2023-12-31-accounts - The Britain-Nepal Medical Trust

This text was generated using OCR and may contain errors. Check the original PDF to see the document submitted to the regulator.

Finding new ways to fight TB

The Britain-Nepal medical trust

Annual Report 2022/23

Gillian Holdsworth

Patrons and Trustees

Royal Patron H M The King KG, KT, GCB

Patrons

Sir Christian Bonington CBE, DSc(Hon) Prof Sir Andrew Haines MB, BS, MD, FRCGP, FFPHM, FRCP, FMedSc Lady Hughes-Hallet Dr J.O.B. Rosedale Prof S. Subedi

Trustees

Dr G. Holdsworth – Chair Ms Sarah Barton Dr R. Dhital Dr Robert Fryatt Mr J.W. Mecaskey Dr J. Payne Professor A. Ramsay

Chair's Foreword

In 2012 the Britain-Nepal Medical Trust established a local Nepalese nongovernmental organisation: the Birat Nepal Medical Trust (BNMT Nepal). This year we celebrated the first ten years of BNMT Nepal, who we continue to support through our close partnership. So this year’s report reflects the exciting and important work which BNMT Nepal is delivering in Nepal – to improve the prevention, diagnosis and treatment outcomes of tuberculosis (TB) in Nepal.

Sometimes I need to remind myself why tackling TB is so hard. TB was a public health problem in the UK once – but its incidence was decreasing before the introduction of TB treatment in 1952. That was primarily because of improved social conditions, notably better housing and nutrition.

In this year’s report we consider the situation in Nepal in terms of social conditions as well as available treatments. BNMT Nepal is seizing new opportunities for prevention and reduction in disease transmission, improved diagnostics and treatment. But it also takes into account the impact of social issues – poverty, poor nutrition and housing – on TB and strives to build these into a more effective TB control programme.

Finally – I would like to thank you all for your continued support for our work, without which none of it would be possible!

Gillian Holdsworth Chair of BNMT UK

Company Secretary/Administrator

Dr Mashbileg Maidrag

Cover photo: Soma Rai, BNMT Nepal human resource and administration officer, paraglides in Pokhara to raise awareness for Stop TB, December 2022

T H E B R I T A I N - N E P A L M E D I C A L T R U S T A N N U A L R E P O R T 2 0 2 2 - 2 0 2 3

Raghu Dhital

A message from the Executive Director of BNMT Nepal

In 2022/23, BNMT Nepal successfully implemented 19 projects, strengthening service provision and making healthcare more accessible in remote areas, and improving health outcomes for underserved communities.

One notable achievement this year was the piloting a new way of treating latent tuberculosis infection in adults. The 3HP treatment regimen, approved by the World Health Organisation (WHO), prevents adults infected with TB bacteria from developing active TB. It is significantly shorter and easier to take than the old treatments. Our project, carried out in collaboration with Nepal’s National Tuberculosis Control Centre (NTCC), introduced 3HP treatment in Nepal and showed that it is not only acceptable, but in high demand among communities with a high burden of TB.

BNMT will continue to work with communities and the government to bring innovative patient-centred models of care to communities in Nepal. Through rigorous research, data collection, and trend analysis, BNMT has produced evidence-based reports and policy briefs which have enabled decision makers to incorporate our strategies into policies that effectively address critical healthcare issues.

We also supported the NTCC by supplying emergency TB drugs to help manage a logistics crisis. This prevented potentially dangerous delays and interruptions in treatment for TB patients.

As Nepal moved beyond the COVID pandemic, BNMT Nepal completed its data collection for SARS CoV-2 sequencing and long COVID analysis in Nepal, within the Epidemic Intelligence project. To push forward pathogen genomics science in Nepal, BNMT Nepal organised a week-long Pathogen Genomics and Bioinformatics Training Workshop in Kathmandu. It was a collaboration with five experts from the Centre for Pathogen Genomics, University of Melbourne, Australia, and our Epidemic Intelligence consortium partners. Forty participants from laboratories

BNMT Nepal’s tenth anniversary celebrations

across Nepal participated and we hope to conduct further training in coming years.

BNMT Nepal celebrated its tenth anniversary on 21 September 2022. BNMT Nepal builds on the 55-year legacy of BNMT-UK in serving the people of Nepal to improve the health and wellbeing of Nepali people. Our celebration reflected on the history and achievements of BNMT over the past six decades and we shared our strategic vision for the future of the organisation with our partners. The Chair of BNMT UK and one of the original BNMT team, Rosemary Boere, who travelled overland in 1968 when the Trust started up were both able to participate. A ceremony was also held

T H E B R I T A I N - N E P A L M E D I C A L T R U S T A N N U A L R E P O R T 2 0 2 2 - 2 0 2 3

to recognise extraordinary contributions from members of the BNMT team with special awards.

None of our achievements would have been possible without the unwavering team spirit demonstrated by our dedicated staff members. I express my sincerest gratitude to every one of them for their tireless work, unwavering effort, companionship, and invaluable contributions to our organisation.

I would like to extend my heartfelt appreciation to our national and international partners, who have been instrumental in our success. These partners include the Ministry of Health and Population, the National Tuberculosis Control Centre, the Nepal Health Research Council, the Health Offices, the Provincial Health Directors, the Centre for Molecular Diagnostics, GENETUP, TB Nepal, Bheri hospital, Koshi hospital, Teku hospital and local government authorities. Their unwavering support and collaboration have played a crucial role in our achievements and the positive impact we have made.

BNMT and BNMT Nepal

The Britain-Nepal Medical Trust established a local Nepalese nongovernmental organisation – the Birat Nepal Medical Trust (BNMT Nepal) in 2012 to continue the work of BNMT UK and this year we celebrated their tenth anniversary. BNMT UK continues to work in partnership with BNMT Nepal and the work described in this report is carried out by BNMT Nepal with support from BNMT UK and other organisations.

I also want to express deep gratitude to all our generous donors. Your continued support and trust in BNMT, particularly during these challenging times, have been vital to our ability to carry out our mission of enhancing healthcare access and quality for all the people of Nepal. We value your partnership in our effort to create a healthier and more equitable Nepal for all its citizens.

Raghu Dhital

Where we work

T H E B R I T A I N - N E P A L M E D I C A L T R U S T A N N U A L R E P O R T 2 0 2 2 - 2 0 2 3

Prevention and diagnosis

Vaccination. The BCG vaccine is good at preventing severe TB disease in the first year or two of life – but it does not protect long term.

Preventing latent TB infection from progressing to TB disease. Some people who have latent TB infection are more likely to develop TB disease than others. Those in the high-risk groups, which includes all household contacts who test positive for latent, TB are recommended to take a course of preventative medicine. This is a shorter, simpler treatment than the treatment for TB disease.

Diagnosing latent TB infection. A positive TB skin test shows only that a person has been infected with TB bacteria. It cannot determine if the person has or will progress to TB disease. A chest X-ray, followed by a sputum test if necessary, can help confirm whether the individual needs to be treated for TB disease or whether they should receive a simpler course of preventative medicine.

The long battle

Effective treatments for tuberculosis have existed for decades and in wealthy countries the disease has been all but eradicated. Why, then, does it persist in Nepal?

What causes TB and how does it spread?

Tuberculosis (TB) is caused by a bacterium called Mycobacterium tuberculosis. It usually attacks the lungs, but TB bacteria can attack any part of the body.

The bacteria spread through the air from one person to another. When a person with TB disease of the lungs or throat coughs, speaks, or sings, TB bacteria can get into the air. People nearby may breathe them in and become infected. People with TB disease are most likely to spread it to people they spend time with every day: family members, friends, co-workers or schoolmates.

But only some of the people infected become sick. Two TB-related conditions exist: TB disease and latent TB.

TB disease

Some people develop TB disease within weeks of becoming infected, before their immune system can fight the TB bacteria. People with TB disease are sick. They may also be able to spread the bacteria to people they spend time with every day. The risk of developing TB disease is much higher for people whose immune systems are weak, for example those with HIV infection, diabetes or malnutrition.

Latent TB infection

People with latent TB infection have no symptoms and do not feel sick, although TB bacteria continue to live in the body. They cannot spread TB bacteria to others. But they usually have a positive TB skin test.

They may never develop TB disease. But if their immune system is weakened, they may get sick – even years later.

World TB Day celebrations in Nepalgunj, 24 March 2023

T H E B R I T A I N - N E P A L M E D I C A L T R U S T A N N U A L R E P O R T 2 0 2 2 - 2 0 2 3

New technologies

BNMT is harnessing new methods to prevent, diagnose and treat TB in a series of pilot projects that show the effectiveness of the technologies and how they can be applied to benefit communities in Nepal.

Prevention: 3HP

TB preventative treatment used to take a long time. People needed to take isoniazid tablets every day for six months, which was difficult for people to complete in areas like rural Nepal. However, in the last decade a new, shorter, preventative treatment called 3HP has become available. People take the medicine once a week for 12 weeks, and it has fewer side effects. That makes it much easier for people to complete the treatment, and for healthcare workers to support the patients. This treatment is recommended by the WHO. BNMT is pioneering its use in Nepal through the IMPACT TB project (see p6).

Professor Andy Ramsay supervises microscopy training in Chitwan

Diagnosis: GeneXpert and microscopy

GeneXpert is a molecular test for TB and is more accurate than microscopy for diagnosing TB. It can help increase TB case detection and get people on to the correct treatment. Nepal’s government has set expanding the use of GeneXpert as a priority, but has insufficient funds to make this happen. BNMT introduced GeneXpert machines in Nepal (see page 6), but much of the country continues to rely on TB microscopy. BNMT, in partnership with provincial and district health authorities, supports laboratories in Bardiya, Chitwan, Dhanusha, Makwanpur and Mahottari districts with theoretical and practical training of laboratory staff, and the service and maintenance of microscopes and other equipment.

Understanding TB: Genomic sequencing

Sequencing the genome of TB bacteria allows us to compare the DNA sequences of the bacteria from different people. This helps us understand how TB spreads between people and communities, and how it has changed over time. It also helps us understand patterns of drug resistance, so we can improve the diagnosis and treatment of drug resistant strains of TB. This technique is one of our most effective tools to understand infectious diseases and respond with better treatments, vaccines, and diagnostic tests. BNMT participates in the Target TB genome sequencing project (see right).

DNA extraction from a TB Culture

Target TB

TARGET TB is the first large-scale whole genome sequencing project for TB in Nepal. The project takes TB bacteria from three contrasting districts of Nepal (Kathmandu (capital), Pyuthan (a rural hill district) and Banke – urban, border with high cross border migration with India). This will improve understanding of TB transmission patterns in different urban and rural environments, and the effects of cross border migration, reactivation of latent TB, drug resistance and strain virulence. All this will help us develop more effective approaches to targeting resources for TB control. The project is being conducted by a consortium including BNMT, GENETUP, and the University of Melbourne (Australia) in collaboration with the NTCC.

T H E B R I T A I N - N E P A L M E D I C A L T R U S T A N N U A L R E P O R T 2 0 2 2 - 2 0 2 3

IMPACT TB

In 2022/23 under the IMPACT TB Project:

30,154 people were screened for TB
22,774 people were tested for TB through GeneXpert
1,366 new cases of TB disease were identified through GeneXpert
500 people with latent TB were enrolled for preventative therapy.

The IMPACT TB project

BNMT’s flagship project is finding better ways to prevent and detect TB. The evidence it gathers at community level informs work to eradicate TB across the country.

IMPACT TB builds on BNMT’s experience of detecting TB in communities, using an approach called active case finding. This means working with a network of community health volunteers who are trained to recognise TB symptoms and to encourage people who have them to go for early diagnosis and treatment. The volunteers also trace the contacts of each person diagnosed with TB, so that they too can be tested for the disease.

The project operates in four districts: Mahottari, Chitwan, Pyuthan and Bardiya. It uses GeneXpert technology to diagnose TB. BNMT supported the installation of five new GeneXpert machines in government health centres in Bardiya, Pyuthan and Mahottari.

The IMPACT TB project is also piloting the 3HP method of preventing TB – the first time this new, WHO-approved therapy has been used in Nepal. Preventative therapy reduces transmission of the disease, because it eradicates the bacteria from the body before it can cause disease and transmit to other people. The 3HP treatment is being piloted in Chitwan and Pyuthan districts, in collaboration with the NTCC.

Five hundred household contacts of TB cases have been enrolled to treatment and 95 per cent of these have now completed the 3HP course. The high completion rate shows that the therapy is acceptable to people with latent TB and is a practical solution in TB-affected communities.

Active case-finding in a remote area of Chitwan

T H E B R I T A I N - N E P A L M E D I C A L T R U S T A N N U A L R E P O R T 2 0 2 2 - 2 0 2 3

The project also includes extensive consultations with provincial and local health officials and hospitals. Scaling up TB prevention therapy is essential if TB is to be eradicated in Nepal. The findings from IMPACT TB will inform efforts to scale up TB prevention.

Promoting End TB at BNMT Nepal’s 10th anniversary

From case-finding to treatment

Through IMPACT TB’s active case finding in Pyuthan, Deva Kumari BK, 72, was identified as having TB. BNMT Field Supervisor Sita GC visited her home for latent TB testing and counselling. It turned out that six adults needed testing, of whom five were living at home. The sixth was one of Deva Kumari’s sons, Baburam BK, who works in Libang, Rolpa district, 90 km from Pyuthan.

Talking with Deva Kumari's family, Sita learned that Baburam had taken responsibility for getting his mother to her appointments before she was diagnosed with TB. Sita realised that it was of upmost importance to test Baburam for latent TB infection. She called him to explain that he urgently needed to be tested. Latent TB was diagnosed and Baburam started 3HP medication the same day.

Baburam said: ‘I saw the pain and suffering that my mother experienced due to tuberculosis, and would not wish it on anyone. I understand that latent TB also occurs, and that it is necessary to diagnose and treat it quickly.’

weeks he claimed leave, saying that his mother was ill and needed his help at home. But in the third week he had to return to work. The latent TB focal person at Pyuthan Hospital coordinated with the nearest treatment centre in Rolpa to enable him to continue to receive his medication locally and on time.

Unfortunately, Deva Kumari died of tuberculosis and for the seventh and eighth weeks of his treatment, Baburam returned home to complete the required rituals, and Sita delivered his medication there. Baburam completed the full course of treatment for latent TB. He is happy to be healthy again and has gone back to work

Because he worked in Rolpa, it was a challenge for Baburam to go to Pyuthan each week to receive his medication. For the first two

T H E B R I T A I N - N E P A L M E D I C A L T R U S T A N N U A L R E P O R T 2 0 2 2 - 2 0 2 3

Bhola Rai interviews a participant in the TB recovery project

The TB Recovery project

Recovery from TB requires at least six months’ intake of medicine, along with a healthy and nutritious diet – something that many poor families cannot afford. BNMT’s TB Recovery project is devising ways to ensure TB patients and their families can eat well.

For many TB-affected households, the cost of TB can be catastrophic. If a breadwinner falls ill, earnings fall, debts accumulate, there is less food to go round, and children may drop out of school. A vicious circle ensues: malnutrition slows down recovery from the disease and increases susceptibility to TB in other family members, and the household falls deeper into poverty.

The importance of healthy food

Sunita (not her real name), 51, lives in one of the more remote areas of Manahari rural municipality in Makwanpur district. She lives with her husband and one daughter. Sunita has physical and mental impairment. The family's primary income sources are her husband's senior citizen allowance and the disability allowance Sunita receives from the government.

supported by healthy foods provided by BNMT’s TB Recovery Project program. Her nutrition package includes 25kg of rice, 1 kg of pulses, 1 litre of vegetable oil, 1.5kg of groundnuts, 1 kg of flour, and a crate of eggs. This makes it easier for her to eat nutritious food and means that she does not have to rely on others to eat. To date, Sunita has received three packages. She notes that her weight is increasing, and that nutritional support helps her have the confidence to take her medications as prescribed.

When Sunita developed a cough, night sweats, loss of appetite and fever – signs that suggest TB – she did not want to seek treatment, hoping that the symptoms would go away by themselves. But they got worse. Sunita went to the nearest health facility, where she was referred to Manahari hospital for TB testing. Her husband borrowed 2,000 rupees from a neighbor, promising to pay it back when he received his senior citizen medicine allowance. Sunita was diagnosed with TB on 6 February 2023.

Sunita thanked BNMT district team and said that medicines alone cannot cure TB: people need support with nutrition to make a full recovery.

Because she lives far away from the hospital, arrangements have been made for her to walk to a nearby health post to receive her medication. Her recovery is

The World Health Organisation recognises the importance of nutrition for recovery from TB and has called for more research and evidence to inform the design of effective, locally appropriate support to ensure TB-affected families can take in sufficient nutritious food.

The TB Recovery project funded by the Australian John Burge Trust Fund provided six months’ nutritional support to 200 TB patients in three TB-affected districts of Nepal: Banke, Pyuthan and Makwanpur. The project also gave training in nutrition counselling to female community health volunteers.

The second phase of the project will explore strategies and create facilities to scale up nutritional support to TB patients and their families.

T H E B R I T A I N - N E P A L M E D I C A L T R U S T A N N U A L R E P O R T 2 0 2 2 - 2 0 2 3

The ASCOT project

Vulnerability to TB is influenced by social and economic conditions. The WHO advocates social and economic support for households affected by TB, but there is no evidence to help policymakers design effective strategies to provide socio-economic support for such households in low-income countries like Nepal. To address this, BNMT decided to develop a locally-appropriate support scheme.

ASCOT is a small pilot study to fieldtest the feasibility and acceptability of various types of support package, before designing a bigger study to test the scheme on a larger scale.

The pilot study was conducted in four districts of Nepal with high levels of both TB and poverty: Pyuthan, Chitwan, Mahottari, and Morang. The pilot study recruited 124 people with TB. Twelve TB clubs to support people affected by TB in the districts were also organised. To evaluate the process, the study recruited 27 stakeholders including National TB Programme staff, TB patients and ASCOT field team members.

Distributing fruit and hygiene kits to TB patients in Pyuthan hospital

The TB patients were assigned at random to the four different types of support: a standard care and food package (this was the control group); social support; economic support (in cash); and combined socio-economic support.

All the support packages had benefits for the participants. They found cash was useful to buy medicine and nutritious food. However, the majority of the participants found socio-economic support useful because it provided both education on TB and cash support. The social support package included a calendar and an animated film which encouraged people to seek TB services. Participants used the calendar for multiple purposes, marking their medicine intake as well as different festivals. The animated film empowered participants to reduce discrimination towards TB patients.

One of the evaluation participants said: ‘If only money is provided, it would be used just for eating. But it is important to learn about how TB is transmitted and caused. TB doesn’t only happen to poor people and, when some people get TB, they overthink and often get stressed and have psychological impacts. When they are like that, if they can understand TB better, they will get relief.’

These findings are being used to inform policy makers at national level and provide evidence to support further funding proposals for a study at increased scale.

TB Recovery

In 2022/23 more than 1,030 members of TB-affected families received nutritional support from this project.

T H E B R I T A I N - N E P A L M E D I C A L T R U S T A N N U A L R E P O R T 2 0 2 2 - 2 0 2 3

TB patient in a special hostel for patients with multi drug resistant TB is supplied with a winter care package by BNMT, Banke.

Addressing the impacts of Covid

BNMT is helping to rebuild health services in the aftermath of COVID-19, and conducting research to improve understanding of long COVID and guide responses to future pandemics.

The Epidemic Intelligence project

Understanding how the SARS CoV2 virus, which causes COVID, spread to and through Nepal can inform the country’s response to a similar pathogen in future.

BNMT’s Epidemic Intelligence project used whole genome sequencing to improve understanding of transmission of COVID 19 in Nepal. It also examined how waves of economic migration drive the seeding of the COVID epidemic in South Asia. The project collected and sequenced SARS CoV2 samples from three locations in different parts of Nepal: Bheri Hospital in Nepalgunj (Far West), Koshi Hospital, Biratnagar (Eastern Nepal) and Sukraraj Tropical Infectious Diseases Hospital in the capital, Kathmandu (central region).

The project recruited more than 2,048 participants and sequenced more than 2,000 patient samples. The participants were followed up after three months, six months and one year to understand the frequency and symptoms of long-term complications of COVID-19 (long COVID).

The study showed that Nepal’s high levels of internal and external migration make it vulnerable to rapid and widespread transmission of emerging infections.

One recommendation arising from this project is that Nepal should strengthen its capacity in bioinformatics. The molecular diagnostic capacity expanded during the pandemic now needs to address endemic infectious diseases and other emerging diseases of concern, including influenza, antimicrobial resistance, drug resistant TB and dengue.

Epidemic Intelligence project findings

Three major waves of COVID 19 hit Nepal
More than a fifth of participants had a history of migration, of which 8 per cent had a history of internal migration
20 per cent of patients reported long COVID, broadly defined as symptoms lasting longer than 12 weeks
The highest risk factors for long COVID were diabetes, hypertension and female gender
Vaccination was highly protective against severe disease and long COVID.

A second recommendation is that specialist care and research centres are needed to understand and treat long COVID. A significant proportion of COVID patients continue to suffer long COVID symptoms and struggle to access appropriate care. A large proportion of them have additional medical conditions. Vulnerable patient groups experiencing long COVID require a broad range of support, including psychosocial support, livelihood support, personalised plans for managing their health and subsidised medical care.

Bioinformatics training course held in Kathmandu for for laboratory expert staff across the country

T H E B R I T A I N - N E P A L M E D I C A L T R U S T A N N U A L R E P O R T 2 0 2 2 - 2 0 2 3

COVID conversations

Media discussions of the pandemic abounded with complex terminology such as ‘sequencing’, ‘genomes’, ‘variants’ and ‘mutations’, which often perplexed the public. To bridge the gap between experts and the public, BNMT conceived Covid Kurakani (COVID conversations) – a series of ‘Question Time’ style panel discussion TV programmes.

BNMT Nepal teamed up with the Centre for Molecular Dynamics and Galaxy Television to produce three discussion programmes for broadcast on primetime national television. Each episode explored different aspects of pathogen sequencing and its applications. They were broadcast in November-December 2022.

Covid Kurakani panel discussion

BNMT was delighted by the enthusiastic response from the expert participants and the public. The Nepal government partners are keen to see similar public engagement for the understanding of science surrounding infectious diseases in Nepal.

The second major goal of the Covid Kurakani project was to build capacity for high quality public engagement within the BNMT Nepal team. Our vision is to embed public engagement throughout our work, from conception, through design, implementation and dissemination of findings.

COVID Kurakani was made possible by the generous support of the Wellcome Trust.

COVID Kurakani can be watched on YouTube or through our website, or scan here to visit our YouTube channel

The SUSTAIN project

The SUSTAIN project, which started in 2020, was designed to respond to the COVID crisis and support continuity in health service delivery. As the situation evolved, with changing community needs and a stronger response from other organisations, BNMT adapted the project to address urgent gaps during different phases of the pandemic.

Since November 2022, SUSTAIN phase V has worked to rebuild and strengthen health services in the aftermath of the pandemic. The project now works in six districts: Mahottari, Chitwan, Bardiya, Morang, Pyuthan and Banke.

BNMT supported five qualified laboratory staff in health facilities to help cope with the post-pandemic surge in medical testing for other diseases. The Trust’s support helped decrease the work burden on staff, reduce overcrowding and increase public access to health services.

The pandemic drove many TB-affected households into extreme poverty, while the need for health services to focus on COVID-19 weakened provision for TB patients. Winter on the Tarai (lowlands) can be bitterly cold, particularly for impoverished families without adequate clothing or fuel. The project therefore provided winter care packages to the most vulnerable TB patients and to those with multi-drug resistant (MDR) TB receiving treatment at MDR TB hostels. Nearly 300 TB patients received winter care packages, hygiene kits or bedding.

The project also supported new furniture (including lockers for patients to keep their belongings) and bedding for two MDR TB hostels in Banke and Morang and new flooring for hostels in Nepalgunj and Morang. Patients must live in the hostels, which have only basic facilities, for more than six months, so the aim was to make their stay a little more comfortable. We continue to consult with patients and caregivers on the most effective ways to provide holistic care and support during treatment.

The primary funders of the SUSTAIN project are BNMT UK and Americares.

Care for TB patients

In 2022/23, project SUSTAIN provided:

300 sets of winter jacket, slippers and a beanie hat
300 hygiene kits
200 winter blankets
40 beds, including mattress, pillow and sheets, to MDR TB hostels
40 electric hot water bottles to MDR TB hostels.

T H E B R I T A I N - N E P A L M E D I C A L T R U S T A N N U A L R E P O R T 2 0 2 2 - 2 0 2 3

Project horizon achievements

Under this project:
166 students, parents and teachers engaged in dialogue in the six schools
120 peer educators were trained among the students
6 information corners were established, one in each school
300+ community people were reached by a municipal SRHR awareness programme
40 municipal leaders and officials received basic information about CSE and SRHR
17 teachers were trained in CSE
530 school students received CSE
13 sanitary napkin vending machines were installed in 12 schools
6 waste disposal pits were constructed to improve menstrual health and hygiene in schools
57 female community health volunteers received basic information about SRHR and cervical cancer

Empowering young people

BNMT’s Project Horizon provides comprehensive sexuality education to adolescents.

In Nepalese society, conversations about sex and sexuality are often deemed taboo. However, education on these topics is crucial if they are to make informed decisions and have a voice in their sexual and reproductive health and rights (SRHR).

Although sex education is included in the school curriculum in Nepal, parents and teachers may be reluctant to talk about sex and sexuality owing to social conventions and their own lack of knowledge. Adolescents, therefore, often hesitate to ask them about sex and sexuality and instead seek advice from their peers, who may give inaccurate information.

To address this gap, BNMT Nepal devised Project Horizon, which aimed to improve access to information on sex and sexuality for adolescents in six schools of Indrawati rural municipality, Sindhupalchowk. The project ran from December 2021 to December 2022. It was based around comprehensive sexuality education (CSE), an age-appropriate and culturally relevant way of teaching about sex and relationships, based on scientifically accurate and non-judgmental information.

The project activities provided adolescents with skills in communication, leadership, negotiation, problem-solving, as well as knowledge about sexual and reproductive health. They empowered adolescents to make informed decisions about their lives and raise their concerns with their peers, teachers, and parents. The challenges discussed included child marriage, adolescent pregnancies, unsafe abortions, gender-based violence, sexual abuse, and mental health.

Project Horizon reached about 2,500 direct beneficiaries including adolescents, parents, teachers, policy makers, community people and female community health volunteers. The initiative received strong support from all involved, and many project partners contributed to its success.

Poster competition for schoolchildren on sexual and reproductive health

Cervical cancer screening

Under Project Horizon, a qualitative study was conducted to explore the acceptability and feasibility of self-sampling for cervical cancer screening in Nepal with the service providers. Selfsampling is where the person being screened takes their own sample, rather than having a clinician do it.

Between August and November 2022, researchers interviewed key service providers: gynaecologists, pharmacists, oncology nurses, online service providers, and representatives from Department of Health services in the Kathmandu valley.

The study found that service providers were positive about the use of self-sampling for cervical cancer screening in urban settings of Nepal. But they said media campaigns were needed to increase women’s awareness before the idea could be implemented.

T H E B R I T A I N - N E P A L M E D I C A L T R U S T A N N U A L R E P O R T 2 0 2 2 - 2 0 2 3

Addressing gender-based violence

Gender based violence training

Sadly, gender-based violence is common in Nepalese society. Through their engagement with households, our field staff and community volunteers may become aware of gender-based violence. To guide our field staff in supporting the victims to access help, we conducted a two-day training session in January 2023. The training aimed to help staff to recognise and prevent such harmful behaviours in their working and domestic lives.

The session explored power and privilege, the types, causes and impacts of gender-based violence, safe places, survivor-centred approaches, and guidelines for managing disclosures of violence in the field. Feedback from the participants was very positive. They appreciated the opportunity to develop psychosocial support counselling skills which will support field staff in responding effectively to gender-based violence issues in the communities they serve.

Sexual and reproductive health training in Sindhupalchowk

T H E B R I T A I N - N E P A L M E D I C A L T R U S T A N N U A L R E P O R T 2 0 2 2 - 2 0 2 3

Saki Thapa presents the vitamin A review from the READ-It project

Building the evidence base for health policy

BNMT is ensuring that relevant research from around the world and the learning from its own projects are available to practitioners and policy makers in Nepal.

The READ-It project

In the Research, Evidence and Development Initiative (READ-It) project, BNMT works with a team of UK-based experts to review the evidence from research around the world on health issues important for Nepal.

BNMT and its project partners organised a policy dialogue in September 2022 to discuss the findings of our systematic review paper entitled ‘Is routine vitamin A supplementation still justified for children in Nepal? Trial synthesis findings applied to Nepal's national mortality estimates’. The participants included the Nepal Health Research Council; the National Tuberculosis Control Centre; the Community Nursing Administrator, Department of Health Services; and representatives from WHO and UNICEF Nepal.

In a lively and wide-ranging discussion, participants noted that Nepal has significantly reduced maternal and under-five mortality rates since Vitamin A supplementation was started in a few selected districts in 1993, gradually expanding to systematic national coverage. However, malnutrition and extreme poverty remain prevalent in Nepal and have risen since the Covid pandemic. The dialogue identified key evidence gaps and the need for further research before considering a revised approach to vitamin A supplementation for under-fives in Nepal.

The READ-It study, published in PLoS One in May 2022, is at https://journals.plos.org/plosone/article?id=10.1371/ journal.pone.0268507

Research grants

BNMT staff Ms Swastika Shrestha, Ms Anchal Thapa and Mr Rajan Paudel have been awarded research grants from the Royal Society of Tropical Medicine and Hygiene and National Institute of Health Research.

Living with epilepsy

Ms Shrestha will explore and understand the lived experiences and psychosocial impact and quality of life of people living with epilepsy (PLWE) in Nepal. Epilepsy has been historically associated with stigma and discrimination: it was viewed as a disease of evil. So people who live with it endure stress, social dissatisfaction, individual isolation, social stigma and helplessness. Gender bias and traditional mental health stigma amplify these effects. The research findings will be among the first to provide robust data on the experience of people living with epilepsy in Nepal.

Medical drones

Ms Thapa’s research will assess the economic efficiency and local acceptability of using drones to transport medical supplies and samples in remote, mountainous rural areas. It will examine whether drones are cost-effective, based on BNMT’s DrOTS project in Pyuthan district which pioneered the use of drones to transport TB drugs and sputum samples. The findings will help inform discussions about whether, where and how to extend the use of medical drones to other parts of Nepal.

Diagnosing multi-drug resistant TB

Mr Paudel’s research aims to develop virtual implementation models to help guide policy makers in deciding which new diagnostic tests to adopt in Nepal. There is an urgent need for better access to drug-resistant TB testing services, particularly beyond the Kathmandu valley. However, given limited resources and competing priorities for healthcare spending, evidence is needed to identify the best diagnostic tools to use.

T H E B R I T A I N - N E P A L M E D I C A L T R U S T A N N U A L R E P O R T 2 0 2 2 - 2 0 2 3

BNMT in the UK

Trustees’ meeting

We had our first face-to-face meeting of the Trustees in May at the Nepal Embassy in London. In the picture, left to right: Dr Maxine Caws, Jeff Mecaskey, Raghu Dhital, Dr Gillian Holdsworth, Gyan Chandra Acharya (Ambassador of Nepal to the UK), Dr Raghav Dhital, Dr Bob Fryatt, Dr Johnny Payne

In memoriam Don Patterson

Sadly, Don Patterson – a former Trustee and director of BNMT – died in November 2022. Don worked initially as a field doctor in Nepal with the Trust (1971-2) and then as director (1976-79) accompanied by his wife Jan. He served as a Trustee from 1981 to 2013.

Don lived a full and meaningful life with a remarkable energy and enthusiasm for using his time learning and giving. His contribution to the Trust was enormous and he will be much missed

Fundraising

Ann and Chris Walters, long term supporters of BNMT, opened their garden to raise money for the Trust in June 2023. Trustee Johnny Payne, his wife Caroline and Gillian Holdsworth joined the family at Bell Bank House, Blockley, Glos for the day. Also attending were Rosemary Boere and her husband Wim. Rosemary was one of the original team who travelled to Nepal in 1968. The day raised £1,000 for the Trust. A big thank you to Ann and Chris.

Welcome to our new Trustees

Two new Trustees and a former patron have joined us this year.

Professor Andrew Ramsay MSc, PhD, FIBM, is an Honorary Professor at the Infection and Global Health, School of Medicine, St Andrews University, Scotland. Andy has more than 20 years of international experience working in infectious diseases, clinical microbiology and antimicrobial resistance with the Liverpool School of Tropical Medicine, the London School of Hygiene and Tropical Medicine and Hygiene and WHO.

Ms Sarah Barton is Director of Operations of the Oxford University Clinical Research Unit (OUCRU). Based in Ho Chi Minh city, Vietnam, she has responsibility for OUCRU operations in Vietnam, Nepal and Indonesia. Sarah has 25 years of experience as a senior leader of multi-cultural, international experience in both programme and operational leadership in the not-for-profit sector.

Dr Bob Fryatt – a former field doctor, Trustee and Patron of BNMT UK has rejoined the board of Trustees in 2023.

T H E B R I T A I N - N E P A L M E D I C A L T R U S T A N N U A L R E P O R T 2 0 2 2 - 2 0 2 3

Financial Report

The financial information presented in this report does not constitute the statutory accounts of the Britain-Nepal Medical Trust. The full accounts for the year ended 31st December 2022 have been submitted to the Registrar of Companies and the Charity Commissioners. A copy of the Reports and Financial Statements may be obtained from the Trust’s office c/o Foot Davson Ltd, 12 Church Road, Tunbridge Wells TN1 1LG

Donations

Many organisations and generous private donors have supported the Trust over the years. Without their generosity much of our work would not have been possible.

The Trust would like to thank the following for their kind support over the last year:

The Acacia Charitable Trust The Janelaw Trust The Stonewall Park Charities

The Trust would also like to thank all individual supporters who continue to support us.

T H E B R I T A I N - N E P A L M E D I C A L T R U S T A N N U A L R E P O R T 2 0 2 2 - 2 0 2 3

How your donation/s can help us …

… reduce the gaps in health service provision, especially for poor and disadvantaged people

£20 provides warm blankets for 10 MDR TB patients in hostels during initiation of treatment

£50 provides two months’ nutritional support to a family affected by TB £100 buys 50 packets of sanitary kits for school children

£250 can buy a set of life-saving basic equipment for a health post in a remote village £2,000 contributes to the purchase and running costs of a GeneXpert machine for early diagnosis of TB

I enclose a cheque/postal order made payable to the Britain Nepal Medical Trust for £

Committed giving and donating online

Alternatively, you can imagine how a regular monthly amount between £10 and £15 would make an even greater impact on the lives of the Nepalese. You
can arrange this by completing and returning this form. Or you can donate, or set up a direct debit, online through the Charities Aid Foundation’s secure
fundraising service by going towww.britainnepalmedicaltrust.org.ukorwww.givenow.org
To the Manager ...................................................................................................................................................................................................................................................................................................Bank)
Address ..............................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................ Post Code ........................................................................
Name ....................................................................................................................................................................................................................................................................................................................................
Address ...............................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................ Post Code ........................................................................
Account No. ..................................................................................................................................................................................................................... Sort Code .........................................................................
Please pay the Britain Nepal Medical Trust the sum of ...............................................................................................................................................................................................................fgures)
...................................................................................................................................................................................................................................................................................................................................words)
Starting on .................................................................../ ........................................... / ....................................................... �Monthly�Quarterly�Half-yearly�Annually
Signed: .......................................................................................................................................................................................................................................... Date: ........................................................................

Tax-effective giving

Since April 2004 a scheme from the Inland Revenue enables you to give to charity through your tax return. All you have to do is quote the reference UAK68HG and nominate The Britain-Nepal Medical Trust as the recipient of your tax repayments.

Gift Aid

The other way you can help BNMT raise funds is by returning the Gift Aid declaration below. This means that you authorise BNMT to reclaim from the HMRC tax you have already paid. All gifts from UK taxpayers now qualify for Gift Aid.

Gift Aid declaration

Please treat as Gift Aid donations all qualifying gifts of money made: today/in the past 4 years/in the future until further notice.

� I confirm I have paid or will pay an amount of Income Tax and/or Capital Gains Tax for each tax year that is at least equal to the amount of tax that all the charities that I donate to will reclaim on my gifts for that tax year. I understand that other taxes such as VAT and Council Tax do not qualify. I understand that the charity will reclaim 25p of tax for each £1 that I give.

Date ............................/ ........................ / ........................... Full name ........................................................................................................................................................................................................... Signature ........................................................................................................................................................................................................................................................................................................................... Full home address ......................................................................................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................................Post Code ........................................................................

Please tick here if you would like to receive details on making the BNMT a beneficiary of a legacy.

Please let us know your email address, either by mail or by email, if you would like to receive information by email, (see below for the address)

.................................................................................................................................................................................................................................................................................................................................................

(No individual personal information will be sold, routed or otherwise transferred to a third party without your explicit consent)

Please return completed form to

The Britain-Nepal medical trust

BNMT, c/o Ms Maidrag, 8 Hazeldean Rd, London NW10 8QU Tel: +44 (0)7375 747038

Email: info@britainnepalmedicaltrust.org.uk www.britainnepalmedicaltrust.org.uk

Charity Registration No 255249

BNMT Nepal Strategic Pillars 2020-2025

Accelerating the elimination of infectious diseases

Building resilient, prosperous and healthy communities

Improving mental health and adolescent sexual and reproductive health

Strengthening health systems and increasing equity of access

Generating evidence to inform policy and facilitate optimal strategy implementation by policy makers

The Britain-Nepal medical trust

Registered Comp any Address

c/o Foot Davson Ltd • Chartered Accountants 17 Church Road • Tunbridge Wells • Kent TN1 1LG Tel: +44 (0)7375 747038 Email: info@britainnepalmedicaltrust.org.uk Web: www.britainnepalmedicaltrust.org.uk

Registered Charity No 255249

Charity registration number 255249 Company rogistration number 921566 (England and Wales) BRITAIN-NEPAL MEDICAL TRUST ANNUAL REPORT AND UNAUDITED FINANCIAL STATEMENTS FOR THE YEAR ENDED 31 DECEMBER 2023

BRITAIN-NEPAL MEDICAL TRUST LEGAL AND ADMINISTRATIVE INFORMATION Trustees Dr G M C Holdsworth Dr R P Dhital MrJ W Mecaskey DfJMVPayne Dr A Ramsay Dr R Fryatt Mrs S Barton (Appointed 12 September 20231 (Appointed 12 September 20231 (Appointed 12 September 20231 Sèeretsry Dr M Maidrèg Chartty number 255249 Company number 921586 Prlncipal addrg$s Lonsdale Gate, Lonsdale Gardens Tunbndge Wells Kent TN1 1NU Registered offic& Lonsdale Gale. Lonsdale Gardens Tunbridge We115 Kent TN1 INU Independent examiner J P van der Merwe ACA Fool Dav50n Ltd Lonsdale Gate. Lonsdale Gardens Tunbridge Wells Kent TN1 INU

BRITAIN-NEPAL MEDICAL TRUST CONTENTS Page Trustees. POrt Slalement of trustees. re5ponsibilrties Independent examineVs report Stalernent of financ¢al a¢tivittes Balance sheet Notes lo the financial sl8lements 8-16

BRITAIN-NEPAL MEDICAL TRUST TRUSTEES, REPORT (INCLUDING DIRECTORS, REPORT) FOR THE YEAR ENDED 31 DECEMBER 2023 The trustees present their anr7ual report and financial slaternenls for the year ended 31 Dec8ffjber 2023. The financial Statements have b&èn prepared in acctsrdance with the accounting polioes sel Dut in note 1 to the financial statemènts and mplY with the Charity's Igoverning éoGumentl, the Companies Aet 2006 and Accounting and Reporting by Chatthes". Statement of Recornmènded Practice applicable to chafilies prepa¥ing their attounts in aceordance wrth the Financial Reporting Standard applicable in the UK and Republie of Ireland IFRS 1021 (effective 1 January 20191. Obj8Ctlvos and activitre$ The overall goal of BNMT is the improvemenl In health and livelihood of marginalised and ctsnfliGt affected commLJnitiès living in remotè and rural areas of Nèpal. The organisalion seeks to achieve this goal through working in partnership with BNMT Nepal. a local NGO established to support BNMT in delivery of a programrne ol work which includes. 51renglhening partners (local community groups and NGOS and local health workers)., efflpowering cc)Fnmunilies for improved a¢sS to hèalth setwces or advocating lor such access,. leading on innov8tion and affvocating for mainstreaming ol 6ffective interventions. The Iruslees have paid due iegard to guidance issued by thè Charity ComTnission in deading what activities the charity should undertake. Achrevernents and perfoTh4nce BNMT'S support lo the National Tuberculosis Pfogramrne {NTPI conlinues through ils the laboratory quality assuran provision in ihe Eastem region Other components of BNMT'S support to NTP have been transferred to our local partner oiganisation IBNMT Nepall - however BNMT ¢ontinues to provide financial and technical support lo BNMT Nepal a5 part ol 8NMT's long leim vision and strategy for sustainabilty. BNMT has worked cltssely with Oiher UK based organisations locussed on the health and wellbeing of the Nepali people advocating foi UK government support lo the Nepal govèmmenl in improving the health and wellbeing of the Nepal population Flnanclal r•view Unrestricted funds showed a sutplus for the year of £109,383 12022.. deficit 01 £525), and an increase in the value of the investments of £1.448 12022". decrease of £2.5301. This gives an overall inuease in unrestrictèd funds of £110.831 12022." decrease of £3,055), leaving a balan of £290.116 (2022.. £179.2851. Restricted funds showed an increase of £1.615 {2022.' decrease of £7,0751, leaving a re5tticted balance of £3,92512tr22-. £2,310) to be used in Lgter peiiods. The Directors aim to hold LsnrÈstricted reserves of bètween 3 and 6 months annual income as working capital. Investments hèld ale rne¢Jiurn term and are reviewed hvo times each year. Thè Tiustee5 have ethical considerations when making decisions lo ensure particularfy that healthcare considèr31ion5 are not compromised. Cash deptssils are held at best inleiest rates wmmensurate with accessibility for cash flow purposes. The trustees have assèssed the major risks to which the chanty is exposed. and are satisfied that Systems a in plaix to mitigate exposure to the major risks. The Directors have a risk manageTnenl strategy whith comprises the maintenance of a detailed nsk registei which is rèviewed annually. Inierirn reviews have also been cariied out to assess and adjust poll¢ies as necessary to lake account of changing security cOnrn5 in Nepal and variations to emergènry procedures. Structure. governance and management The charity was established as a Eharilable company limited by guaranteè on 71h Novembei 1967 (cumpany number 9215661. The company is registered with the Charity Commission (charity nutnber 2552491. The Board of Trustees meets in the UK. The Charty's prograrnme of activitiès 15 carried out in Nepal by Nepalese staff, untler the direction of a Country Director.

BRITAIN-NEPAL MEDICAL TRUST TRUSTEES. REPORT {CONTINUED)(INCLUDING DIRECTORS. REPORT) FOR THE YEAR ENDED 31 DECEMBER 2023 The trustee5, who are also the d1clorS for the purpose of company law, and who served during the yèar and up to thè date of signature of the financial statements were". Dr G M C Holdsworth Dr R P Dhital Mr J W Mecaskey DrJMVPayne DrA Ramsay Dr R Fryatt M15 S Barton IAppoint8d 12 September 20231 IAppoinled 12 September 20231 IAppointe¢J 12 SeptÈmbÈi 20231 New candidates for the Board are proposed by existing Trustees. Candidates receive wntteTr adwce on the roles and responsibilities of Trustees and are inviled lo attend 3 8oard meéting Thereafter the Chair of the Board and the candidate exchangÈ views and If appropriate the incoming Trtsslee is proposed. seconded and elected at the next Board rrTeeting. None of the trustees has any beneficial interest in the company. All of the Iw81ees are membèts of the ¢ompany and guarantee to contribute £1 in thè eveni of a winding up. The Board of Trustees is the Iinal deci5ion-making body Thè Board is advised by a Finan & General Purposes Committee. Ccpmposed ofTiustees, the Country D1ctOr, the Company Secretsry and Financtal Adviser. The trustees, report was 8pproved by the Board of Trustees. Dr G M C Hold$worth Trustee Dated".

BRITAIN-NEPAL MEDICAL TRUST STATEMENT OF TRUSTEES. RESPONSIBILITIES FOR THE YEAR ENDED 31 DECEMBER 2023 The trustees, who arè also the directors ol Britain-Nepal Medical Trust for thè purpose of company law, are responsible for prèparing the Tmsleès, Report and the financial stalemgnts in accordance with app5icable law and United Kingdom Accounting Standards (United Kingdom Generally Accepted Accoufjting Piacticel. Company Law requiies the Irusttres to prepare financ4al statèments for each financial year which give a true and fair view of tha state of affairs of the chaiity and of the incoming rèsources and application of resources, including Itie income and expendrture, ol the charitable company for that year. In preparing these financial statements, the trustees are required to.. select suitable accounting poliGies and then apply them consistently., observe the methods and principles in the Charities SORP., make judgements and estitnales that are reasonable and prud2nt', state whèther applicable UK Accounting Standards have b&en followed, subject lo any material departurès disclcTrsed and explained In the financial slatemenls.. and prèpare the fin8ncial statements on the going conrn basis unless it is inappropriate tu presumè that the charity will contlnue in operation. The trustees are responsible for keeping adequate accounting records tPTat disclose with reasonable accuracy at ny lime the financial position of the charity and enable Ihem to ensure that the financial statements comply wilh the Companies Act 2006. Thoy are also responsible lor safeguarding the assets of th6 charity and hence for taking rea50n8ble steps for the prevention and delectM)n of fraud and Dther IrrUlalieS

BRITAIN-NEPAL MEDICAL TRUST INDEPENDENT EXAMINER'S REPORT TO THE TRUSTEES OF BRlTAlNEPAL MEDICAL TRUST I rewrt lo the trustees on my examination ofthe finanrAal stslements ol Britain-Nepal Medtcal Trusl Ithg charity) for the y98r ended 31 D8mber 2023. Responsibilitlfrs and ba81# of report As Ihe InJ8teès of the thatity land also its directors for the purposes of company lawl you are responsib fDr thg pr8paiatb)n of Ihe finanattl statements in acrordanrR woth the iequifemenls of th& CompanEs Act 2006 {Ihe 21J06 H8Mng satiSfd myself that the financlal slatements of Ihe charity are not Tequiied lo be audited under Part 16 of the 20C6 Act and ore eligib for independent examinat)n. I report in fesp8ct of my examinalK)n of the charfty's financial stsleJnents carried out under sedon 145 of the Ch8rities Ad 2011 (the 2011 Act). In carrylng out my examinion I havg follN8d all the appllcable DiTe(aions grven ty th8 Charity Commission under se(ion 14515)(b) ofthe 2011 ACL Ind•ndent oxamln•rf$ 8tatsmgnt I have completed my oxamlnation. I confirm that no mattarn have com8 to my attentkjn connethon with tho examinatffi giving me Se lo b811gva that in any mal8rfal respéct.. a¢eounting IgrS were not k¢pt In re8pe(a of the tharity as requirèd by section 386 of the 2008Ad", tha financial stslemenls do not aco¥d those rgcor(Js,' or the finand81 statements do not comply with the arUntIng requiremants of section 398 of the 20Cfj Act other than any requiremonl that the aco)unts give a true 8rvJ fair view which is not a matter ¢on5idered as part of an Independent examination: or thg financial statements hav9 not been prepared h) 8c%cffdan wlth the metho(ts 8nd winciples of the Statement of Recommended Practrce for acounling and reportwig by chaFilte6 appficable to charities Preparing their accounts In 8co)r(lanc* wlth the Finanoal Reportwjg StandaTd appllcablg in the UK and Rewbli¢ ol Ireland IFRS 102). I have no concèmg #nd have come across no other matters in u)nnectton wtth the exarnination lo whTch atten1n should be drawn in this reFbOrt in ordèr lo enab a propel uThJerstsnding of the Ilnandal statements lo be reached. dgr ACA For on behalf of Lonsdale Gate Lonsdale Garden$ Tunbridge Wells Kent TN1 1NU Foot Davson Ltd Chartered ACuntants I,d8+

BRITAIN-NEPAL MEDICAL TRUST STATEMENT OF FINANCIAL ACTIVITIES INCLUDING INCOME AND EXPENDITURE ACCOUNT FOR THE YEAR ENDED 31 DECEMBER 2023 Unrostricted R*3trictod funds fund Total 2023 Totsl 2022 Notes Income from: Oonations and legaGies Inveslmenls Other incDme 166.712 1,183 24,416 16.040 182,752 1,183 24,416 50,842 328 2.21 S Total income 192.311 16,040 208,351 53,386 nditure on.. Raising funds 11,303 11,303 10,gg9 Charitable acltvthe5 71,625 14.425 86,050 49,987 Totsl •xpenditurÈ 82,928 14.425 97,353 60.986 109.383 1,615 110,998 17,600) Net Ilossesll gains on investments 10 1.448 1.448 12,5301 Net movèrnent tn fttfid$ 17CI,831 1,615 112,446 110.1301 Fund balances at 1 January 2023 179,285 2.310 181,595 191.725 FurTd balances at 31 Decembèr 2023 290,116 3,925 294,041 181.S95 The statement of finantyal activiti.es indudes all gains and losses recognised in Ihe year. All income and expendtture derive from continuing acbvities. The ststement of financial a(Xivrties a150 complie5 Wlth the requirèmèn15 for an income and expendituie account nder the Companies Act 2008.

BRITAIN-NEPAL MEDICAL TRUST SUMMARY INCOMEAND EXPENDITURE ACCOUNT FOR THE YEAR ENDED 31 DECEMBER 2023 All income funds 2023 2022 Gross income Gainsl{lossesl on investments 208,351 1,448 53,386 12,5301 Tolal iftcgtne in Ihe reporting periTr 209,799 50,856 TcFlal expenditure from income funds 97,353 60.986 Nèt incomellexpenditur¢l for th• year 112,446 110.1301

BRITAIN-NEPAL MEDICAL TRUST BALANCE SHEET AS A T 31 DECEMBER 2023 2023 2022 Notes Fixed assets Tangible assets 11 299 Curront as8èts DèbloTS Investments Cash al bank and in hand 13 e,657 101,807 190,450 8,259 100,359 80,724 298.914 Creditors: amtsunts falling due within onÈ year 189,342 14 14,874} 18.0461 Net cuirent asset5 294,040 181,296 Total ass¢ts loss current liablliti•¥ 294,041 181.595 Income fund Restrictèd fvnds Unrestricted funds 16 3.925 290.116 2,310 179,285 294,041 181,595 The charitable cornpany Is entitled lo the exemption from the audit requirement con¢Bined in section 477 of the CompaniÈ5 Act 2006 lor the year ended 31 Decembei 2023. The difectorsArustees acknowledge their responsibilities for complying with the requirements of the Companies Ad 20 with respect to aCntIng records and the pieparation of financial staternents. The members have not reouired the company to obtain an audil of rts finanual statements for the year in question in accordan wrth section 476. These ftnancial stalernenls have been prepoied in accordance wrth the provisions applicable to companie5 subject to Ihe small cotnpanies règime. The ftnancial state¥nerils were approved by the Tiustees on Dr G M C Holdsworth Trust8e DfJMVPay Trusteo Company reglstration number 921566

BRITAIN-NEPAL MEDICAL TRUST NOTES TO THE FINANCIAL STATEMENTS FOR THE YEAR ENDED 31 DECEMBER 2023 Accounting policies Company inforn)ation 8ritain-Nepal Medical Trust was established as a charitable company limited by guarantee Dn 7th November 1967 {eompany nufflber 9215661. The company is registered with the Charity Commission (charity number 2552491. 1.1 Accounting convention Thè financial statemènts have been prepared In accordance with the charity's govèrning dotument, the Companies Act 2006, FRS 102 "The Financial Reporting Standard applicable in the UK and Republic of Ireland I"FRS 102.1 and the Charities SORP 'Ac¢ounling and Reporting by Charitiès. Statement of Recommended Pia¢tice applicable tts ¢h8rilies preparing IheiT acLy)unts in a¢cord8nce with the Financial Reporting Standard applicable in the UK and Republic of Iieland IFRS 1021" lèffectivÉ 7 January 20191. The charity is a Public Benefrt Entity as defined by FRS 102 The charty ha5 taken advantage of the provisions in the SORP lor charities not lo prepare a Statement of Cash Flows. The finanual statements are prepared in sterling, which is the functional CunCY of the charity. Monetary amounts in thesè finanoial statemen15 3re rounded to the nearest £. The finanaal statements have been prepared under the historical wst convèntion. The principal accounting policre5 adopted are sel out below. 1.2 Going concem At the time of approwng the fin¥n&al slatements. the trustees have a rèasonable expectslion that the c*arity has adequate r6sourGe5 to continLte in operational existence for the toreseeable future Thus the trustéés continue to adopt the going conGem basis of accounting preparing the financial 5tateTllentg. 1.3 Charitable fvnd5 Unrestricted funds are available for use at the diScretn of the Iruste@s in furtherance of their charrtable objectives. Reslri¢led funds are subject to speofic conditions by donofs as to how they may be usèd. The purposes and uses of the reStrted fvnds are sel out in the notes to the financi21 statements. 1.4 Income Income is recognised whèn the charty 15 legally elllitled to it after any performance conditions have been met, the amounts can be measured reliabty. and it Is probable that income will be Ceived. Cash donations are ie¢ognised on receipt. other cjonations are recognised once the charity has been notified of the donatiofi. (Jnless performancè ¢onditions requi¥e deferTal of the amount. Income tax recov6rablè i relation to donations reied ullder Gift Aid or deeds ol wvenant is r8cognised at the time of the donation. Legaci&s aTe recognised on receipt or otherwise rfthe charity has been notified of an impending distribution. the amount is known, and receipt is èXP8Cted. Ilthe amount is not known. the legacyls treated as a ¢onlingent asset. 1.5 EXndItUre and irrècoverabl• VAT Expenditure is recognised as soon as there is a legal or constructive obl(gation committing the charity to that exper)diture. it is probable that settlemènt will be required and the amount of the obligation can bè moasured

BRITAIN-NEPAL MEDICAL TRUST NOTES TO THE FINANCIAL STATEMENTS {CONTINUED) FOR THE YEAR ENDED 31 DECEMBER 2023 Aceountlng policies Icontlnuedl All expènditure is accounted lor on an awuals basis. All expenditure including support costs and governance costs are allo(3ted or apportioned to the applicable expenditure heading5. Iriecov8rable VAT Is charged against the expenditure heading for which it was IncurTed. Grarrts Payab are payments to charities in Nepal, which are charged in the year when the grant is awarded by the Trustees. 1.6 Tangible fixed a88ets Tangible fixed asse15 aTe initially tneasured al cost and subsequently measured al c05t or valuation. net of depreciation and any Impairment losses. Depreciation is recognised so as to write off the cost or valuation of assets less their re&dual values over their useful lives on the following bases". Computers 25% on cost The gain of loss arising the dispo1 of an asset is deterrnined as the differen between the sale proceeds and the carrying value of the asset. and 15 recognised in the staletnent of financial actiwlies. 1.7 Iwnpaimient of fixed a$sets At each reporting end dale, the charity reviews thB calg amounts of its tangible assets to delerniine whethèr there is any indication that those assels have suffered an impairmènt loss. If any such indication exists, the recoverablè arnount of the asset is eslimaled in order to determine the extent ol thg Impairfflent loss {if any). 1.8 Cash and cash oqufvalents Cash and cash equivalents include cash in hand, deposits held at call with banks, other short-term liqu investments with original malurilies of three months or less, and bank overdrafts. B8nk overdrafts are shown within bom)wings in cuirent liabilities. 1.9 Flnancial in$truments The triJs1 only has finan¢i81 assets and finanoal liabilities of a kind that qualify as basi¢ fjnanaal instwments. Basic financial instruments are inilially recognised at transa¢tion value and subsequently measured at Iheir settlement value with the exception of current asset investments which are subsequently rrieasured at fair value with any gains or losses 3rising on rerneasuremenl COgnised in profit or loss.

BRITAIN-NEPAL MEDICAL TRUST NOTES TO THE FINANCIAL STATEMENTS (CONTINUED) FOR THE YEAR ENDED 31 DECEMBER 2023 Donations and lègac5 Unrestrictod R$$trict•d funds funds Totsl 2023 Total 2022 Donations and gifts Legacies receivable 35.824 130,888 16.040 51.864 130,888 4S,086 5,756 186,712 16.040 182.752 5CI.842 Unrestricted donations Restricted donations 166.712 16,040 47.838 3,004 182,752 50.842 DOnaon¥ and gifts Young Dung Scholarship and specific Nepali family support Gift aidèd and olhei donation5 420 15.620 420 15,620 35,824 420 2,584 42.082 35.824 35,824 16.040 51.864 45,086 Investmènt income Unrestricted funds Total 3023 2022 Income from listed invéslmenls Interest receivablè 159 1,024 97 231 1.183 328 All investment income eamed, during both this finanaal reporting period and the pievious reporting period, was of an unrestricted nature. Other income 2023 2022 Other Income 24,416 2.218 10.

BRITAIN-NEPAL MEDICAL TRUST NOTES TO THE FINANCIAL STATEMENTS (CONTINUEDI FOR THE YEAR ENDED 31 DECEMBER 2023 Othor income (Continued) All other income received, during both this financial reporting period and the prewou5 reporting period, was ol an unrestrict1 nature. Ral$ing funds Unrestricted fund$ Totsl 2022 Cost of eneratin donations and le Publicity and fundraising Annual Rèport Accountan Consultants and professional se$ Staff salaries Oepreciation Office expenses acies. 705 4,477 908 1,589 3,006 89 529 1,194 4,332 876 1,416 2.754 131 296 11.303 10,999

BRITAIN-NEPAL MEDICAL TRUST NOTES TO THE FINANCIAL STATEMENTS {CONTINUED) FOR THE YEAR ENDED 31 DECEMBER 2023 Charitsble actlvltles Pro9fdmmÈ costs Support costs Gov'nco costs Totsl 2022 Staff costs Depreciation Office expenses Travel and TrLsslees expenses Consultants and professional semces Independent examination fees Accountancy 2,004 60 522 1.360 397 5,010 149 787 7,014 209 1.309 1,360 6,355 3,405 227 6,426 305 7S4 1.741 5.663 3,285 219 5.958 3.405 227 4,570 15.309 19,879 18,403 Grants payable (see note 71 66,171 66,171 31,584 Total 66,171 4.570 15.309 86.050 49.987 Analysls by fund Unrestricted funds ReslriGterl funds 51.746 14,425 4,570 15.309 71.625 14.425 6.171 4,570 15,309 86,050 For tho year ended 31 Decomber 2022 Unrestricted fund5 Restricted funds 21.505 70.079 4,583 13.820 39.908 10,079 31,584 4.583 13,82 49,987 Grants payable 2023 2022 Grants lo BNMT Nepal 66,171 31,584 66.171 31,584 12_

BRITAIN-NEPAL MEDICAL TRUST NOTES TO THE FINANCIAL STATEMENTS (CONTINUED) FOR THE YEAR ENDED 31 DECEMBER 2023 Trusts¥$ None of the trustees lor any persons connected with them) received any remuneration during th8 year. bul a total of £1,360 was reimbursèd for travelling expenses12022- total of £1,741). Employees Numbgr of employees The 8vera9e monthly number of employeès during the year was". 2023 Number 2022 NUrntr Employment costs 2023 2022 Vvages and SalaeS 10,020 9,180 10 Net gainslllossg$1 on investments 2023 2022 Revaluation ol investments 1,448 12.5301 1,448 12,5301 All gainslllossesl on investments. duii119 both this financial reporting period and the previous reportillg period, telaled to unfeslricted funds.

BRITAIN-NEPAL MEDICAL TRUST NOTES TO THE FINANCIAL STATEMENTS (CONTINUED) FOR THE YEAR ENDED 31 DECEMBER 2023 11 Tangible fixed assets Cornputers C05t Al 1 January 2023 1,743 At 31 December 2023 1,743 Deprèciation and Impalmnt Al 1 January 2023 Depreciation charged in the year 298 At 31 December 2023 1.742 Carying amount Al 31 December 2023 Al 31 December 2022 299 12 Financlal instrufflents 2023 2022 Carying amount ol financial assets Instruments measured at fair value through profit or loss 101,807 1 QO.359 Current 855et investments aTe initi4lly recognised al cost and are subsequently remeasured al fair value. being the quoted m2rkel price, wrlh any gains or losses aiising on remeasuremefjl recognised in the SOFA At the year eRd the investments held had an ongiftal cost value of £8.706 12022." £8,706) and a faif value Iquoled markèt price) of £101,80712022'. £100.3591. 13 Debtors 2023 Amounts falling due within one yèar. 2022 Other debtors 6.657 8,259 14 Creditors: amounts falling due within one year 2023 2022 Other taxation and social secunty A¢ctuals and deferred income 274 4,600 821 7,225 4.874 8,04fj 14-

BRITAIN-NEPAL MEDICAL TRUST NOTES TO THE FINANCIAL STATEMENTS {CONTINUED) FOR THE YEAR ENDED 31 DECEMBER 2023 IS Analysls of net assèts bètwÈÈn funds Unrestrictsd funds Restrlcted funds Total Fund balances al 31 December 2023 are represented by.. Tangible fixed asse15 Current asseisllliabilitiesl 294.040 294,040 294.041 294,041 16 Rostriet•d funds The income lunds of the charity inGlude Testiided lunds GorRpr15ing the foll¢)wing unexpended balances of donations and grants held on trust for specific purposes. Movoment in fund¥ Ineoming Rèsoure•8 8alane• at 31 re50ur¢e$ expended December 2023 Balaneé at 1 January 2023 Young Dung Scholarship and specific Nepali family support 2,310 420 15,620 12,4851 111.9401 245 3,680 2,310 16,04Q 114,4251 3.925 15-

BRITAIN-NEPAL MEDICAL TRUST NOTES TO THE FINANCIAL STATEMENTS (CONTINUED) FOR THE YEAR ENDED 31 DECEMBER 2023 17 Fund6 held as admlni¥trator 2023 2022 Funds held at 31st December PDP Funders Group The Institue ol Canr Research 90,970 77.OL13 14.616 90,970 91,619 The charily administers the above funds. These funds are not ¢hanty assets and are therefore not included in the charity's financial slatemenls. 16