Bricks or Scaffolding, Working with the Health Services

Presentation by:

Dr Neil Hamlet
(Director Tuberculosis Leprosy Project International Nepal Fellowship )
Mid West Region
NEPAL

Address:
INF TLP, PO Box 1230, Kathmandu, Nepal
Fax: +977 83 20389, E-mail: tlp@inf.wlink.com.np

Bricks or scaffolding? The permanent or the transient?

On site until the building is finished and tested, or to be removed by a set time scale? Scaffolding on a building site, a picture of the relationship of NGO support to local or national TB programmes of government. All to often as NGO's we find ourselves literally 'in with the bricks'.

Turning to the analogy of a ship, are we mostly involved in strengthening the hull? Creating a solid watertight foundation on which TB services can be built. Building the basics? Sadly all to often we concentrate on building our own superstructures, highly visible yet in the end damaging to the infrastructure we came to serve.

This presentation is about questions not statements.

These and many other issues need grasped and wrestled with. I intend to lay my project's experiences before you as bait. Take the meat, wrench it apart and let's explore honestly the issues we are all to often afraid to touch for hurting ourselves, our donors, or our host governments.

I invite you to pull holes in my arguments, to state the opposite, and take this conference right into the arena of honest exposure and exploration of answers which fit our experiences.

I will demonstrate the development and current state of operations within my NGO by OHP's and a slide set.

Please seek to constantly be asking yourself. If I were up front what would I be saying? How did my NGO handle that problem?

Before I introduce you to INF let me quote you a statement from WHO.

'For the poorest of the poor, the services provided by NGOs may be their principle source of health care. It is our impression that ministries of health are sometimes inclined to take non-governmental organisations for granted whilst NGOs are often too wary of establishing a close relationship with government. The resulting lack of dialogue interferes with the establishment of partnership and coordination of effort which is essential if the limited resources of both are to be used effectively in providing access to the most vulnerable. Much more attention needs to be given to this issue. It is our observation that full NGO involvement in the formulation and implementation of health policies is a vital step in building stronger working relationships.'


John Martin
Division of Intensified Cooperation
WHO

So who is INF? And what is TLP?

The International Nepal Fellowship (INF), the oldest INGO in the Kingdom, has been working in the west of Nepal since 1952. INF runs health projects & support programmes in various areas including; disease control (Tuberculosis and Leprosy), community health, government hospital assistance, drug education. In 1995 these projects employed approximately 500 national staff. There are currently 140 adult expatriate members of INF drawn from 13 different countries.

INF is a Christian organisation, which seeks to serve the people of Nepal on an impartial basis without regard to political or religious persuasion.

The Tuberculosis Leprosy Project (TLP) operates as a named counterpart to the National Tuberculosis and Leprosy Programmes in the Mid West Region.

In fact to be here without the Regional Director of Health is like going to a formal occasion without my wife. Without my wife by my side only part of me is here. Without the Regional Director of Health, only part of the Project is here today. We are in a partnership as committing as marriage.

But let's turn to our roots. For most NGOs a lot of the present policies and activities can be explained by our past decisions be they conscious or unconscious.

This chart lays out the salient features:

THE HISTORICAL PERSPECTIVE

1952-1984 : TB CLINICS

1985-1987: HEALTH POST BASED FIELDWORK

From this patient cure based approach the Project moved to more of a Public Health perspective in accepting responsibility for TB control in a few districts in the Mid West Region.

1988-93 :INTEGRATION & SERVICE FACILITATION

The district field programmes were linked as closely as possible to the District Public Health Offices and the respective government officers requested to oversee certain aspects of INF field staff operations. A growing relationship developed between NGO and Government health services at the district and health post level. A natural progression towards integration of services was occuring.

1994-1997 : THE REGIONAL COUNTERPART ROLE

Our role now is one of partnership under national and regional guidance and regulation. I believe this has been a healthy maturation of INF's involvement in TB services in Nepal.

Having described the current relationship that TLP has within the National TB Programme we must now look at the operation area and physical difficulties of the location.

INF OPERATIONAL AREA -THE MID WEST REGION

ELEVATION



COMMUNICATIONS


POPULATION

Having set the backcloth we now turn to review the Project Statements, Aims, Policies and Strategies. These statements are critical to planning our units and their annual activities. It cannot be overstressed that clear 'statements' are the key to effective management of the project. Please note that although this presentation is in the context of the role of NGO involvement in TB control, the project I represent has dual disease responsibilities and this is reflected in equal weighting to both diseases in our project statements.

PROJECT STATEMENTS

PROJECT AIM PROJECT AIMS

With respect to tuberculosis

To assist HMG/N in it's National Tuberculosis Programme in the reduction of mortality, morbidity and transmission of tuberculosis to such a level that it is no longer a public health problem in the Mid West Region.

With respect to leprosy

To assist HMG/N in it's integrated leprosy control activities so that leprosy is eliminated as a public health problem in the Mid West Region.

To provide appropriate medical & social care during and after MDT treatment for individual leprosy patients, to prevent impairment and hence reduce disabilities, deformities, handicap, dehabilitation and destitution.

PROJECT POLICIES

To work in close co-operation with the National Tuberculosis Centre, Central Leprosy Unit, Regional Director of Health and District Health Officers in support of the National Tuberculosis Programme & National Leprosy Control Programme.

Support of HMG in the implementation of the National Tuberculosis Programme and National Leprosy Programme through the integrated Basic Health Services. This process is achieved by means of training of Government health manpower, motivation, supervision and support.

Close evaluation of Project activities and outcomes, including the impact of the integration process on the quality of services.

PROJECT STRATEGIES

Provision or facilitation of all components needed by tuberculosis and leprosy control programmes, particularly as defined in the Development Plan for the National Tuberculosis Programme 1995-1999 and the Development Plan for the National Leprosy Control Programme 1995-2000.

To provide accessible, acceptable and sustainable tuberculosis & leprosy services through the Government Basic Health Services at District and Health Post level, as well as INF operated Referral Clinics and other NGO clinics.

Achievement of sustained high rates of case detection through passive case finding. For tuberculosis this will be by microscopic examination.

Achievement of sustained high rates of cure/completion of treatment.

Use of the nationally approved regimens of Short Course Chemotherapy (SCC) for Tuberculosis and Multi Drug Therapy (MDT) for Leprosy.Provision of logistics expertise and some supply including small set up capital needs and supplies.

PROJECT ACTIVITIES

Field Programme:

District Support. A supervisory team is placed in each district in which there is an active tuberculosis or leprosy field programme. This team of one to three INF staff works closely with the District Heath Officer and his staff. Most teams are dual disease trained.

Regional Support. Additionally there are staff placed at Regional level to assist HMG staff in the planning and operation of activities. Below them are four Area Supervisors who have responsibility for 3-4 districts each. This strong emphasis on supervision is one of the key elements of TLP support to the National Tuberculosis and Leprosy Programmes.

Referral Clinics:

Static. These clinics act as referral points for the integrated field programme of surrounding districts. TLP Clinics are situated in Surkhet, Ghorahi, Jumla (and Nepalganj from March 1996). Another INGO, TEAM, runs a clinic in Chaurjhari, Rukum District which was incorporated into the network of referral services for tuberculosis and leprosy patients in 1995. Each centre provides outpatient and inpatient services with the emphasis on Prevention of Disability activities for leprosy patients. Daily health worker supervised retreatment regimens are given to tuberculosis patients on an inpatient basis until sputum conversion takes place. Centres also provide clinical training opportunities.

Mobile. A landrover based leprosy service currently operates in some health posts of the high case load districts of Banke & Bardiya. It is hoped to restructure this service in the near future to provide a monthly 'mobile referral clinic' service at each district centre accessible by road. The emphasis would be on Prevention of Disability activities.

Laboratory Services:

There is a laboratory attached to each Clinic where AFB sputum & skin smear reading and other standard laboratory procedures are available. Training and Quality Control is given to District Health Office (DHO) laboratory assistants.

Training Unit:

Initial and refresher training and post training follow up is given to all levels of Basic Health Service staff and INF staff according to the training programmes of the national tuberculosis and leprosy programmes.

Health Education Unit:

This unit supports all Information, Education and Communication activities relating to tuberculosis and leprosy control. The unit is active at national, Regional, district and community levels in planning, and implementing key activities together with HMG and other NGO health educators.

Logistics:

TLP provides the logistics management necessary for the timely distribution of HMG leprosy and tuberculosis medicines from Kathmandu Logistics and Management Division to District Health Offices in the Mid West Region. Laboratory chemicals, anti-reaction leprosy drugs and other items are provided in kind by TLP directly to the District Health Offices.

Research & Evaluation Unit:

This unit maintains the database for all patient statistics and reports received from the reporting treatment units in the Region for both diseases. It reports regularly to district, Region and centre.

Perhaps more important than all the talk of activities and grand plans for the future is an NGO's insight into it's own mortality. How many of us have clear 'endpoint' when we will withdraw. This is increasingly the first question asked by new donors.

At present our stated endpoints are as follows but the project is currently seeking to be much more specific in endpoint planning.

PROJECT END POINTS

Sustainable TB control activities as measured by :

P+ve Cure Rate > 85%
P+ve Case Finding > 70%

Phased withdrawal of INF support with maintenance of the above rates over the withdrawal period.

Thus far we have not looked at the matter of INPUTS. Yet how many of us struggle to find the necessary funding or manpower. Like baking a cake we must pay attention to finding the ingredients before we can begin to hope for any success when the mixture emerges from the oven.

Serious attention to available inputs takes us away from the dreamland of desired 'impacts' or 'outputs' and back to the practicalities of what is possible with limited resources.

Of the 5 'M' that make up the Input equation I would underline the importance of MANAGEMENT and MOTIVATION. These two are the only way to maximise the usefulness of the other three. NGO's should be models of motivation and management.

Project Inputs

Having a realistic approach to our limited resources we then can move on to set clear and measurable OBJECTIVES. In TLP we have moved to using a unit based Logical Framework Analysis format. Once again this is increasingly requested by donors and we have found it very helpful once the concept was mastered. The effort is well worth while. This is the LFA for our 1996 Plans and Targets....

UNIT(S) SUMMARY OF OBJECTIVES INDICATORS & TARGETSASSUMPTIONS & RISKS
Field & Referral ClinicsHigh rates of sputum positive tuberculosis case detection Overall Project case finding rate of 70% for sputum positive cases. *

Minimum district case finding rate of 60% for sputum positive cases *

Assumptions: Accuracy of our ARI data; applicability of Styblo formulae.

Risk: Encouraging case finding in districts with poor case holding

Field & Referral Clinics High cure rates for sputum positive tuberculosis cases detected Overall Project cure & completion rate of 75% for new sputum positive cases. **

Minimum district cure and completion rate of 60% for new sputum +ve cases. **

Assumptions: Reliability of follow up smear examinations, and data collection systems (both old & new.)

Risk: Potential for reduced compliance with new regimen with non-combined drugs.

Field & Referral Clinics Full implementation of new NTP policies National regimen, protocol, manuals & R&R system in use in all clinics & districts. * Assumption: Access given to HMG staff for training in new policies.

Risk: New R&R system is heavily dependent on DTLA posted & active in each district.

Field Extension of field programme, as requested by NTP Extension of tuberculosis services into two new hill districts, Jajarkot & Rukum. * Assumption: Adequate HMG staffing levels in these districts (DTLA, laboratory, BHS), without which there would be risk of poor service.
Referral Clinics Extension of referral clinic services Building work kept to schedule on new referral centre in Surkhet. ****

Open a new referral clinic in Nepalganj. ****

Assumption: Full donor funding

Risk: Nepalganj Clinic needs to develop as a support, rather than an alternative, to the integrated field programme.

Laboratory Assist the development of functional HMG network of district laboratory microscopy services District level sputum microscopy services operating for at least 8 months per year with acceptable quality control in at least 7 out of 10 districts. * Assumptions: QC slides will be sent appropriately. Reliability of data collection systems (both old & new.)

Risk: Staff not posted, or not active in the districts.

Training Unit Effective impact of regular training programme Maintain level of TB trained government health workers above 60% in all districts. * Assumption: Access given to HMG staff for training in new policies.

Risk: Non-correlation between training and subsequent activity

Turning tables such as the above Logical Framework Analysis into reality require a full understanding of the realities in the field. The following summary points outline the issues as I see them in TLP.

Life at the Cutting Edge: - What happens in the District?

The Players - District Health Officer

The Plan - Currently Monthly Clinic Day

The Practice - Manpower muddles

The Props - Formal/On-the-Job Training

These issues will be demonstrated in the slide presentation to follow

However the key point must be that Action in the Field leads to Advocacy at the Centre and visa versa.

At this point we will break for questions and discussions and here are some starters:

Points to Ponder

  1. Are we transparent and thereby tangible?
  2. Integration of Inputs - is it possible?
  3. Can manpower migrate?
  4. 'In kind' or 'in cash'?
  5. Should NGO's be entrusted to use government resources?
  6. Is communication the key?

Summary Following Slide Presentation:

Measurements of Involvement

1. At the Strategic Level:

2. At the Implementation Level

Where the bricks are cemented in place, the scaffolding is coming down.


Images of Integration

1. Everest towers above all other mountains. Yet for many centuries it was unrecognised, hidden by it's remote location, and the clouds which surround it. It is a killer mountain yet rarely will we hear of the deaths that occur on it's slopes year upon year.

2. Tuberculosis as a public health problem towers above other health concerns. Similarly the dimensions of the TB epidemic lie concealed behind other closer concerns. TB is a major killer yet rarely do our papers inform us of the claimed lives. As a treatable disease and one of the most cost effective interventions available it is shocking that so little has been done to banish this disease. TB has become an Epidemic of Injustice.

3. I therefore need no persuasion that involvement in control of TB is a worthy cause for the Christian Non Governmental Organisation (NGO) that I represent or indeed any NGO active in the health sector in the developing world.
Here is Surkhet valley, 600km west of Kathmandu. Surkhet is the regional centre for the Mid West Region, the largest, remotest and least developed of Nepal's 5 regions. The International Nepal Fellowship's (INF) Tuberculosis Leprosy Project (TLP) is located here.

4. This is the dawn light over Libang , the district centre of Rolpa, one of the 11 districts in which TLP are assisting the government in delivering integrated TB and leprosy diagnosis and treatment services through the existing Primary Health Care (PHC) network.

5. The challenge lies in the task of delivering sustainable services in these steep and remote mountain valleys.

6. Behind the breathtaking views lies the harsh realities of subsistence agriculture for families such as these.

7. These villages seem to have been suspended in time. Sadly this is reflected in short life expectancies. The average life span in this village in Mugu is 37 years.

8. In such mountain communities, there is much seasonal and occupational migration. Another mountain of a challenge to TB control.

9. Sadly, this is often the result. This man came for treatment for his TB. But he came to late and died on arrival. Our only service to this man and his community was to bury him. The death toll for TB in Nepal is equivalent to one air crash evey 6 days at Tribuvan airport. TB is estimated to be the number one killer of adults in Nepal.

10. This young man did get treatment for his TB, but he was given inappropriate medications from the private sector and quickly developed a multi resistant strain. He too died but not for LACK of treatment. He died because of POOR treatment.

11. Women and children are also struck down. Our wards are full of scenes such as these. TB is a disease of families, hitting the wage -earners and the mothers and infecting the children who carry the legacy of TB into the next generation.

This is the backcloth. Those are the problems. Now to the solutions.....

12. This is the nerve centre of Tuberculosis control in Nepal. It is here that the policies are set for the National TB Programme (NTP).

13. From the centre comes the framework for operations as laid out by WHO a number of years ago.

14. These 9 key operations are a useful guide when assessing the priorities for supporting government services as an NGO.

15. It is at this point that NGO's such as INF can step in at the request of government,. Their value relates to how well their activities can be harnessed by the host government to achieve a seamless framework. Patchwork quilts look nice but soon fall apart at many places!! So can NTPs when made up of many differing pieces.

Here is the INF as I like it to be seen. Not a pretty building in a central location but rather a service being carried into the hills.

16. Our target groups are villagers such as these, where a chronic cough is not a matter for concern. So how do we raise awareness of TB in the community?

17. A cured patient is the very best health education message. This woman will get the news back to her community that TB is curable.

18. In Europe it was known as Consumption. What are the local names given to TB in our area? The sociological aspects of TB control are far too often underplayed. This is dried meat, 'sukuti' an apt description for the disease which consumes. As NGO's we can play a large part in local health education initiatives grounded in the necessary socio-cultural understanding.

19. We use health education notice boards like this on the side of our Project Office.

20. But more significant are the boards set up in the hill bazaars and bus stands around the region.

21. This is a village committee. INF has sought to raise awareness among all such village leaders and political leaders by visits and a region wide mailing exercise. Similarly much work is done in schools where INF staff will take classes with the children and teach the teachers about TB and Leprosy.

22. Here are Community Health Volunteers (CHVs) receiving training by government staff with materials prepared by the INF training unit.

23. Simple things but they make a difference. Here is a notice prominently displayed outside the government health post giving the date of the next TB clinic.

24. Here is a typical middle hills Health Post where a monthly clinic has been running for a number of years originally under the responsibility of INF visiting staff, but now fully in the hands of the local government staff.

25. The first problem is finding someone willing to handle the sputum and fix it on a slide. Not always easy. INF has taken the initiative to train the peons (caretaker, sweeper, ward tea lady), as often more senior staff find it menial and 'dirty'. This alternative approach is working well in many places.

26. Then the prepared slide must find it's way to the nearest working microscopic centre, which is usually at the district centre many days walk away. INF has been working for years, training, equipping and monitoring district labs to undertake this critical task. Progress is slow with frequent staff transfers and low work performance. But successes also occur. Here is well stocked lab operating out of a Primary Health Centre.

27. Sadly though, the norm is for slides to be brought to the nearest INF referral centre where the INF microscopists ensure the job gets done. Please note this is a training microscope so when local staff become available the training cycle can begin again.

28. Returning to our health post and we find a TB clinic in full swing out in the warm sun. Such a scene warms my heart also. This is what it is all about. Remote PHC staff conducting their duties to an exemplary standard. Checking the patient's card.

29. Handing out the medicine.

30. Giving time for the patient and explaining his progress.

31. The patient leaves with his month's supply of drugs. But here is a problem. In this district INF had taken the responsibility of changing regimens to Rifampicin (R) containing Short Course Chemotherapy. The Rifampicin was part of a bioavailable triple combination formulation to protect the R from monotherapy due to patient non-adherance.

32. But now this is the practice. Single combination drugs and an armful of them to last out the next 30 days. The drugs are part of the strengthened NTP and a greatly improved drug logistics system and they are available countrywide. Should INF have continued to buy it's own combination drugs or should we have accepted the new positive steps in TB drug supply in Nepal. As you can see we have stayed in line with national policies.

33. This slide is another joy to my heart. The clinic is over and the health worker is demonstrating his figures that he has charted himself for the last 6 months. He OWNS his data which is vital to quality recording and reporting procedures. A success story.

34. But when you visit other clinics the picture is different. Here is a treatment room where Streptomycin was given using the old regimens.

35. And here are the used needles and other medical debris. A poignant reminder of the dangers of HIV spread through poor clinical practice.

36. As you move further north the facilities become more cramped. This is a Health Post in Jumla, 6 days walk from the nearest roadhead.

37. How can work be done in such conditions.

38. But yet there are committed staff who have been working there for years. I believe it is here that NGO's can have a major input. With what I called earlier the 'friendly face factor' in the form of regular assistance and non-threatening technical supervision.

39. The visits of senior officials can be a great boost to such workers, but obviously this cannot be a regular arrangement.

40. In the month by month business of a TB clinic the arrival of the INF team to give a hand and get the work done is essential due to the low staffing levels in many health posts. Here we see the INF staff working in the health post alongside the government workers on a TB clinic day. In this health post it would be wrong to stand back and 'supervise'. The need is to get the job done together.

41. The pressure of work is taken off and that means time can be taken with the individual patients and proper health education given to a newly diagnosed case.

42. Support can also come in assisting the timely transfer of drugs and other consumables from Regional Stores seen here....

43. ..to the cupboard in the Health Post to be available at the next clinic day. At present INF has been delegated responsibility for the logistical supply of the government NTP drugs. INF money which was once sunk into purchasing drugs is now used to set up logistical delivery systems which can operate within the government health care administration despite the difficulties of terrain and communication in the Region.

44. Adequate recording and reporting is a key operation of any NTP. INF had it's own system in place at all treatment centres. Here is the old INF District Register so vital to calculate cohort outcomes.

45. Monthly cross sectional data was also collected and displayed so staff had a clear picture of the TB workload across the district.

46. The management of district TB activities requires planning so charts like these can plot out activities month by month.

47. Since those last three slides were taken, there has been the intensification of the NTP in Nepal and other government initiatives to streamline data collection and reporting. Now these NGO data systems are being dismantled and our energies are channelled into making the new NTP system of reporting work efficiently at the local level. The measure of the usefulness of an NGO may not lie in what it can set up for itself, but rather what it is prepared to dismantle.

48. Staff motivation and ownership of data has been a central feature of INF's field teams. Meetings were held 6 monthly where staff would travel in from all corners of the region and spend 2-4 days analysing each others data and setting new personal targets for the next 6 months. Such peer group review meetings are recognised to be an important part of effective NTP's.

49. Now these meetings have been replaced by quarterly data collection meetings for the government DTLA's. Another example of 'giving way' to the emerging needs of the new NTP.

50. Regular supervision in the field has not changed however. INF has a three tier supervisory system so that local and district level workers know that interest is being shown in their work. Such supervision can be painstaking as registers are cross checked with patient cards and laboratory records.

51. It's not just the health post staff who need the encouragement of a visit. The District Health Officers, and Public Health Officers must be fully informed of INF's role in the district. Without such face to face communication it is easy for the frequently changing local decision makers to see the assistance of a counterpart NGO like INF as a cop out clause from their responsibilities.

52. From these frank and impromptu field meeting INF can bring the practical realities direct to the table of the NTP co-ordination meetings in Kathmandu. We have come full cycle from that first photo of the National TB Centre. Thus the policies can be adapted to fit the constraints as INF can act as the ears and eyes in the districts and then sit as partners round the table.

53. Then when the official face of the NTP is presented before the Health Minister, and the International Partners we speak as one voice with authority.

54. But back to Surkhet and the face of the 4 referral clinics which act as safety nets to the field programme. This is the INF TB Referral clinic in Surkhet. Such referral centres do not exist in the NTP 5 year Plan although they are recognised and requested within INF's 5 year Agreement with government. How best can such facilities find their place as a support to the NTP? When is an NGO clinic obsolete?

55. The facilities are undoubtedly better and more patient and staff friendly. Here is the registration desk at our Ghorahi clinic.

56. The laboratories located within these clinics are critical to the field work. Training and quality control are major components of the work.

57. We have the capacity to perform cultures but this facility is kept for retreatment cases and studies on primary and secondary resistance patterns in the Region. Cultures are sent to Kathmandu for sensitivity testing by another NGO.

58. The numbers of patients receiving first line treatment has dropped year by year in this clinic as patient's diagnosed are referred back out to their nearest health post. Here is one aspect which is all but obsolete as the NTP capability gains momentum and more importantly the trust of the communities.

59. For our in-patient wards the story is different however. As we stringently apply the rule that all patient's requiring second line treatment must be 'hospitalised' or come daily for fully observed treatment until sputum conversion occurs.

60. These patients are in the main young people. This photo is typical of the clientele on 2nd line treatment in our clinics. Despite requests, we have found district hospitals unwilling to take such patients into their wards for fear of transmission.

61. Training undergirds the capabilities of the field work. The clinics form a base for clinical and technical training. INF accepts secondments from government training institutions while also monitoring the level of trained staff in the districts and providing training when required. It is a bottomless pit scenario due to the frequency of government staff transfers.

62. For such trainees we demonstrate how clinics can be managed. For example in the layout of filing for record cards as shown here or in the storage of medicines.

63. Research opportunities can be made available to medical elective students like this visiting student from Germany.

64. So back to my desk, littered with papers and not a stethoscope in sight. Doctors are, in the main, recognised to be poor managers. Could the same be said of NGO's who seek the glamour of hands on patient care? It is a painful lesson to make the step from the clinical model, one to one doctor (or nurse) - patient relationship to the less tangible public health responsibility of viewing the district population as your patient. In cutting the chain of transmission of TB there is no other perspective but that of peripheral health worker based TB services. As NGO's are we monoliths to the old ways or models for the future?

65. We need long term perspectives. It will take this girl's lifetime to see measurable changes in the risk of infection (measure of transmission) of TB in her community.

66. DOTS may well be the solution for these ambulatory TB patients in the sprawling border towns.

67. But how do we fully observe this man who is many days walk from his nearest functional TB clinic? NGO's can be the probes to find local initiatives which work.

68. Nepal has a timelessness much of which is centred around the hills which do not change as health policies do year by year.

69. Our public health endeavours will be reaped by the next generation so how do we keep our donors happy with year by year reports of our 'progress' and 'successes'?

70. But the clock is well advanced in Asia. Multi resistance to TB drugs is rising. And the deadly duo of TB and HIV is taking hold in many countries. We have little time to prepare ourselves for the wave of new cases brought by HIV. NGO's must be involved. To not do so is like Nero watching Rome burn.

71. Quoting Prince Aga Khan, ' To the habitual formula of ill, pill and bill, we should try to add will.' Motivation and management is the key.

72. In the centuries old battle against this bacteria, we are moving towards either a sunrise of success, or a sunset of all hopes. I believe in Nepal thanks to the synergy of an ever strengthening NTP and the stability of committed NGO's we are moving towards the dawn.

Neil Hamlet
Director
INF Tuberculosis Leprosy Project
Mid West Region
NEPAL
11/2/97