Danish Disability Fund
APPLICATION
To be filled in by DPODDisability Fund ref. no.
Date received
B: partnersHIP INTERVENTION (max. DKK 500,000)
or small-scale project (max. DKK 1 mill)
1. Cover page
Grant modality(Insert X) / Partnership intervention: X / Small-scale project:
Danish applicant organisation (financially responsible): / SIND Landsforeningen for psykisk sundhed
Contact person for the project: / Name: Else Lillebæk Nielsen
Email:
Phone: 21 79 77 00
Other Danish partner(s): / No
South Partner(s): / National Organization of Users and Survivors of Psychiatry in Rwanda
Project title: / Organizational capacity building of districts and advocacy of NOUSPRs national administration
Country(ies): / Rwanda / Country’s GDP per capita: 1279
Project period: / Commencement date:
01.2.2018 / Completion date:
31.12.2018 / Total number of months: 11
Total amount applied for: / 199.327 DK
Is this a new activity? / [x ] Yes
[ ] An activity in extension of a previous project, namely:
Is this a re-submission? / (i.e. a revised version of a previously submitted application).
[x ] No
[ ] Yes, date/year of previous application:
Do you want a response letter in / [ ] Danish or
[x ] English
Insert synthesis of the project in Danish
Denne ansøgning vedrører det andet projekt i vores samarbejde med NOUSPR i Rwanda. Projektet fokuserer ligesom det første på at udvikle NOUSPRs organisation; her er det distrikterne projektet målrettes imod. Gruppen af frivillige ledere i NOUSPRs self-help groups (SHG) forøges for at kunne imødekomme den stigning, der har været i NOUSPRs medlemskab. De frivillige ledere trænes i deres peer to peer opgaver i de psykisk sårbares hjem og omgivende samfund med henblik på at styrke og forbedre indsatsen for medlemmernes recovery proces. Samtidig styrkes advocacy indsatsen i forhold til Ministry of Health.
Date / Person responsible (signature)
Place / Person responsible (block letters)
2. Narrative application
- WHAT IS THE CONTEXT AND THE PROBLEM?
1.a The overall context
Rwanda is located in East Africa. The country is land-locked and covers 26.336 km2. It is bordered to the north by Uganda, to the east by Tanzania, to the west by the Democratic Republic of Congo and to the south by Burundi. Rwanda is mountainous and is often referred to as ‘the land of a thousand hills’. Although located only two degrees south of equator, Rwanda's high elevation makes the climate temperate.
Rwanda has a predominately young population with amongst the highest density in Africa. The population is comprised of just one ethnic and linguistic group, Banyarwanda. Christianity is the largest religion although there is a growing interest in Evangelical religion. Kinyarwanda is the predominate language with French and English being used as official languages. Rwanda joined the East African Community in 2007.
The Genocide 1994
After the genocide of the Tutsi population in 1994 mainly two things shaped the current form of the disability movement in Rwanda. Conflict and the genocide had resulted in much greater prevalence of disability: soldiers with disabilities from the battlefield, civilians with disabilities through the conflict as well as the effects of landmines and children impaired because conditions for good health had lapsed in some areas during the 4 years of intermittent conflict. People with disabilities were all more numerous and their needs were listed and recognized by the government as the country emerged from conflict and instigated rebuilding and rehabilitation programs.
Economy
Rwanda's economy suffered heavily during the genocide. Widespread loss of life, failure to maintain the infrastructure, looting and neglect of important cash crops caused a large drop in gross domestic product (GDP) and destroyed the country's ability to attract private and external investment. The economy has since strengthened with per capita GDP estimated at $1785 in 2015 compared with $416 in 1994.This growth, however, is predominately (if not entirely) found in urban areas and the vast majority of NOUSPR’s target group live in poor rural areas.
Mental Health Facilities
In Rwanda, only two psychiatric centers exist - one in Ndera and one in Huye - and few district hospitals have been equipped with basic amenities to take care of mentally ill people.
In the national referral hospital, Ndera Hospital, only 120 beds are available, which in reality accommodate 150 patients. An increasing number of patients seek psychiatric services. Records for Ndera show that 20.124 patients were admitted or attended the hospital in 2006 while 36.392 patients were admitted it in 2010. The environment is therefore crowded and far from ideal for people with psychosocial disabilities. It is expected that the number of people attending Ndera will continue to increase because of a greater awareness of mental health issues. A local approach for providing support is therefore likely to become more important. This is emphasized in the Draft Mental Health Act currently under discussion.
Also, lack of qualified staff re. mental illness is prevalent. Rwanda counts only six psychiatrists and four among them are still following their specializations. So Ndera Hospital relies on only two psychiatrists and one neurologist, who also serve two of the hospitals units (Caraes Butare in Huye and the neuron-therapeutic center Icyizere in Kigali). Whenever a person with mental illness is introduced to Ndera Psychiatric Hospital he/she must pay 10000 RWF before he/she is admitted. Most NOUSPR members find this prohibitive and those that have been abandoned by their families find it impossible.
Due to such treatment circumstances people with mental health problems either have no other choices ore choose to seek treatment within traditional healing systems.
The “Patient Experts:
In 2012 The Ministry of Health called for more local intervention on mental health. The National Organization for Users and Survivors of Psychiatry in Rwanda (NOUSPR) responded to this and with the help of Voluntary Service Overseas (VSO) Rwanda, The Patient Expert Program (PE Program) was developed. The Patient Experts are now one of the core activities in NOUSPR. It consists of self-help groups, led by a person (Patient Expert) who has experienced psychosocial problems. The ideology is that people with psychosocial challenges can support each other through dialogue and conviviality. The group members meet on a regular basis, discuss and support each other in understanding and handling their mental health problems as well as support each other in lively-hood strategies. During time patients, their families and health professionals have started to have confidence and trust in the PEs and they are now often consulted on various occasions. In addition, there has been considerable success in developing working relationships with local leaders.
1.b Specific challenges faced by those groups of persons with disabilities, or their organisations, for whom the project aims to bring about change
Psychosocial disabilities in Rwanda
It is estimated that app. 28% of the 13 million Rwandan population have experienced mental health challenges, most of it attributed to trauma and poverty caused by the genocide in 1994. Mental health problems in Rwanda include several conditions which can be recurring, and extremely disabling. The term ‘psychosocial disabilities’ reflects the challenges that people face as they are often shunned from their communities, exposed to discrimination and abuse as well as challenges in finding work and other responsible duties. Most often mentally ill persons lack the most basic needs. Such discrimination has made them void of normal life as the care of the entire community is missing and to many, mental illness means the end of life.
Patients who are discharged from the hospital will often find that their property has been confiscated by relatives which triggers more disagreements and relapses. Stigma and discrimination have a negative effect on self-perception of even those who have recovered, which consequently impacts their ability to exploit their full potential in contributing to society and providing for their families and themselves.
Limited knowledge and information about mental illness and psychosocial disability, its causes, complications and challenges effect how family members and the community treat people with psychosocial disability. This lack of knowledge has encouraged speculation and superstition about mental illness in Rwanda and has put people with psychosocial disability in a quagmire of discrimination. Chaining and shackling individuals who have mental health problems are perceived to be violent acts against humanity, but still such behavior dominates the treatment.
Organizational development
NOUSPR is an organization in Rwanda advocating for people with psychosocial disabilities. The organization has existed since 2007, and has to some extend achieved psychosocial services coverage for activities, because that is what there has been an opportunity to raise funds for. Accordingly, the fundamental resources for investment in organizational structure and stability have been absent. After several years working with a VSO volunteer administrative adviser it seems there has been insufficient development of NOUSPR’s organization. There has been a lack of funding to cover the organization’s core costs as well as limited efforts to develop a sustainable organization. There was no strategy for fundraising and for incorporating core costs in the funding for activities from various development partners. Finally, there was no strategy or plans to ensure that the staff as well as the board was capable of meeting and handling NOUSPR’s challenges and mission. All in all, this has negatively influenced the financial stability and NOUSPR’s self-sustainability. This situation was a kind of baseline for the first Partnership Project between NOUSPR and SIND Mental Health year 2017. This project was based on a pre-study in October 2016 and the objective was to strengthen the organizational structure in NOUSPR. The capacity in the organization has been strengthened and the economic situation has changed to the better as NOUSPR has been succeeding in getting an application to OSIEA approved for 2017 and 2018. The objectives of this project are mainly focused on human right based advocacy to health workers and administrators at district levels.
- WHICH EXPERIENCES AND RESULTS DOES THE PROJECT BUILD UPON?
2.a Knowledge about or previous experience of cooperation with the South partner
Is the partnership between the Danish applicant and the South partner organisation known to the Danish Disability Fund, i.e. described in (an) other application(s) in previous years?
Yes / X / 129 - 129No
Does the project’s theme lie within the partners’ normal field of work?
Yes / XNo
2.b Assessment of partner capacity
In SMH, we asses that NOUSPR is able to implement and to monitor this project. During the first project year of cooperation the organizational structure has been strengthened and both the board and the staff in the national office, has been trained in their core duties like project management, leadership and administrative management. The board members have been trained in their obligations as board, in communication and in advocacy to be able to perform networking and to advocate for better conditions for people with psycho-social challenges in the communities. NOUSPR has for the time being one other partner, but development of a five-year strategy and a fundraising course for board and staff there is a possibility for establishing more partnerships.
NOUSPR has through their timely reporting and implementing of activities shown responsibility and ability to manage a minor international partnership. During the monitoring visit in September 2017 it was found that the outputs for the first half year of the project was reached and even more than that.
NOUSPR has before partnership with SMH implemented more comprehensive project and they have been cooperating with more organizations at the same time like VSO, OSIEA and ASK. Against these background SMH asses that NOUSPR will be able to implement and monitor the project applied for.
2.c Learning of relevance to the application
The learning the Danish partner SMH will bring into this project is partly attained from the visits at NOUSPR, attending meetings with their board, meeting their members in the communities and the staff at the national office. The first visit with NOUSPR in November 2017 made it clear that the core of the organizations objectives was the Self-Help Groups and their leaders the Patient Experts in the districts. Those volunteers, themselves recovered from psycho-social challenges, are the spear heads in meeting NOUSPRs members in the communities. If SMH wants to improve the life for people with psycho-social challenges we will have to increase the numbers of PEs and develop the PEs capacity through training.
This activity will be a continuation of the capacity building object in the first project. Thus, in this project the main goal will be capacity building in the districts.
2.d Preparatory process
Both NOUSPR and SMH have taken part in the planning of this project. During the pre-study in October 2016 a 7-year partnership strategy was agreed upon, which this project is part of. During a monitoring visit in September 2017 the first outcomes/outputs were formulated together by the application of the model of a problem tree. NOUSPRs board has discussed the formulations and made some changes. The final outcomes/outputs have been formulated of SMH to make them fit into the LFA matrix with the acceptance of NOUSPRs staff. A concept note has been used as a flexible working paper.
- WHAT CHANGE WILL THE PROJECT ACHIEVE AND HOW?
3.a Change which the project aims to bring about
We expect an ongoing capacity building of the organization. The focus in 2018 is on the districts with the direct contact to NOUSPRs members. This takes place through the Self-Help Groups where the volunteering Patient Experts are in leadership. Follow-ups of last year`s objectives are conducted as well.
The number of PEs is increased in the districts and they are in a position to reach the growing number of people with psycho-social disabilities (PWPD) in the communities. They have an upgraded first aid kid and give a first line treatment in public areas and at their home visits. Through trainings they have strengthen their qualifications in peer to peer through recovery oriented medical educational methods and create awareness among the members and care takers on how to support a recovery process. In their peer to peer home visits they use their obtained knowledge in alternative ways of recovery – how - if possible, they can profit from traditional healing, other forms of wellbeing and take their own choices in their recovery process.
NOUSPR take part in the advocacy work regarding influencing the ongoing process about the Rwandan Mental Health Bill. Also, they take part in the pre-visit in Geneva 2018 in the Commission on Rights of Disabled People (CRPD) to articulate their issues on PWPD. They are recognized as an important organization in their network and in the Ministry of Health.
3.b Target groups– among whom will you achieve change?
Primary target group:
NOUSPR as organization and its membership are the primary target group as the focus is on capacity building the organization in the districts. There will as well be follow-up from the capacity building program which took place in 2017. In the districts the PEs will be increased to a number of 5 in each district in 15 districts. As the membership of NOUSPR has increased through the registration in 2017 and there in general are more people with a psycho-social challenge in the communities, a raise in the number in PEs has been necessary to reach more members.
To provide the PWPD with a qualified peer to peer effort the PEs needs to strengthen their skills and capacities through training. The PEs is NOUSPRs direct contact to its members and all activity from the national office goes through the SHG where the PEs is in leadership. Strengthening the volunteering PEs and their work in the SHGs is therefore of great significance to NOUSPRs organization.
Secondary target groups:
The secondary target group of this project is the app. 1600 members of NOUSPR as well as all individuals with a psychosocial disability in Rwanda. They are the right holders and the beneficiaries of a development of the organization on a district and a national level. The members will benefit from well trained PEs and the extended knowledge the PEs will have on peer to peer educational methods and the extended number of PEs in the SHG.
The mental health authorities and the Ministry of Health are the targets for advocacy for improved health care and treatment in hospitals on local, district and national level to people with psychiatric disabilities. The Ministry of Health is lawmakers on these issues and the authority to facilitate changes in the mental health care system e.g. through the Rwandan Mental Health Bill. To influence the content of the bill is a focus area for NOUSPR. The mental health bill will allow the recognition of rights for people with psychosocial disabilities to know the type of medication they are taking, for how long, side effects and to ask questions and discuss treatments with the health professionals. Also local health insurance to cover the therapy and non-medication coverage is a very important issue for NOUSPR.