An End-Line Evaluation Report of Rehabilitation and Reintegration Support for Abandoned Women with Mental Health and Psychosocial Issues Project

Background: The overall objective of the project was "Universal health coverage for people living with mental health conditions and psychosocial disability is ensured through accessible community- based holistic rehabilitation services in Nepal". The project had three aspects: development and management of the transit home for the rehabilitation of vulnerable women, sensitization and strengthening of government and communities on mental health issues, and acceptance of the transit home as a rehabilitation model by stakeholders working in the field of mental health and psychosocial well-being of women with Mental Health and Psychosocial Issues (MHPSI).

Purpose/objective: The evaluation's goal was to gather, analyze, and provide evidence-based information in order to determine the extent of convergence between planned targets and actual achievements and to synthesize lessons that can help improve the selection, design, and implementation of future activities. Relevance, coherence, effectiveness, efficiency, impact, and sustainability were the six primary criteria used to evaluate the project.

Methodology: The evaluation used primarily a qualitative approach, which was supplemented by quantitative data. Primary data were collected from field visits through interviews with beneficiaries and relevant stakeholders. Secondary data were collected through the project proposal, progress reports, and other relevant records and reports.

Key findings:

Relevance: The project was suitable for addressing the rescue and rehabilitation issue of vulnerable women who have been abandoned, chained, or locked. The project had successfully coordinated with government bodies and other relevant stakeholders, and the project was found to be highly relevant to the needs of beneficiaries and the relevant national policies.

Effectiveness: The results and achievements have been consequential in achieving the overarching objective of ensuring universal health coverage for vulnerable women through accessible, holistic and accessible rehabilitation services of the community in Nepal to a large extent. The project was successful at managing symptoms and has improved the overall wellbeing of the beneficiaries at the institutional level, but the long-term effectiveness of the achievements seems questionable. Although some of the indicators were underachieved, the project successfully implemented the targeted action as delineated in the proposal. Beneficiaries and stakeholders reported that the project was effective in the bringing about attitudinal change in public about mental health issues.

Coherence: Assessment of internal coherence showed that the project was in line with the relevant international norms and standards to which KOSHISH adheres. It was also consistent with the previous projects undertaken by KOSHISH, particularly “Mainstreaming Mental Health and Psychosocial Disability” project. Co-ordination of KOSHISH throughout the project with government line agencies and other actors working on the same field indicate that external coherence of the project was also considerably high.

Efficiency: The project was run with a minimum administrative and management cost. It was found that project staffs were competent and dedicated and that an effective and systematized management structure was maintained. KOSHISH was able to sustain itself with a small team and a low budget primarily due to solid ties with local government bodies and the community. The internal monitoring system for information flow and

keeping records at the local and central levels was found to be good. Annual financial audits were also performed.
Impact: The project has been successful in terms of sensitization and awareness and changing attitudes. Both the output and outcome level achievements have been important to make the project impactful. The key impact level indicator established by the project was universal health coverage for people with mental health conditions and psychosocial disabilities. One major component of universal health coverage is financial protection, which should be given consideration, and coordination with local government bodies and the healthcare sector would be beneficial.

Sustainability of the project: The ability of the project to partner with relevant organizations and government bodies for advocacy, the recognition of the project as highly essential, relevant and replicable by the government and the befitting nature of the project to the local needs and issues have rendered the project sustainable. The high degree of ownership of the intervention by the beneficiaries and their families attests to the sustainability of the project. However, the relapse and high risk of relapse for some of the beneficiaries reflect the need for more focus on educating beneficiaries and their family members to recognize the early symptoms of relapse. Also, a system of symptom monitoring and a crisis plan would help to ascertain the sustainability of the project.

Recommendations: Despite its limitations, the project has been successful; and future directions should consider reinforcing the positive aspects demonstrated by this project. Given the project's positive results, continuation would be highly recommended to attempt to replicate and upscale the activities already undertaken and move beyond them.

The evaluator recommends:

• Effective means of preventing relapse by addressing the biopsychosocial aspects of the beneficiary seem essential.
• Proper education about early symptoms of relapse to the beneficiaries, their family members and community people and systems of symptom monitoring and crisis plans need to be implemented.
• Family members are to be involved in the overall process, from rescue to reintegration; they are to be educated, sensitized, and made responsible for their family members' health and wellbeing.
• Except for M&E visits, the concerned government line- agencies’ involvement in the overall activities of the project seemed minimal. Strong lobbying for including a provision of “model transit care service” for rehabilitation and reintegration support for abandoned women with mental health and psychosocial issues at the national, federal, and local levels is recommended.
• Coordination and partnership with relevant government bodies are recommended while developing projects, such as the Ministry of Women, Children & Social Welfare, the National Women Commission, and other relevant government bodies.
• Since strong links with local authorities increase the chances of internalizing policy and sustainability, their support needs to be built through a more targeted approach, primarily through disseminating current achievements.
• Despite sensitization activities, community mental health knowledge gaps and services were noticeably high. Future projects need to employ media and other relevant dissemination tools to sensitize people on mental health issues at grassroots levels.
• During the design of such projects, the concerned body should pay more attention to the likely livelihood problems and vulnerabilities that beneficiaries may face after reintegration into the family and community. Interviews with beneficiaries and family members indicated that financial difficulties in beneficiaries' lives are almost ubiquitous, which may be implicated in their relapse.

Comments from the organisation, if any: Koshish has written a thorough management response to the final evaluation. All the recommendations are taken seriously, and they have either been accepted or partially accepted, all explained with reasons. The recommendations have also been considered in the planning of the continuation of this project from 2023.