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End-term evaluation report of Mainstreaming Mental health in Nepal through Self. Advocacy Project (2016-2021)

Summary of the evaluation: End-term evaluation report of Mainstreaming Mental health in Nepal through Self. Advocacy Project (2016-2021) Funded by HimalPartner Background: Nepal is one of several low- and middle-income countries, where mental health issues are poorly addressed. Over the past few years mental health disorder has been increasing in Nepal, due to several reasons. Even though Nepal has ratified numbers of international human rights conventions and documents (including UNCRPD), people with mental health problems are often discriminated and excluded from the community, from receiving treatment and other basic rights. Moreover, they are considered as a burden to the family, society, and nation as well as incapable and unproductive.   Purpose/objective:The overall project goal is to increase the national budget to the need of mainstreaming mental health into general health. The key components of the project consisted of sensitization of state agencies and political parties and influencing them to review and adopt laws, policies, and programs that promote and protect the human rights of persons with mental health problem. The project emphasized advocacy and awareness of human rights of persons with mental health problems in order to promote equal human rights and to reduce all forms of barriers against them. Methodology: The evaluation study used quantitative and qualitative approach of data collection. The study collected data from Bagmati and Gandaki provinces of Nepal. The national information related to the project were collected through desk reviews and interviews of national and federal stakeholders. The respondents in this evaluation were people with mental health problem, government officials, political leaders, human rights defenders, community representatives, self-help group members and self-advocates at federal level and province reached by the project. They have participated in this project through interviews, group discussions and documents review.   Key findings: Relevance: The project is relevant in relation to the context, country policy and the methodology used. The project was successful in organizing and building advocacy capacity of people who experienced mental health problems. The strategy working with different stakeholders at national and local level was relevant. Despite of the appropriate approach applied by the project, it was found that there was a wide gap in the application of strategy with the activities focused on federal level with limited horizontal and vertical links at subnational and local levels. Effectiveness: The project had ambitious indicators and targets at both outcome and output levels. The project has achieved most of the log-frame targets. A few indicators exceeded the targets while some others were under achieved. Measuring changes in awareness level, reduced stigma and changes in attitudes towards mental health among the public and policy planners could be important indicators in a mental health project, which the evaluators noticed missing in this project. Nonetheless, as reported by the study participants, it was found that the project was successful to bring some changes in public attitude towards mental health. The key project activities, such as policy reviews, training, communication and advocacy tools/materials development and their use were reported effective in general. Moreover, all the activities run by the project found relevant and effective. Both duty bearers and right holders expressed that they were benefitted directly and indirectly by the project. Impact: Both the beneficiaries and stakeholders including government authorities reported that the project is having an impact in multiple aspect such as influencing on policy planning, increasing mental health service (counselling and treatment) access of person with mental health problem. Moreover, self-help group (SHG) members reported that the project enhanced their capacity for self-advocacy and claiming their rights. However, the evaluation team think that all those achievements are limited, not realized fully, and sustaining change. In relation to the budget allocation by the government in mental health, it was increased more than double from 2016 to 2020. From the year 2018, budget for health sector had been allocated at the province and local level as well, however, it was not possible to track down the allocation in mental health. Sustainability: The project was successful in creating an enabling environment for the long-term viability of project initiatives engaging SHGs and enhancing their capacity. Also, coalition building with various actors including other right-based organizations for advocacy and working with government in service development are good examples towards sustainability. Recommendations: Overall, the project was successful to achieve its objectives. The project had numerous strengths and learning. This offers several recommendations in which most are mentioned below: The project focused on national level advocacy intending to strengthen tertiary care services, whereas the mental health knowledge and service gaps is huge at local levels. Future projects should therefore focus on all levels for advocacy and service development. Advocacy needs to influence the media's portrayal of real issues in society, and that is a continuous process. This process should be designed to help advocacy groups to be more effective in their advocacy and generate the policy change they are seeking. The evaluation found that the project involving SHGs was an appropriate strategy, however they were not developed well and built their capacity for self‐advocacy. More attention should be given in capacity building and institutionalization of the group. It was found that duty bearers especially at local level, had poor understanding about mental health issues and had no idea about the health service provision at local level government system. It is recommended to sensitize local representative and authorities in this issue and help them in local service development integrating with primary healthcare system. More awareness program is needed to expand the people’s voice. Mental health promotion program, psychological support/counseling is needed to increase or expand at community level. Citizen’s participation, particularly the involvement of vulnerable and excluded such as persons with mental health problem was found completely ignored at local and subnational planning and policy process. It is recommended in future projects to be designed for the promotion of target group participation in government planning and policy process. Knowledge production and sharing/dissemination: as mental health is a complex issue, stigma associated and there is very limited knowledge and understanding about it among the public and stakeholders, it is strongly recommended for knowledge and evidence production through case studies, research in various aspect of mental health and its sharing/dissemination could be very important and is proved an influential means for advocacy and policy formation. Comments from the HP/Digni, if any: HimalPartner is impressed with Koshish and all that they have been able to achieve through this project. Koshish has written a thorough management response to the final evaluation. All the recommendations are taken seriously, and they have either been accepted or partially accepted, all explained with reasons. The recommendations have also been considered in the planning of two new projects with HimalPartner starting in 2022. Digni is pleased to see that Koshish has incorporated many of the timely and relevant recommendations in the new project starting 2022, such as targeting provincial and local levels, as well as more actively using media in the activities funded by the mental health funding stream.