Event Date: August 10-11, 2023

Organized by: Prayatna Nepal in Collaboration with Lalitpur Metropolitan City

Number of Participants: 23 Health worker representatives from different health institutions within LMC

Day 1:

The event kicked off with a warm welcome by Jima Lamkoliya, vice-chairperson of Prayatna Nepal who set the tone for the program by introducing the distinguished guests in attendance. Among the guests was Sarita Maharjan, the Health Section Chief of Lalitpur Metropolitan City. In her address, she delineated the key areas of discussion for the forthcoming two-day training session. The primary focus was on establishing accessible and accommodating healthcare services for individuals with disabilities.

Sarita Maharjan delved into the strategies to render health services more accessible for persons with disabilities. She expounded on the significance of addressing infrastructural and structural challenges, emphasizing the importance of creating an inclusive environment. She highlighted the diverse conditions that give rise to disabilities and underscored the existing gaps in disability inclusion within healthcare services. Particularly, she emphasized the need to provide specialized care and create a supportive environment for women with disabilities.

The founder-chairperson of Prayatna Nepal, Miss Sarita Lamichhane, then clarified the program's objectives. She stressed the importance of not only making healthcare facilities physically accommodating but also ensuring behavioral inclusivity. The aim was to create an all-encompassing approach that integrates both structural and interpersonal friendliness towards individuals with disabilities.

Specific Objectives:

1. Health workers will receive information about disability inclusion,
2. Health workers will be able to sensitize women with disabilities about sexual and reproductive health,
3. They will start keeping records of women with disabilities who receive reproductive health services in health institutions.

Introduction:

The participants introduced themselves, bringing a diverse range of perspectives on disability to the forefront. Views included:

• Recognizing physical impairments as a major aspect of disability.
• Acknowledging how various impairments can impede functional capacities.
• Advocating for the recognition of diverse abilities and granting equal opportunities for exploration.

Participants shared their experiences of indirectly supporting people with disabilities in healthcare settings. However, it was evident that they lacked comprehensive understanding in terms of addressing unique needs and accessibility requirements for individuals with diverse disabilities. Notably, a common perception among the majority of participants was that disability primarily referred to physical impairments. This pointed to the need for broader education on the diverse dimensions of disability.

The introductions unveiled a collective willingness among the participants to foster disability-friendly healthcare services. They expressed a strong commitment to expanding their understanding of disability beyond physical limitations.

Following the introductions, roles were assigned for the event's management. Reviewers, evaluators, timekeepers, and entertainment coordinators were identified for the first day's sessions.

Subsequently, the participants' expectations for the training were gathered. These included:

• Understanding the government's provisions for accessible healthcare services for persons with disabilities.
• Learning the steps to create disability-friendly healthcare services.
• Gaining insights into delivering accessible healthcare to individuals with disabilities.

Preceding a brief 15-minute tea and coffee break, participants were given pre-test forms to assess their initial understanding of the subject matter. Consent was also obtained for photography, recording, and documentation purposes throughout the two-day training.

After the break, participants shared their expectations for the training. A prevalent desire emerged among the majority to garner insights into government initiatives supporting healthcare access for individuals with disabilities. Learning how to render healthcare services disability-friendly and developing a nuanced understanding of accessible healthcare delivery were also highlighted.

First Session: Understanding the Evolution of the Concept of Disability

Facilitator: Sarita Lamichhane

In the first session, participants were engaged into groups for discussion to comprehend the historical and evolving concept of disability. The voting process was utilized to explore different perspectives presented in the election manifestos of four distinct parties. Each party's focus on disability was examined, leading to insightful conclusions on the most inclusive approach.

Summary of Discussion:

The four parties' manifestos were analyzed, highlighting their respective approaches towards disability:

1. The First Party: Emphasized the "Charity Model," which historically viewed disability as a cause deserving of sympathy and assistance.
2. The Second Party: Advocated the "Medical Model," where disability was perceived as an individual's medical condition, often emphasizing medical treatment and rehabilitation.
3. The Third Party: Supported the "Social Model," which stressed the importance of society's role in facilitating the participation and inclusion of individuals with disabilities.
4. The Fourth Party: Focused on the "Rights-Based Model," recognizing disability as a matter of human rights and emphasizing the need for inclusion and equal opportunities.

Voting Results:

Following the discussions and analysis of the party manifestos, a majority of participants voted in favor of the "Inclusive Party" (16 votes) and the "People's Voice Party." (7 votes) These two parties received support due to their commitment to holistic inclusion of persons with disabilities, both during the planning phase and through practical measures for genuine inclusion in society.

On the other hand, the "Ramite Party" and the "Social Service Party" did not receive votes, as participants identified their negative outlook on disability. These parties were observed to view persons with disabilities as not entitled to basic education, employment, and other essential services in society. Additionally, they focused on charity-based approaches and social rehabilitation, perpetuating the perception of persons with disabilities as burdens on their families and society.

Overall, the participants collectively emphasized a rights-based approach, recognizing the importance of human rights, inclusion, and positive development for persons with disabilities while casting their votes based on the four parties' manifestos.

Following the voting process, participants engaged in a thought-provoking discussion about the model of disability, and it was evident that some still perceived a lingering presence of the charity model. This perspective has led to the realization of the paramount significance of providing equal opportunities for individuals with disabilities.

The discourse prompted a collective understanding that disability is not confined to a fixed state but rather a condition that can affect anyone at any point in time. This realization underscored the importance of fostering inclusivity in all aspects of life, ensuring that opportunities are extended regardless of one's physical or cognitive abilities.

Subsequently, the facilitator shed light on the concepts of universal design and reasonable accommodation in the context of delivering healthcare services to people with disabilities.

Conceptual Clarity:

Universal design refers to the concept of designing products, environments, and systems that are inherently accessible and usable by a wide range of people, including those with disabilities, without the need for special adaptations or accommodations. It aims to create inclusivity from the start, considering diverse needs from the beginning of the design process.

Reasonable accommodation, on the other hand, refers to the legal requirement to make necessary modifications or adjustments to accommodate individuals with disabilities. This ensures they have equal opportunities and access to employment, education, housing, and other areas of life, without imposing undue hardship on the involved parties. It's about removing barriers to enable participation and inclusion.

This segment of the discussion emphasized the crucial role of creating physical infrastructure that is accessible to all, contributing to a disability-friendly environment.

In response to these insights, a constructive debate ensued among the participants, aimed at comprehending the multifaceted notion of access for individuals with disabilities. This exploration unveiled gaps in the inclusivity of infrastructural design, with participants sharing instances of insufficient public awareness, inadequate implementation of formulated policies, and the need for behavioral reform at decision-making levels.

Overall, the discussion served as a catalyst for participants to critically examine prevailing paradigms surrounding disability, urging a shift away from the charity model and towards a more inclusive and equitable approach.

Second Session: Exploring the Dimensions of Disability: Personal Difficulty or Social Diversity?

Facilitator: Sarita Lamichhane

Within the framework of this subject, the facilitator delved into the varying interpretations of disability, the criteria for identifying disabilities, and the diverse categories encompassing disabilities.

Engaging in a thought-provoking conversation, the central inquiry revolved around the nature of disability: whether it is best understood as an individual challenge or as a facet of societal diversity. Prompted by this question, Sarita Lamichhane, the facilitator, encouraged participants to express their viewpoints on the nature of disability.

Participants collectively voiced a range of perspectives. Disability was described as physical impairment, often present from birth, characterized by enduring effects rather than fleeting illness. Drawing from the participants' insights, the facilitator proceeded to expound upon the fundamental conditions that constitute disability, highlighting three pivotal factors: the presence of long-term impairment, functional limitations, and constraints on participation.

The discourse then transitioned towards an examination of the various types of disabilities prevalent in Nepal. Initial suggestions from attendees hinted at the existence of either four, seven, or perhaps eight disability categories. To provide clarity, the facilitator elucidated that there are indeed ten distinct categories of disabilities in Nepal. A concise video presentation was showcased to enhance participants' comprehension of the holistic concept of disability, encompassing the wide-ranging scope of disability conditions, particularly in the context of Nepal.

Subsequently, the dialogue expanded as the facilitator addressed participants' inquiries and concerns, further enriching their understanding, and raising awareness about this intricate topic. The session concluded with a brief lunch break, providing participants with 45 minutes to recharge.

After the lunch break, an engaging activity was organized for the participants. This activity was designed to simulate various communication barriers that often arise when delivering health services to individuals with disabilities. Its purpose was to shed light on the gaps in accessible communication. By experiencing these challenges firsthand through the game, participants gained a deeper understanding of the significance of clear and inclusive communication in healthcare settings.

Subsequently, the facilitator conducted a comprehensive review of the earlier discussions. In addition, the facilitator addressed the concept of disability, focusing on its classification according to the severity of the condition.

Conceptual Clarity

Categorization of Disabilities by Severity:

The government of Nepal has introduced a system of disability cards categorized based on the severity of the individual's condition:

1. Profound Disability: Indicated by a red disability card. This category entitles individuals to receive disability allowances.
2. Severe Disability: Designated by a blue disability card. Individuals in this category are eligible for disability allowances.
3. Moderate Disability: Designated by a yellow disability card. However, individuals within this category are not eligible for disability allowances.
4. Mild Disability: Identified by a white disability card. Similar to the previous category, individuals with a mild disability do not qualify for disability allowances.

After the preceding discussion, Miss Lamichhane delved into the topic of appropriate behavioral etiquette, particularly concerning healthcare facilities catering to individuals with disabilities. These individuals require specialized attention when seeking healthcare services from providers. The discussion encompassed several key points to enhance the quality of care and interaction.

To initiate, it was emphasized that using individuals' proper names is paramount to foster effective communication and prevent miscommunication. Moreover, attendees were encouraged to offer assistance tailored to each individual's needs, especially for those with visual impairments. For instance, tactile cues were recommended for providing health-related equipment, such as condoms, to visually impaired individuals, enhancing their understanding through touch.

When interacting with individuals with visual impairments, it was advised not to rely on physical gestures, but instead to answer their inquiries using verbal communication. Similarly, when offering mobility assistance, healthcare workers were advised to gauge the individual's comfort level and preferences. Furthermore, when providing directions or guidance, clear and concise instructions were recommended to prevent confusion.

Direct engagement with individuals who have hearing impairments was highlighted as best practice. Engaging them directly, rather than communicating through intermediaries like parents or friends, respects their autonomy, and promotes effective communication. Additionally, it was stressed that, during interactions with individuals with hearing impairments, refraining from eating or placing objects in the mouth is essential to facilitate clear communication.

In instances where individuals cannot speak or hear, engaging with their parents or guardians was suggested to ensure effective communication. Additionally, when interacting with those with visual impairments, the significance of clear communication was underscored. Abruptly leaving without informing such individuals, who rely heavily on auditory or tactile cues, should be avoided to prevent undue confusion.

When addressing individuals with hearing impairments who are unable to comprehend spoken language or express their concerns effectively, written communication was proposed as a viable alternative. Before extending assistance, it was advised to inquire whether an individual requires help, ensuring their agency and dignity.

Moreover, it was highlighted that allocating sufficient time is crucial when assisting individuals with speech impairments, as it may take longer for them to communicate their needs. Lastly, safeguarding the privacy and confidentiality of individuals with disabilities during healthcare service provision was emphasized as an ethical imperative.

Third Session: Concepts and Areas of Sexual and Reproductive Health

Facilitator: Sarita Lamichhane

Exploring the Components of Reproductive Health Rights:

The fundamental aspects encompassing Reproductive Health Rights (RHR) are multifaceted and pivotal. These components lay the groundwork for ensuring comprehensive and inclusive healthcare for all individuals, with a particular emphasis on addressing the needs of those with disabilities. By delving into the distinct dimensions of RHR, a comprehensive framework is established that underlines its significance in guaranteeing holistic well-being for every individual, regardless of their physical or cognitive abilities.

1. There should be access to education, information and counseling regarding sexual reproductive health, motherhood, safe abortion, and family planning.
2. There should be access to services regarding health care and safety related to sexual reproductive health, safe motherhood, safe abortion, and family planning.
3. There should be access to the right for accessible information about family planning and to choose its means.
4. Pregnant women, women with newborns or women with illness or complications associated with reproductive health should have the right to nutritious, balanced diet and physical rest.
5. Person with disabilities should have the right to receive health related services with respectful ease.
6. Health institutions that provide services such as family planning, reproductive health, safe motherhood, safe abortion, emergency delivery and neonatal reproductive health (including health complications) must be disability friendly.
7. Pregnant woman should not be forced or influenced to abort or use methods of contraception by coercion or threat.
8. No one should be discriminated against in any way based on their disability to access services such as family planning, reproductive health, safe motherhood, safe abortion, emergency delivery, neonatal reproductive health, and menstruation related services and rights.
9. Women should not be exposed to frequent and heavy work/labor during pregnancy and while breastfeeding newborn and family members should take extra care of them.

Addressing Healthcare Challenges for Individuals with Disabilities:

Efficient provision of healthcare services to individuals with disabilities necessitates a thorough understanding of their unique requirements. To enable equitable access to family planning for this demographic, a series of considerations come into play. Ensuring a Safe Maternity Facility is paramount, as it not only promotes physical safety but also accommodates diverse needs. Delving into issues of Infertility among individuals with disabilities offers a chance to extend appropriate assistance and support, fostering their reproductive well-being. Moreover, the provision of suitable Assistive Aids becomes imperative, empowering individuals with disabilities to engage with family planning and reproductive health practices effectively. Simultaneously, offering Comprehensive Counseling that caters specifically to the concerns of persons with disabilities fosters a supportive environment that acknowledges their needs without discrimination.

Crafting Inclusive Family Planning for Persons with Disabilities:

Facilitating accessible family planning for individuals with disabilities demands a comprehensive approach that considers their unique circumstances. The establishment of Safe Maternity Facilities serves as a foundation for promoting dignified and secure reproductive health services. This encompasses physical accessibility, trained staff, and equipment designed to accommodate diverse needs. Moreover, delving into the realm of Infertility among individuals with disabilities opens avenues for research, intervention, and support to address their distinct challenges. Embracing Assistive Aids tailored to their requirements enhances their agency in family planning decisions, empowering them to participate actively. Central to this endeavor is the provision of Comprehensive Counseling, tailored to their emotional, psychological, and informational needs. Such counseling not only informs but also empowers, ensuring that individuals with disabilities can make informed decisions regarding their reproductive health, without any form of bias or neglect. Through this holistic approach, family planning becomes an inclusive reality for individuals with disabilities, upholding their reproductive health rights and well-being.

Social Values ​​and Clarity Regarding the Sexuality and Sexual and Reproductive Health of Women with Disabilities

A debate session, skillfully moderated by the facilitator, Sarita Lamichhane, was orchestrated with the aim of dispelling myths and misconceptions surrounding disabilities, ultimately connecting them to health and well-being. The session gathered participants who engaged in thoughtful discourse on the following statements:

1. Regarding individuals with multiple disabilities and their challenges in managing menstrual health, the proposition of removing their uterus was discussed.
2. Another point of contention arose with the consideration of administering permanent birth control or family planning through injections for individuals with multiple disabilities, who are often vulnerable to violence such as rape.
3. The notion that individuals with disabilities should exclusively marry others with disabilities was also brought to the forefront.
4. A pivotal statement questioned whether individuals with disabilities are differently abled rather than simply disabled.
5. Additionally, the discourse touched upon the belief that individuals with disabilities do not experience sexual desires.

In concluding the debate, it was evident that a majority of participants disagreed vehemently with the presented statements, emphasizing that such propositions flagrantly violate the fundamental human rights of individuals with disabilities. The consensus emerged that attempting to control violence through birth control measures is fundamentally flawed, and marriage should inherently remain an individual's choice, unrestricted by their disability.

There was a notable point of confusion among participants regarding the distinction between disability and being differently abled. The facilitator, with her expertise, elucidated that disability encompasses the broader spectrum, including long-term impairments and functional limitations, rather than categorizing individuals into specific "types" of abilities.

Lastly, the topic of sexual desires among individuals with disabilities proved to be an area of uncertainty for participants. The debate failed to yield a definitive conclusion on this matter. It remains clear that there is a need for further exploration and understanding in this complex realm.

In summation, the debate served as a platform for exchanging insights, debunking myths, and challenging preconceptions about disabilities, ultimately fostering a more nuanced and empathetic perspective among the participants.

Fourth Session: Enhancing Insight into the Sexual and Reproductive Health Rights of Women with Disabilities through Case Story Workshops

Facilitator: Sarita Lamichhane

Group 1:

Case story:

In the case story, when women with vision disabilities underwent pregnancy, the doctor directed their questions exclusively to the parents rather than addressing the related person. This led to the individuals with disabilities feeling neglected by the healthcare professionals.

Myths:

There was a misconception that women with disabilities seeking healthcare services should not be taken seriously. Additionally, it was assumed that the parents of individuals with disabilities possessed all the necessary information about the person with a disability.

Problem:

The issue at hand was rooted in a social taboo that marginalized individuals with disabilities. Moreover, the healthcare professionals failed to recognize the uniqueness and individuality of the person with a disability, opting instead to interact solely with the parents.

Solutions:

To address these challenges, it was imperative to ensure that physical infrastructure is accessible to all, accommodating individuals with disabilities. Furthermore, a shift in focus was needed – away from the personal or disability status of the service recipient, and towards resolving the underlying problems in the healthcare service delivery.

Group 3:

Case Story:

The case story presented during the event shed light on a sensitive situation involving a person with hearing disabilities who sought assistance for an abortion. Tragically, rather than addressing her distinct needs, the doctor prescribed iron tablets. This particular case underscores the critical intersection of sexual and reproductive health rights and disabilities.

Myths:

It is crucial to debunk prevalent myths related to this scenario. One widespread misconception is the belief that individuals with disabilities do not require specialized healthcare, mistakenly assuming that conventional medical practices are universally suitable. Another fallacy is that discussions about reproductive health are inconsequential or even inappropriate for people with disabilities, disregarding their entitlement to comprehensive and all-encompassing care.

Problems:

Numerous challenges came to the forefront within this context. Primarily, a noticeable dearth of accessible information regarding family planning for individuals with hearing impairments obstructs their ability to make well-informed decisions. Furthermore, healthcare professionals frequently lack proficiency in sign language, resulting in ineffective communication and inadequate care. Additionally, some doctors hesitate to genuinely comprehend the multifaceted issues encountered by individuals with disabilities, leading to misguided treatment strategies.

Solutions:

First and foremost, establishing accessible family planning facilities that cater to the distinctive requirements of people with disabilities is imperative. This encompasses not only physical accessibility but also addressing communication barriers by providing sign language interpreters. Moreover, it is crucial to create counseling facilities that are attuned to the sensitivities and needs of individuals with disabilities. Importantly, doctors must prioritize acquiring a comprehensive understanding of the specific disability-related challenges faced by everyone before suggesting any interventions. Insufficient knowledge can prove detrimental. Lastly, integrating disability-focused training into the curriculum of healthcare professionals is vital to cultivate awareness and empathy.

With the culmination of participants' reflections, the first day of orientation came to a close. Here are some perspectives shared by the participants:

One individual remarked that the orientation significantly shifted their outlook on comprehending disabilities. They found the training to be exceptionally inclusive, expressing a strong appreciation for the group sessions. The experience left them feeling more resolute and dedicated to delivering healthcare services tailored to the distinct needs and requirements of individuals with disabilities. These sentiments were echoed by several others in the group, who also found the orientation to be transformative and motivating in fostering a commitment to improving healthcare provisions for this demographic.

Day 2:

August 11, 2023

The second day commenced with active participant engagement as individuals took the lead in sharing their experiences regarding the reporting and evaluation tasks from the first day's orientation. Similarly, the finalization of participant roles in reporting, evaluating, entertainment, and timekeeping for the second and final day of the orientation took place.

Following that, the continuation of the workshop from the previous day occurred, focusing on "Enhancing Insight into the Sexual and Reproductive Health Rights of Women with Disabilities through Case Story Workshops."

Group 2 - Case Story:

A woman using a wheelchair visited a hospital for an HIV check-up. Unfortunately, she encountered negative attitudes from health professionals who questioned why she, as a person with physical disabilities, could suffer from HIV. This led to a denial of services and a distressing experience for her.

Myths:

There exists a misconception that HIV/AIDS can only affect specific groups. The myth here is that persons with disabilities are somehow immune to such health issues.

Problems:

1. Biased Attitudes of Health Professionals: The prevalent negative mentality among health professionals that perpetuates discriminatory treatment towards persons with disabilities.
2. Lack of Awareness: A significant lack of awareness within healthcare providers about the rights, needs, and challenges faced by persons with disabilities regarding sexual and reproductive health.
3. Inadequate Counseling for Persons with Disabilities: The absence of proper counseling services that consider the unique needs and concerns of individuals with disabilities when dealing with sensitive health issues.
4. Stereotyping by Doctors: Doctors often hold preconceived notions about the limitations and capabilities of individuals with disabilities, impacting the quality of care they receive.
5. Inaccessible Healthcare Facilities: Many healthcare facilities lack physical accessibility features, making it difficult for persons with disabilities to access services comfortably.
6. Communication Barriers: The lack of accessible communication tools and techniques within healthcare settings hinders effective communication between healthcare providers and patients with disabilities.

Solutions:

1. HIV/AIDS Testing and Treatment: Ensuring that HIV/AIDS testing and treatment services are accessible to all, regardless of their physical abilities.
2. Accessible Materials for HIV/AIDS Education: Developing informational materials about HIV/AIDS in accessible formats (braille, sign language videos, etc.) to raise awareness among persons with disabilities.
3. Gap Analysis in Treatment: Conducting regular audits to identify gaps in the treatment and care of persons with disabilities and taking necessary steps to bridge those gaps.
4. Healthcare Provider Training: Offering training programs for healthcare professionals to sensitize them about the rights and needs of persons with disabilities, promoting unbiased and inclusive care.
5. Disability Sensitivity Workshops: Organizing workshops to raise awareness among healthcare providers about disability etiquette and communication strategies when interacting with patients with disabilities.
6. Diverse Representation in Healthcare: Encouraging the hiring of healthcare professionals with disabilities to create a more inclusive and empathetic healthcare environment.
7. Supportive Counseling Services: Establishing specialized counseling services that address the psychological and emotional needs of persons with disabilities regarding sexual and reproductive health concerns.

Group 4:

Case Story:

A woman who used a wheelchair visited the hospital for her pregnancy check-up. However, upon arrival, she encountered prejudice from the healthcare providers. She was subjected to questioning about the feasibility of providing pregnancy-related care to a woman with a physical disability.

Myths:

There is a prevailing misconception about how women with disabilities can experience pregnancy.

Problems:

1. Unwelcoming Hospital Environment: The hospital lacks a welcoming environment from the moment of entry, which can be particularly distressing for individuals with disabilities.
2. Prejudice Among Healthcare Providers: Attitudes of bias and misunderstanding among healthcare providers towards individuals with disabilities result in inappropriate and insensitive questioning.
3. Inadequate Disability-Friendly Facilities: The hospital infrastructure is not designed to be disability-friendly, making it difficult for women with disabilities to access necessary services.
4. Insufficient Healthcare Provider Knowledge: The lack of understanding among healthcare providers about the specific needs and requirements of individuals with disabilities creates barriers to appropriate care.

Solutions:

1. Construct Disability-Friendly Hospital Infrastructure: Hospitals should prioritize the construction of facilities that are accessible to individuals with disabilities. This involves ramps, wider doorways, and accessible restrooms to ensure smooth entry and movement within the premises.
2. Develop Disability Training for Healthcare Providers: Healthcare professionals need training to enhance their awareness and understanding of the needs of individuals with disabilities. This will promote a more empathetic and inclusive approach to care.
3. Allocate Budget for Disability-Inclusive Care: Hospitals should allocate a specific budget to cater to the unique requirements of women with disabilities during pregnancy. This can involve procuring specialized equipment and providing training for staff.
4. Ensure Equity in Treatment: The principle of equity should guide the treatment of women with disabilities. They should receive the same level of care and attention as any other patient, with adjustments made to accommodate their specific needs.
5. Make Payment Processes Accessible: Payment counters and methods should be designed to be accessible to individuals with disabilities. This ensures that they can independently manage their financial transactions related to healthcare.
6. Adapt Labor and Delivery Facilities: Labor beds should be designed to accommodate the specific needs of women with disabilities. This might involve adjustable beds, appropriate positioning aids, and trained staff to ensure a safe and comfortable birthing experience.

Group 5

Case Story:

An adolescent girl grappling with multiple disabilities was subjected to repeated acts of sexual violence within her close-knit neighborhood. Tragically, she became pregnant, and her condition was discovered only after she had reached the 18th week of her pregnancy. Following consultations with medical experts, a difficult decision was made to terminate the pregnancy. To prevent further unwanted pregnancies, a contraceptive implant was recommended and inserted, with due consideration for the girl's wishes and her family's input.

Myths:

The notion that implants placement can effectively mitigate violence is a misconception perpetuated by some health professionals.

Problems:

1. Assault against Vulnerable Adolescents: The harrowing reality of sexual violence against adolescent girls with multiple disabilities is a grave concern. Their vulnerability makes them susceptible to abuse, demanding comprehensive safeguards.
2. Inadequate Family Consultation: The lack of involving the girl's family in the decision to place the contraceptive implant raises ethical questions. Collaborative decisions should be the cornerstone of such interventions.
3. Insufficient Consent Protocols: Consent, especially from the adolescent herself, must be central to any medical procedure. Failing to secure proper consent undermines the autonomy and dignity of the individual.
4. Unfamiliarity with Safe Abortion Laws: The medical community's lack of familiarity with safe abortion laws perpetuates ignorance and may hinder timely interventions in cases like these.

Solutions:

1. Robust Legal Measures: Stringent legal action against sexual offenders is paramount. Creating an environment where perpetrators are held accountable can serve as a deterrent.
2. Inclusive Healthcare Training: Healthcare professionals must receive comprehensive training that equips them to address the unique challenges faced by individuals with disabilities. This training should emphasize sensitivity and understanding.
3. Empowerment of Vulnerable Individuals: Empowering adolescent girls with disabilities with knowledge about their rights and available resources can bolster their ability to assert their autonomy in medical decisions.
4. Dissemination of Information: Initiatives to raise awareness about safe abortion laws and related medical options should be actively pursued within the medical community.

With these sharing, the group workshops ended successfully and productively.

Following the conclusion of the previous day's group workshop, a concise reflective session was organized. This session centered around a Poster Presentation that aimed to delve into the realm of sexual and reproductive health among women with disabilities. The posters featured a set of 9 carefully crafted questions, each pertaining to various aspects of this crucial topic.

Participants were encouraged to engage with the material by reading and contemplating these questions. From the array of queries, they were then prompted to select and discuss 3 questions that resonated as particularly vital and pertinent to them. This facilitated a focused and thoughtful exchange of perspectives, contributing to a deeper exploration of the subject matter.

To enhance the engagement and gauge the participants' comprehension of the gaps in health service delivery for individuals with disabilities, a brief game activity was incorporated. This activity sought to visually map out the participants' grasp of the challenges and discrepancies within this sphere.

Then, a short interlude was provided, during which participants could enjoy tea and coffee.

Fifth Session: Navigating Sensitivities in Delivering Sexual and Reproductive Health Services to Women with Disabilities

Facilitator: Sarita Lamichhane

During this session, facilitated by Ms. Lamichhane, health workers shared their invaluable experiences, highlighting both triumphs and difficulties encountered while providing sexual and reproductive health services to women with disabilities. The participants, all seasoned health professionals, were grouped together to exchange their perspectives. They were encouraged to delve into successful and unsuccessful cases they had encountered in delivering healthcare services to individuals with disabilities, along with the strategies they employed to enhance the quality of care.

Experience Sharing:

Case 1: Navigating Complexities in Period Management

A mother approached us, seeking assistance in administering period-controlling injections for her daughter with multiple disabilities. Although we complied with her request, we now recognize that this action violated the girl's fundamental human rights. A sense of guilt lingers as we understand the importance of respecting autonomy and dignity.

Case 2: Bridging Communication Gaps for Individuals with hearing impairment

Conveying medical information to a couple with hearing impairments posed a challenge initially. However, we adopted a typing technique, allowing the couple to articulate their concerns through written communication. This adjustment has enabled us to offer comprehensive healthcare services while ensuring inclusivity.

Case 3: Empathy and Support for Family Planning

A blind couple, residing at a considerable distance, sought guidance on family planning due to their existing seven children. By providing a respectful and private environment, we engaged in a compassionate conversation, ultimately convincing them of the benefits of birth control. This interaction showcased the importance of understanding individual circumstances.

Case 4: Overcoming Isolation and Challenges

A married woman lost her sight and subsequently faced abandonment by her husband. Forced to live with her family, she encountered difficulties during menstruation due to the persistence of the Chaupadi practice in the far-western region. This situation underscores the need for comprehensive support systems and education to challenge harmful practices.

Case 5: Ethical Decision-making for Psychosocial Well-being

Implanting a contraceptive device in an 18-year-old girl with psychosocial disabilities was initiated based on her mother's request. However, we later realized the importance of obtaining the patient's consent. Upon observing adverse effects, we removed the implant, highlighting the significance of ethical considerations and patient autonomy.

Case 6: Improving Accessibility for Hearing-Impaired Individuals

Our approach to individuals with hearing impairments evolved as we recognized the limitations in non-verbal communication. We introduced a writing method for interaction and identified the need for health professionals to receive sign language training, ensuring more effective communication and better patient care.

With these poignant experiences shared, Ms. Lamichhane concluded the session. This insightful gathering reaffirms the imperative of creating an all-encompassing healthcare environment that respects human rights, promotes communication inclusivity, and addresses the unique needs of women with disabilities.

Sixth Session: Disability Inclusive Development:

Facilitator: Sarita Lamichhane

Points to consider when providing sexual and reproductive health services to women with disabilities.

During this session, Miss Lamichhane delved into the crucial topic of making health institutions disability-friendly in the context of sexual and reproductive health services.

Key Components of Disability-Friendly Services:

• Physical Accessibility: Implementing features like ramps, elevators, wide doorways, and accessible bathrooms to enable easy movement for individuals with disabilities.
• Communication Accessibility: Ensuring accessibility through sign language interpreters, user-friendly materials, and websites designed for easy navigation.
• Staff Training: Equipping healthcare professionals with sensitivity training, disability awareness, and effective communication techniques to interact more effectively with patients with disabilities.

Understanding Disability Accessibility Services:

Disability accessibility services encompass a comprehensive range of policies, procedures, and resources aimed at making healthcare institutions inclusive for people with disabilities. These services encompass not only physical access to the premises but also equal access to vital information and medical services.

Importance of Disability Accessibility Services:

• Individuals with disabilities possess the fundamental right to access healthcare services on par with their able-bodied counterparts.
• Disability accessibility services ensure that people with disabilities receive the necessary care and support they require.
• Implementation of these services can contribute significantly to enhancing the overall quality of healthcare services.

Types of Disability Accessibility Services:

• Physical Access: This category includes provisions such as ramps, elevators, and accessible restrooms, enabling unimpeded movement within healthcare facilities.
• Information and Communication: Providing accessible information and communication materials in formats like Braille and large print documents, along with facilitating communication aids such as TTS devices.
• Assistive Technology: Offering devices like wheelchairs, walkers, and hearing aids that cater to various mobility and sensory needs.
• Personal Assistance: Extending support through personal assistance services, aiding tasks like bathing, dressing, and eating.

Enhancing Disability Accessibility Services:

• Conduct thorough disability accessibility assessments to identify areas in need of improvement.
• Develop comprehensive disability accessibility plans outlining specific steps for enhancing accessibility across the institution.
• Train healthcare staff to better understand and cater to the unique needs of individuals with disabilities.
• Create mechanisms for individuals with disabilities to share their experiences and offer feedback on the quality of accessibility services provided.

By incorporating these strategies, health institutions can create an environment that promotes inclusivity, allowing individuals with disabilities to access vital sexual and reproductive health services with dignity and ease.

Following the discussion, miss Lamichhane subsequently conducted a comprehensive assessment of disability-inclusive development with participants, using a scale ranging from the highest score of 1 to the lowest score of 0, with a medium score of 0.5.

Statements:

1. Does your healthcare center facilitate easy access and service provision for individuals using wheelchairs?
2. Is your healthcare center designed to accommodate and serve individuals with disabilities effectively?
3. Does your healthcare center regularly solicit feedback from you regarding its services?
4. Does your center provide training to its health workers on issues related to disabilities?
5. Is there a provision in your health center for offering services and counseling to individuals with vision impairment in an accessible manner?
6. Does your health center offer services to individuals with hearing impairment through typing or sign language?
7. Do you directly obtain consent forms from individuals with multiple disabilities, rather than going through their parents or guardians?
8. In situations where your health center lacks expertise, do you refer cases of disability issues to organizations specializing in disabilities?
9. Have you extended your services to the homes of individuals with multiple disabilities?
10. Have you conducted a time audit of your service delivery to assess progress in terms of disability-friendly practices?

Voting Results:

The voting results indicate a clear trend in health institutions priorities regarding disability-inclusive development. Statement 1, addressing easy access and service provision for individuals using wheelchairs, received the highest number of votes, highlighting the importance placed on physical accessibility. Statement 6, focusing on services for individuals with hearing impairment through typing or sign language, garnered significant support as well. Statement 8, which pertains to referring cases of disability issues to specialized organizations, received slightly fewer votes but still demonstrated notable interest. These results suggest that health institutions prioritize tangible, immediate accessibility measures (such as physical access and communication services), while also valuing external expertise for more complex cases. Other statements received relatively fewer votes, indicating a comparatively lower priority in the context of this assessment.

Subsequently, the video presentation was delivered with the purpose of elucidating the significance of comprehensive accessibility for individuals with disabilities within healthcare establishments. The presentation featured a pertinent case study from smart Municipality, underscoring this subject. Notably, this event took place in the backdrop of a brief birthday celebration, during which Miss Sarita Lamichhane's special day was commemorated. This festivity was further accompanied by a cake-cutting ceremony. Following these engaging proceedings, a 50-minute lunch break was observed.

Seventh Session: Policy Provisions Regarding Persons with Disabilities

Facilitator: Sarita Maharjan

In the seventh session, led by Facilitator Sarita Maharjan, participants delved into the vital policy provisions that pertain to individuals with disabilities. The focus was on the Rights of Persons with Disabilities Act, 2074, relevant sections of the Constitution of Nepal, Convention on the Rights of Persons with Disabilities, Policy and Program for Persons with Disabilities (2077-2086) as well as Safe Maternal and Reproductive Health Rights Act, 2075.)

Rights of Persons with Disabilities Act, 2074

Article 19: Empowerment of Women with Disabilities

Article 19 of the Rights of Persons with Disabilities Act, 2074, places a spotlight on the rights of women with disabilities. This article underscores the commitment of the Government of Nepal to ensure the protection of health and reproductive rights for women with disabilities. The provision considers the unique challenges that women with disabilities may face, highlighting the need for targeted measures to address their specific situations.

Paragraph 7: Health, Rehabilitation, Social Security, and Recreation

The Act outlines comprehensive provisions for the well-being of individuals with disabilities in Nepal. It mandates that the Government of Nepal establish mechanisms for providing free health services and therapies, including speech and occupational therapy, to individuals with disabilities. The scope extends to those with an annual income falling below the specified threshold or those admitted to government hospitals for specific treatments.

Additionally, the government is tasked with supplying necessary medicines and related factors for genetic bleeding conditions like hemophilia, free of cost and on a prescribed basis. The Act also stresses the importance of breaking down barriers that hinder disabled individuals from accessing healthcare facilities. Furthermore, health workers are expected to prioritize the delivery of quality healthcare services to individuals with disabilities while they are within hospital premises.

To ensure sufficient accommodation, government and privately-run hospitals with more than twenty-five beds must allocate at least two beds for individuals with disabilities. Furthermore, the government's responsibility extends to preventing and addressing disabilities that can be avoided or treated. Efforts will be undertaken to identify the root causes of disability, leading to measures for prevention, control, elimination, and treatment.

Constitution of Nepal

Article 35: Right to Health

Article 35 of the Constitution enshrines the right of every citizen to receive fundamental healthcare services from the state without any financial burden. It guarantees access to emergency healthcare without any discrimination. Additionally, individuals have the right to be informed about their healthcare treatment and enjoy equal access to healthcare services. The Constitution also acknowledges the right to clean drinking water and sanitation.

Article 38: Women's Rights

Within the framework of Article 38, the Constitution reinforces the rights of women in Nepal. Subsection 2 ensures that every woman has the right to safe maternal and reproductive health. Subsection 3 explicitly condemns all forms of violence or exploitation against women, irrespective of their religious, social, cultural background, or any other basis. Legal repercussions await those who engage in such actions, and victims are entitled to compensation as per the law. Subsection 5 addresses the positive discrimination needed to provide women with enhanced opportunities in education, healthcare, employment, and social security.

CONVENTION ON THE RIGHTS OF PERSONS WITH DISABILITIES

Article 25: Ensuring Inclusive Health and Well-being

Promoting Health Equality:

States Parties deeply affirm that individuals with disabilities deserve unwavering access to the highest attainable standard of health, devoid of any prejudice based on disability. To this end, States Parties shall undertake all necessary measures to ensure that health services are inclusive and sensitive to gender, including health-related rehabilitation.

Comprehensive Health Provisions:

Specifically, States Parties commit to providing individuals with disabilities the same breadth, quality, and excellence of cost-free or affordable healthcare and programs as extended to their counterparts. This extends to areas such as sexual and reproductive health, as well as population-based public health initiatives.

Tailored Services for Well-being:

States Parties recognize the unique health needs of individuals with disabilities. Consequently, they pledge to offer health services specifically designed to address disability-related requirements. This encompasses early identification and intervention when relevant, alongside services aimed at reducing and preventing additional disabilities, especially among children and older individuals.

Community-Centered Care:

Health services should be available in proximity to communities, even in rural areas, ensuring that individuals can access care conveniently.

Equal Care and Informed Consent:

Health professionals must provide individuals with disabilities with the same standard of care as they do for others. This commitment is rooted in the principles of free and informed consent, guided by respect for the human rights, dignity, autonomy, and needs of individuals with disabilities. This entails training and ethical standards to ensure that healthcare is unbiased and just.

Ending Insurance Discrimination:

States Parties resolve to end discrimination against individuals with disabilities in health and life insurance. Fair and reasonable access to insurance will be assured under national laws.

Upholding Dignity:

No one should face discriminatory denial of healthcare, health services, or basic necessities like food and fluids solely due to their disability.

Policy and Program for Persons with Disabilities (2077-2086)

Empowering Rehabilitation and Healthcare:

Strategy 7: This strategy envisages the provision of all-encompassing rehabilitation and healthcare facilities for individuals with disabilities.

Creating Inclusive Medical Environments: Hospitals and health centers will undergo comprehensive transformation to become fully disabled-friendly. This will enable the delivery of rehabilitation and habilitation services, thereby enhancing therapeutic, physical, and mental activities at local healthcare facilities.

Ensuring Accessibility to Medical Supplies:

Individuals affected by various disabilities will be granted access to necessary medicines and equipment. This includes items essential for conditions like intellectual disability, cerebral palsy, psychosocial disability, hemophilia, autism, and leprosy. Moreover, critical supplies like urinary bags, catheters, and medicines required by those with spinal cord injuries will be provided free of charge.

Empowering Women's Health:

The Act commits to offering high-quality and accessible maternal, sexual, and reproductive health services for women with disabilities.

Specialized Reproductive Health Services:

Hospitals will be equipped to provide specialist services for reproductive health, catering to the needs of women with disabilities. The goal is to ensure their well-being through quality care and accessible maternity rooms.

Ensuring Health Security:

The Act underscores the importance of providing free health insurance and a contribution-based social security program for disabled individuals.

Safe Maternal and Reproductive Health Rights Act, 2075

Inclusivity in Services:

This Act emphasizes that all services related to family planning, reproductive health, safe motherhood, safe abortion, emergency delivery, and newborn care should be rendered in a girl and disabled-friendly manner. This aims to ensure that individuals with disabilities have equal access to quality healthcare services, fostering inclusivity and dignity for all.

Throughout this session, the intricate web of policies and rights aimed at safeguarding the dignity, health, and well-being of individuals with disabilities and women in Nepal was explored.

After presenting the policy provisions, Miss Sarita delved into the primary challenges and inquiries, ultimately concluding the session with valuable insights.

Several critical issues:

• Non-adherence to convention and legal provisions has resulted in work being conducted without due accordance.
• The provision of disability-friendly health services has yet to be realized, posing a significant concern.
• A lack of awareness among healthcare personnel and employees regarding the reproductive rights of disabled individuals, particularly women, has been observed.
• The prevalent misconception that 'disability-friendly' pertains solely to physical infrastructures restricts the broader scope of the concept.
• Reproductive health rights awareness among disabled women is notably deficient.
• Insufficient positive familial and guardian support undermines the well-being of women with disabilities.
• Despite the complex health needs of disabled women, no supplemental facilities or provisions have been established.
• The dehumanizing treatment of disabled women as devoid of sexuality persists.
• Persistent barriers spanning institutional, physical, attitudinal, and communicative domains remain unaddressed.

The Local Level's Role:

• Upholding and empowering individuals with disabilities aligns with the nation's international commitments, as well as Nepal's Constitution and other statutory frameworks.
• Ensuring the safeguarding of personal assets for those severely disabled through local arrangements is imperative.
• Offering physiotherapy services within the homes of individuals with complete disabilities enhances accessibility.
• Providing free medications and essential aids to impoverished disabled individuals is a priority at the local level.
• Establishing inclusive and accessible infrastructure in public schools, thereby fostering a disability-friendly environment, is a key local responsibility.
• Collaborating with unions and the state to formulate and enforce requisite legislation for the betterment of disabled individuals is an essential role undertaken by the local level.

With the ending of this session, the formal two-day orientation on Disability and Sexuality, designed for Health Workers of Lalitpur Metropolitan City, successfully concluded. As the event came to a close, participants were requested to complete post-test forms, facilitating the assessment of their newly acquired knowledge. Subsequently, they were provided with feedback forms, allowing them to contribute their thoughts, and an action plan form to further solidify and elaborate upon their insights and observations.

Analysis of Participants Reflections and Commitments through Action Plan:

Upon reviewing the outcomes of the "Orientation on Disability and Sexuality for health workers," an analysis of the participants' action plans reveals several key observations. During the orientation, participants actively engaged and absorbed the information, prompting them to reflect on their practices and commit to implementing positive changes.

Most participants recognized the imperative to enhance both their behavioral attitudes and the physical infrastructure within their facilities. Their aim was to create an environment that is more accommodating to individuals with disabilities. They astutely acknowledged the significance of orientation programs like the one they attended, as these programs serve to sensitize health service providers to matters concerning disability rights and issues related to sexual and reproductive health and rights (SRHR) within the context of disabilities.

Furthermore, a notable insight emerged regarding the need for sign language training for health service providers. This need was particularly highlighted by participants who recalled the communication challenges they faced when interacting with patients who are deaf or hard of hearing.

In order to realize these envisioned changes, participants emphasized the importance of regular monthly meetings involving various stakeholders, such as ward chairpersons, health section chiefs, and health service providers. The purpose of these meetings would be to deliberate on and address the identified needs and gaps.

Many participants underscored the pivotal roles played by entities such as Lalitpur Metropolitan City, the concerned Ward office, Ward officials, and health service providers in addressing the identified needs. The majority of participants articulated that a collaborative effort involving these entities would be essential to make the actionable changes outlined in their plans.

The collective sentiment expressed within the individual action plans indicated a resolute commitment to making health services more accessible and inclusive for all, including individuals with disabilities. Several participants went so far as to recommend that Prayatna Nepal, in partnership with Lalitpur Metropolitan City, should extend disability awareness programs to broader networks within their respective health institutions. This suggestion stems from the belief that expanding such programs would effectively bolster support for and promotion of disability-sensitive health services and greater inclusion.