HF - Health Facility HP - Health Post RCHC - Rural Community Health HWs - Health Workers 1 - Completely Damaged 2 - Partially Damaged 3 - Not Fully Equipped 1 - Available 2 - Partially Available Jeep/Foot - 6 months Jeep (Dec - May) and 6 months foot (June - Nov)

SWAN's Design of Semi permanent Health Shelter and the Working Modality: SWAN proposal of reestablishing health facilities in Gorkha and Sindhupalchowk district was to provide immediate support to health workers to provide quality basic health care services to the people in a physically safe, clinically hygiene and medically equipped environment. For this, SWAN proposed to construct a semi permanent health shelter of 3 rooms of total space 24x10 square feet with concrete foundation. We proposed to use metal for poles, side bars and the truss, CGI sheet for the roof and the wall and waterproof plywood for the inside wall and the ceiling. The technical team suggested to install electricity, aluminum plain sheet and enamel painting in the inside wall to the proposed semi permanent health shelter and approved the design. SWAN used a team of 10 members to construct temporary health shelters in Sindhupalchowk. Same team was used to construct these semi permanent health shelters in direct supervision of Technical Advisor. The unskilled labors were used from the community as per the need. Signing of MoU with MoHP and Extension of the Time Period: On Sept 1, 2015 SWAN and MoHP signed in an agreement to implement the Reestablishing Health Shelters in Quake affected Areas in Gorkha and Sindhupalchowk district. The agreement was signed by PPICD chief Mr Mahendra Shrestha from MoHP and Mr Khem Thapa from SWAN. The project was planned to complete by 15 Dec, 2015. However there was problem in fuel supply, this forced to stop the work. In 22-23 November, 2015 MoHP called a meeting of all partners and discussed on the issue. All the partners requested for the extension of the time period. Accordingly, SWAN proposed MoHP to extend the time period until 31st March, 2016. At the mean time, SWAN coordinated with am-AoG for the extension of the time period until 31st March, 2016. On first week of Jan, 2016 we received extension letter from MoHP and on 26th Jan, 2016, am-AoG agreed to extend the time period until 31st March, 2016.


CHAPTER: FOUR

PROJECT IMPLEMENTATION

Formation of Project Management Team: In the leadership of Executive Director, SWAN deployed a team of program manager, emergency analyst assistant, finance assistant, admin officer, technical advisor, field supervisor cum store keeper and construction members. A technical advisor was also hired for short period of time and construction team members were hired in a daily basis for the period of construction of the health shelters. The finance assistant and admin officer procured all the construction materials and recorded all the financial transactions. Preparation of Detail Work Plan: SWAN together with Ms Eliette Fischbach discussed in a detail work plan to reconstruct health shelters during her visit to Nepal in 25 August, 2016. We submitted the final work plan to am-AoG on 14 September, 2015 based on the same discussion and the format suggested by Ms Eliette Fischbach. The work plan was prepared based on the following criteria:

- The construction work for one health facility is 10 days for 10 persons excluding travel days. - Engineer will stay whole construction days in a first health shelter and guide the construction

team. - After completion of a first health shelter, two construction teams will be mobilized separately

to complete the work in time. - Engineer will visit health shelters two times; once during the site plan and second when the

construction is complete. - Field supervisor will visit each site before the construction work begins to coordinate with the

health workers and the health facility management committee. - Handover will be done after the completion of each health shelter.

However, after the completion of the first health shelter at Ganku, we experienced blockade and the transportation of the construction materials halted due to fuel crisis. After the construction of two health shelter (Gankhu health shelter and Sera, Dhuwakot health shelter) we had to stop our construction work. Our worked resumed on January and second detail work plan was submitted to am-AoG by the end of Jan, 2016. Coordination with Health Facilities and Discussion on Design: SWAN organized a coordination meeting in each health facility with health workers and the health facility management committee members. The purpose of these meetings was to prepare a ground work for the construction work. The field supervisor visited each site prior to the reconstruction work begun, met health workers and health facility management committee members, organized a meeting and discussed on the roles and responsibility of SWAN, the health workers and the health facility management committee. In each health facility, the design of the health shelter was also discussed. We used local labor force and the local materials as per the field need. The health facility management committee members helped SWAN to identify the local labor and local materials like sand, aggregate and stone. In Dharapani in Jaubari, the water was a big problem. There was not enough water for drinking too. The health workers and management committee members facilitated to use the water for construction work. Selection and Hiring of the Construction Team: SWAN constructed 6 temporary health shelters in SIndhupalchowk and Nuwakot immediately after the earthquake. During this construction a construction team of 10 members was formed. These were the dedicated team members. They had working experience in the emergency and had skills and knowledge that our construction work needed. Therefore, SWAN management team hired the same working team to work in Sindhupalchowk and Gorkha. Besides, SWAN also selected a technical advisor to provide technical support to the construction team. Purchase of the Construction Materials SWAN purchased the construction materials following to the SWAN financial guidelines and the financial guidelines as stated in the contract agreement. The purchase of the goods included


collection of quotations, selection of the vendors, purchase order, original bills, payment bills/vouchers and receipt. While selecting the vendor, lowest bid amount were selected. Different 10 tenders were invited to purchase the construction materials. The tender invited were in electronic items, aluminum sheet, paintings, sanitary items, construction (hardware) materials, metal works, transportation, medical equipment, and plywood and furniture items. Total 52 vendors; 6 vendors for electronic items, 6 vendors for aluminum sheet, 6 vendors for paintings, 4 vendors for sanitary items, 10 vendors for construction (hardware) materials, 6 vendors for metal works, 4 vendors for transportation, 3 vendors for medical equipment, and 4 vendors for plywood and 3 vendors for furniture items submitted the quotations. Construction Work: In the initial agreement SWAN proposed to construct 15 health shelters (10 in Gorkha and 5 in Sindhupalchowk district). But due to fuel crisis and increase in the transportation cost, SWAN reworked in the budget and agreed to construct 11 health shelters. Among the 11 health shelters, 4 were proposed at Sindhupalchowk and 7 were proposed at Gorkha. However, SWAN could complete only 8 health shelters by the end of the extended period. Among these 8 health shelters, 6 were built at Gorkha and 2 were built at Sindhupalchowk.

The health shelters constructed is of three rooms with space of 80 square feet (8x10 sq feet) for each room. It has a concrete plinth (base) of 12 inches above the ground level. The floor is cemented. 8 metal poles of 2x2 inches have been used for the support with side bars. The outer wall of the health shelter is of CGI sheet and inner wall is of water proof plywood of 6 mm thick. The roof is of CGI sheet. The ceiling is of 6 mm thick waterproof plywood. There is 24 hours water supply in the health shelter. For this, a tank of 500 liter is placed in each health shelter with regular supply of water. The water is distributed in toilets and the rooms inside. There is a two room toilet in each site. To keep the health shelter technically hygienic, we have placed aluminum sheet in the inner wall up to 1.4 meters high from the ground level and have fitted electric systems in six health shelters.


The foundation of the health shelter is 3 feet. The portion of the foundation below the ground level is 2 feet and above the ground is 1 feet. At the bottom of the foundation is a stone soiling of 6 inches high. Above that is a PCC work at the ratio of 1:3:6. 16 mm Iron Rod has been used as a reinforcement bar and this reinforcement bar has been covered round by PCC work at the ratio of 1:2:4. 8 mm distribution bar is also used here. Above the ground level there is earth filling, stone soiling of 6 inches, PCC work of 3 inches, course

plaster and plaster punning. The metal poles have holes at the bottom and these metal poles are fixed under the ground inserting the reinforcement bar of 16 mm. There are total 8 metal poles and are fixed the same way. The wall of the health shelter is of CGI sheet and waterproof ply wood. The outside wall is of color CGI sheet of 0.41 mm and the inner wall is of waterproof plywood of 6 mm thick. The aluminum sheet is put in the inside wall therefore it is easy for the health worker to clean the wall. These sheets and plywood are fixed at metal side bars. There are 4 trusses. These metal trusses support the roof. We have used 0.41mm thick CGI color sheet in the roof.


DETAIL OF THE WALL AND THE ROOF

In each site we have built 2 rooms toilet except in Baruwa. The materials used in the construction of the toilet are same that is used in the construction of health shelter. The foundation under the ground is 2 feet and above the ground is 1 feet. The reinforcement bars and distribution bars are used as used in the health shelter. The wall until 1 meter high from the ground is of stone mortar and above that is the CGI sheet. The metal poles are used in the corners and side bars are supporting them as a structure. The roof is of color CGI sheet. In Gankhu we have constructed wall using stone mortar.

There is a good water and sanitation system designed in each site. There is 24 hours supply of water. The wastage water and wastage from the toilet is collected at safety tank. We also installed 500 ltrs poly tank in each site. The water is supplied inside the health shelter and toilet 24 hours through this tank. We also supplied HDP pipe in each health shelter to join water from the main source. The electricity is fitted in 6 health shelters. 2 health shelters which were constructed before November, they do not have electricity and aluminum sheet in the inner wall. Technical Support to the Construction Team: To assist construction team technically and to ensure the construction meets the agreed design we hired technical advisor in a short term basis. The technical advisor guided the construction team


staying at the first site (Gankhu health shelter) throughout the construction period. In other sites, the technical advisor visited the site as per the need and supported the construction team. In Sindhupalchowk, Mr T.M. Shrestha was hired. He stayed in the site throughout the construction period and supported the construction team. Deviation in the Plan: In the first agreement in 17 July, 2015, we agreed to construct 15 health shelters. Due to fuel crisis and the increase in the transportation cost and labor cost in October-December, we reworked in the budget and concluded that we can construct only 11 health shelters from the agreed budget. Among the 11 health shelters, two health shelters were constructed before 15 Dec, 2015. Therefore, in January, 2016 we agreed to construct additional 9 health shelters with the remaining budget. Although we agreed to construct 11 health shelters all together, we could complete only 8 health shelters by the extended time period (31st March, 2016). In the first proposal we submitted, SWAN proposed that wooden post and wooden side bars will be used for the construction of health shelter. When we further discussed with DHOs and the MoHP they suggested for the metal post and the metal side bars. When the cost was calculated, the price of the wood and the metal was similar. Therefore we used metal poles and metal side bars in construction of all health shelters. In Gankhu, we constructed toilet using the stone mortar. Our original plan was to construct wall of a toilet with stone mortar wall up to 1 meter and then construct wall of CGI sheet. This was the change in the original plan in case of Gankhu. Rest of the toilets is constructed as per the original plan. In the original design of the health shelters, the windows are in the back side. In Gankhu, we placed windows in the back side. But, the DHO and community people requested to place windows in the front side. Except in Gankhu, the windows are placed in front in other sites. SWAN signed the agreement with am-AoG in July 17 and with MoHP on 1st Sept, 2015. We were already one and half months late to start our project. SWAN started its work in 13 Sept, 2015 in Gankhu. When SWAN completed 2 sites, SWAN had to stop the work due to fuel crisis. SWAN stooped its work on 13th Oct, 2015. Due to earthquake all the roads that connect Nepal to China was also closed. The blockade in the Indian boarder lasted for almost 3 months. During that time, we had no option except closing our work. This resulted in a deviation of work plan in the first. In 22-23 Nov, 2015 PPICD organized a consultation meeting with development partners. This consultative meeting made a request to extend the time period of the construction work. The high level meeting of the secretaries, extended the time period. We received extension letter in the first week of January, 2016. The approval of extension of the time of the project was agreed by am-AoG in 26th Jan, 2016. We planned 10 working days for 10 persons to construct one health shelter. The first site took 16 days to complete. It took more than the planned days because all the construction team members needed thorough guidance. Also we constructed stone mortar wall for the toilet. This took more days in construction of toilet than the planned days. Some of the sites completed in 10 days and some of the shelters took even 12 days. This also affected our work plan. In Sindhupalchowk, we hired local labors but they were not skillful enough. We had to wait to the team of Gorkha to complete the work in Sindhupalchowk. Handover of the Health Shelter: Until now, 4 health shelters have been handed over to the community people. The handed over health shelters are Gankhu, Sera in Dhuwakot, Dharapani in Jaubari and Ranchowk in Saurpani. The health shelters in Gankhu and Sera were handed over in November and December, 2015. Dharapani and Ranchowk health shelters were handed over in March, 2016. Two health shelters in Ratamata and Borlang in Gorkha and two health shelters in Sindhupalchowk (Baruwa and Gunsakot) are yet too handed over. All the health shelters were handed over in the presence of District Public Health Office (DPHO), Gorkha or the representative from DPHO, Gorkha.


CHAPTER: FIVE

MONITORING AND EVALUATION

SWAN together with DHO conducted the monitoring and supervision of the reconstruction work to ensure that the health shelter was constructed as per the agreed design and fulfills all the criteria as specified. The monitoring and supervision was also conducted to assist working team by providing on the spot technical feedback where as necessary and assist in timely completion of the construction work. Monitoring by Technical Advisor: SWAN technical advisor visited each site two times. Once before the construction work begun to plan a site and instruct construction team how and where to construct the health shelter. This included health shelter plan, sanitary plan and the toilet plan. Second visit he carried was after the completion of the health shelter whether the health shelter constructed is as per the agreed design or not and whether it meets all the technical specifications or not. Monitoring and Evaluation by DHO and MoHP: While the construction work was going on, the DPHO and the DPHO representatives from Gorkha and Sindhupalchowk visited the construction site and observed the construction work. The DPHO Gorkha visited Gankhu and Sera in Dhuwakot in September-October and gave a feedback to make changes in the health shelter specifically to install electricity, aluminum sheet and the painting. They also said that the rooms are of small size, are less in number and therefore they suggested to construct health shelter of 6 rooms. After lots of discussion with DPHO Gorkha and technical team of MoHP, we agreed to construct 3 rooms space health shelter, install electricity, put aluminum sheet in the inner wall and paint the inner wall. The MoHP team also visited Gorkha in the month of Jan, 2016. They did not visit our sites physically but talked to DPHO and SWAN staff in the field. Based on that, the MoHP suggested SWAN to follow MoHP guidelines and construct prefab structures with 6 room spaces if SWAN is going to construct more health facilities in the future. Monitoring and Evaluation by SWAN Board: In February 2016, the Chairperson Mr Krishna Karki visited Dharapani in Jaubari and observed the construction work and talked with construction team members. Others who participated in this visit were program manager and the technical advisor.


CHAPTER: SIX

ISSUES / CHALLENGES AND ITS RESOLUTION

During the implementation of the project we faced lots of issues and challenges. Some of the challenges were resolved within the management team; some were resolved with the support of partners and some of the challenges were out of our control. SWAN tried its best to resolve these issues timely and operate the project smoothly. The major issues / challenges and our efforts for the resolution are described here in detail. Delay in the signing of the MoU: The delay in the signing of the MoU was due to allocation of the same health facilities to two organizations and the design of the health shelter that we proposed for the reconstruction of health shelter. Few of the health shelters we were allocated in Sindhupalchowk were allocated to other organizations too. For example, the Baruwa and Marming were given to SWAN as well as to American Nepal Medical Foundation. Similarly, Simple Kavre, Hagam, Baramchi was allocated to SWAN as well as to MdM France. For this a meeting with DHO Sindhupalchowk and PPICD was organized. SWAN requested DHO Sindhupalchowk to give a letter of recommendation. We also visited DPHO Gorkha and requested DHO to provide us a recommendation letter. Based on these recommendation letters, the PPICD finalized the names of the health facilities to SWAN. When we started our first reconstruction work (May 16, 2015) in Sindhupalchowk, the government had yet not started the reconstruction work. The government was providing tents for the shelter. With am-AoG, we agreed to continue the same temporary health shelter in other VDCs of Sindhupalchowk and Gorkha district with some modifications. These modifications were done after the lesson learnt from the Sindhupalchowk. For example, the base of the health shelter was raised by 1 foot high above the ground and the height of the health shelter was increase to 7 feet from 6 feet. We also planned concrete foundation and floor so that the floor is easy for cleaning and is permanent and therefore when the community constructs new health center, the same foundation could be used. We planned inner wall of 6 mm thick waterproof ply to maintain the temperature inside the health shelter. All these modifications were done in consultation with technical team in MoHP. Based on these feedbacks SWAN signed MoU with am-AoG in 17, July 2015. SWAN submitted proposal and agreement to MoHP in 25 July, 2015. The PPICD developed standard guideline for the reconstruction of the health facilities in July. When we read the standard guidelines, the guidelines could be followed strictly when the situation was normal but in the case of emergency these guidelines were restricting the early reconstruction of the health facilities. For example the land and the construction materials that the guideline purposed were not easily available. We wanted to immediately restore the delivery of the quality health services to the people. We facilitated series of meetings to technical teams at PPICD in MoHP, DPHO in Gorkha and DHO in Sindhupalchowk to discuss in the health shelter design. We agreed that when DHOs recommend health facilities for the reconstruction, they will recommend the health facilities that have less land or no land at all. They will also provide sub health post for us for the reconstruction because these health facilities need less space to the health posts. Based on these criteria, the DPHO Gorkha and DHO Sindhupalchowk recommended the health facilities and the MoU was done with MoHP only on 1st September, 2015.. Monsoon: When we signed the MoU, the monsoon was already begun. The roads were wiped away by the land slides in many parts of Gorkha and Sindhupalchowk district. In September, we started our first construction work in Gankhu. After construction work in Gankhu, we moved to Sera in Dhuwakot. Other sites were not accessible by then and we could not form two construction teams in September-October. It took next 2-3 months to repair the roads. Fuel crisis and increase in the transportation cost: We started our construction work from 20 September, 2015 from Gankhu. After we completed the construction work at Gankhu, we moved to Sera, Dhuwakot. When we started our work at Sera, the blockade from India was already effective. This also hampered our construction work in Sera, Dhuwakot. The first impact was in the supply of the construction materials. Due to fuel shortage, the transport of construction materials was stopped and we had to stop our work from Sera, Dhuwakot. The construction team came back to Kathmandu on 13th October.


In October, 2015 we faced road blockade from the south. The blockade lasted for 3 months. However, the effect was until the 5th month. The northern side roads were blocked by the land slides. Due to these blockades the lives in Nepal become miserable. There were no fuel, any gas and food items available. Due to fuel crisis, there was no transport and we had to stop our construction work. The World Food Program was supporting organizations in the transport and storage of goods. It was providing fuels to the organizations. In November we participated in the logistic clusters meeting at Airport in Kathmandu and Deurali in Gorkha. But WFP said that it cannot provide fuel at this moment. The reasons were SWAN was not involved in logistic cluster meetings from the beginning that WFP and development partners were organizing. We also did not use the storage hubs that they were providing because we purchased our construction materials from Gorkha and had our own store room in Gorkha. They said that they will support fuel to the organizations that were involved in the logistic cluster meetings from the beginning and are using their storage hub. This entire situation raised the cost of the fuel 3.5 times higher compared to the regular price. On 26.02.2016 we amended our contract agreement with am-AoG second time which helped to resolve these issues. Proposal to Redesign the Health Shelter from DPHO Gorkha: DPHO Gorkha visited Gankhu and Sera to monitor the construction work and to participate in the handover ceremony. After these visits, the DPHO Gorkha suggested to modify the design of the health shelter. They requested for the 5 rooms space. The DPHO Gorkha clearly said us to further stop the reconstruction work until MoHP revisits the design of the health shelter. SWAN talked with DPHO Gorkha; SWAN talked with technical team in PPICD and agreed to make some amendments in the health shelter design. We (SWAN, DPHO and MoHP) agreed to put aluminum sheet in the inner wall, install electricity and to enamel pain in the wall. We also agreed to continue with the 3 room space health shelter. Revisiting and redesigning of the health shelter was agreed by the end of the Dec and MoHP gave a letter to SWAN to work in the first week of Jan, 2016. Based on the new design of the health shelter, we reworked on the budget and this increased the cost of the construction of unit health shelter. On 26.02.2016 we amended our contract agreement with am-AoG second time where all these costs are included. This amendment says "Due to new requirements as proposed by the Ministry of Health and Population (MoHP) and the District Health Office (DHO) in Gorkha and due to delays in the project implementation, AoG, action medeor and SWAN have agreed to amend the project agreement. This is the second amendment …………. 3. Revised budget with changes within the budget lines. 4. Minor changes in the design of the health shelter." Local Work Force: We planned to use local work force and make two teams. However, local work force was not competent and we had to rely on the one construction team formed at Kathmandu. When we coordinated the health workers and the HFOMC members and talked about the local work

force, they said that there are local work forces available. We also talked to the workers and they said

that they are constructing houses in the community. We briefed workers on the working modality,

working hours and the benefits they receive. The local workers said that they can do. But when the

actual work begun they could not work as our construction team was working and also they were not

skillful enough to continue the work. For example, our team worked from early in the morning to late in

the evening (normally 6:30AM-6:00PM), the local labor worked normal hour (10:00 AM - 5:00 PM) but

demanded the high daily wages. The local workers were not dedicated to the work as our team

members were. This created tension among the workers. It was difficult to team leader to mobilize the

local workers.

This did not resolve our problem fully but was helpful to resolve the issue in some extent. We used local labor to excavate the foundation, mix the sand, aggregate and cement. Where there was need of skilled labor force, we used our first construction team. SWAN was new to the big procurement and this lengthened our procurement time.


Method of Resolution: The method of resolution of the problem was often, to discuss in a team and come up with a conclusion. When we encountered problems, we shared this in a staff meeting in Kathmandu. This team suggested what to do next and gave responsibility to one of the staff members. S/he would contact DHO or contact MoHP to discuss on the issue and come up with the resolution. Series of meetings were carried with respective DPHO, DHO and technical teams in PPICD to overcome these issues. We also shared this to our donors when there was a problem and that needed their support.


CHAPTER: SEVEN

LESSON LEARNT

SWAN started its first reconstruction work of the temporary health shelter (May 16, 2015) in Sindhupalchowk, the government had yet not started the reconstruction work. The government was providing tents for the shelter. SWAN submitted proposal of semi permanent health shelter to am-AoG in the first week of May, we thought that we can initiate our work before the monsoon begins and we can construct them. When we selected the VDCs together with DHO, we requested DHOs to provide VDCs that are even accessible during the monsoon too. There were some administrative procedures that we needed to complete. With am-AoG we signed agreement in July 17. The monsoon had already begun. Meantime, the government announced that any organizations who want to work in the districts, have to sign an MoU with Ministry. We started coordinating with MoHP for signing of the MoU. The MoHP came up with the standard guidelines. These guidelines, if followed strictly would lengthen our construction works. Therefore, we lobbied to go with semi permanent health shelter until there are permanent structures in place. With some modifications, the MoHP agreed to sign the MoU. With MoHP we could sign MoU in 1st September. In October Nepal faced blockade and there was fuel crisis. SWAN had to stop its construction work due to transportation problem. All these pushed us back to our agreed date to complete this project. Our learning is:

There are different layers of decision making and it takes lots of time. Although the proposal was submitted with the view of humanitarian response (emergency response), the decision making followed all the details of a project that runs in a normal situation.

The changes in the government policy affect our decision. When we were designing our proposal we had in our mind that we sign the agreement with respective DHOs. But the government decision prolonged our time to start the project. However, the decision of the Government was good. With this decision, the government deployed the technical team in MoHP, which provided minute technical details that we need to include in our design.

When we did the first amendment in August, 2015 we stocked with the deadline of 15 Dec, 2015 because that was the deadline from the MoHP. We could have discussed with am-AoG that if there is possibility of extending the project time if we do not complete by 15 Dec, 2015. We could not be far sighted. We have to think out of the boxes.

We managed this project from SWAN's existing team. Depending upon the emergency work, risks and the challenges we should have deployed a separate team who were fully responsible to implement this project. The SWAN staff members had to involve in other projects too and this limited their time, effort and direct engagement in this project.

Although we tried to communicate on time, there were cases observed where we missed the timely and appropriate communication to the donors. It is our learning that appropriate communication in time makes project more transparent and helps in smooth implementation of the project.


CHAPTER: EIGHT

VISIBILITY

Meetings:

FIGURE 1: MOU SIGNING AND HANDOVER

FIGURE 2: DISCUSSION ON DESIGN OF SEMIPERMANENT HEALTH SHELTER

FIGURE 3: MEETING WITH DHO SINDHUPALCHOWK


Initial photos of the Health Facilities:

FIGURE 4: BORLANG HEALTH FACILITY UNDER THE TENT

Photos during the Construction:

FIGURE 5: EARTH EXCAVATION AND FOUNDATION WORK AT BARUWA


FIGURE 6: DPC WORK IN THE FOUNDATION

FIGURE 7: FOUNDATION WORK AT GUNSAKOT

FIGURE 8: IRON WORK AT GANKHU


FIGURE 9: ENGINEER FITTING THE METAL TRUSS

FIGURE 10: SETTING OF METAL TRUSS

FIGURE 11: DHO REPRESENTATIVE INSPECTING THE CONSTRUCTIO WORK


FIGURE 42: SAFETY TANK FOR THE TOILET

FIGURE 13: FLOORING

FIGURE 14: MEDICAL EQUIPMENTS AND FURNITURE


FIGURE 15: TOILET PAN AND INTERNAL PART OF THE TOILET

FIGURE 16: HEALTH SHELTER AT BARUWA

FIGURE 17: HEALTH FACILITY AT GUNSAKOT


FIGURE 18: HEALTH WORKER AT DHARAPANI IN JAUBARI AT HER DESK

FIGURE 19: RANCHOWK, SURPANI HEALTH SHELTER

Photos during the Handover:

FIGURE 20: SPHA MR MAHENDRADDHOWJ ADHIKARI HANDING OVER THE HEALTH SHELTER TO COMMUNITY


FIGURE 21: MS MARGRET MULLER AT HANDOVER CEREMONY IN RANCHOWK

FIGURE 22: IN CHARGE SERA DHUWAKOT LOOKING AT THE STOCK

Documents

Reestablishing Health Shelters in Quake-affected Areas in ... · Reestablishing Health Shelters in Quake-affected Areas in Gorkha and Sindhupalchok Districts PROJECT COMPLETION REPORT