Statistical Appendix
Goal 1:
Reduction of infant and under-five mortality rates by one third or to 50
and 70 per 1,000 live births respectively, whichever is less
Under-five mortality rate
Probability of dying between birth and exactly five years of
age, per 1,000 live births
Infant mortality rate
Probability of dying between birth and exactly one year of age,
per 1,000 live births
Nepal does not have a national vital registration system from which mortality rates can be
calculated. The Nepal Family Health Survey (NFHS1996) is considered to be the most
recent and reliable source of data for mortality rates in Nepal.
NFHS used the direct method to estimate mortality rates. Full reproductive histories were
obtained from each woman interviewed. Women of child bearing age (15 to 49 years) were
asked about all living children, all children who had died, and all pregnancies, whether they
had resulted in a live birth or not.
The estimated infant mortality rate (IMR) for the five-year period preceding the survey (19921996) is 79 per 1,000 live births. The under-five mortality rate (U5MR) for the same period is
118 per 1,000 live births.
IMR and U5MR by 5 year periods preceding NFHS 1996
Years preceding survey
IMR
U5MR
0-4 years
78.5
118.3
5-9 years
108.3
161.6
10-14 years
126.7
195.6
According to the table above, mortality levels have declined by about 40 percent since the
80s. Findings from earlier surveys are plotted in the graph below.
Trends in Infant Mortality in Nepal (1969 -1994)
200
150
100
50
0
1979
1984
NFFS 1986
90
103
NFHS 1991
123
115
80
127
108
NFS 1976
`
NFHS 1996
1969
1974
156
140
1989
1994
79
1
The IMR for boys is typically
higher than that for girls.
However, the higher rate of
child mortality (between 1-4
years) is not biologically
expected,
and
suggests
discrimination against girls in
child rearing practices, such
as feeding patterns and care
seeking.
U5MR by Place of Residence (1986-96)
deaths per 1,000 live births
250
208
200
178 179
143.4
150
127
139
138
119
113
100 82.2
50
Far-West
Mid-West
Western
Central
Eastern
Terai
Hill
Mountain
Rural
Urban
0
Mortality Rates by Sex (1986-96)
200
deaths per 1,000 live births
To determine disparities in
IMR and U5MR, rates were
calculated for a 10-year
period to increase the
number of cases. The
disparity pattern for IMR and
U5MR is the same, although
they differ in the magnitude.
IMR and U5MR are higher in
rural areas than they are in
urban areas. Mortality rates
in the Mountains are much
higher than they are in the
Terai or the Hills. The MidWestern and Far-Western
regions have the highest
mortality rates.
Boys
Girls
142.8 135.5
150
101.9
100
83.7
45.5
50
56.5
0
IMR
Goal 2:
Child Mortality
U5MR
Reduction of maternal mortality rate
Maternal mortality ratio
Annual number of deaths of women from pregnancy-related
causes, when pregnant or within 42 days of termination of
pregnancy, per 100,000 live births
There are no reliable registration systems on deaths or cause of deaths in Nepal, from which
one can derive maternal mortality rates (MMR). The most recent survey conducted on the
maternal mortality rate is the Nepal Family Health Survey (NFHS) of 1996. NFHS used the
sisterhood method. Direct estimates of male and female adult mortality were obtained from
information collected in the sibling history.
The MMR for the period 0-6 years prior to the survey has been estimated at 539 per 100,000
births. This contrasts with the estimate of 515 per 100,000 derived by the indirect method
(with some adjustments) from the Nepal Fertility Family Planning and Health Survey
conducted in 1991.
The MMR estimate from the NFHS (1996) is considered to be the most reliable in Nepal.
This survey was ranked fifth best in an assessment of the quality of age data in 40
`
2
Demographic Health Surveys.1 In NFHS 1996, maternal deaths are defined as those that
occur during pregnancy, childbirth or within two months after birth or termination of
pregnancy. A detailed discussion on data quality with regard to MMR can be found in the
NFHS 1996 report.
Goal 3:
Reduction of severe and moderate malnutrition among under-five children
by half
Underweight prevalence
Proportion of under-fives who fall below minus 2 and below
minus 3 standard deviations from median weight-for-age of
NCHS/WHO reference population.
Stunting prevalence
Proportion of under-fives who fall below minus 2 and below
minus 3 standard deviations from median height-for-age of
NCHS/WHO reference population.
Wasting prevalence
Proportion of under-fives who fall below minus2 and below
minus3 standard deviations from median weight –for-height of
NCHS/WHO reference.
Current status of PEM
The most recent national nutrition survey, Nepal Micronutrient Status Survey (NMSS),
conducted in 1998, showed that that child malnutrition is still widespread in Nepal and that
there has been very limited progress over the last decades. The survey found that 54
percent of children below 5 years of age are affected by stunting and that 47 percent of the
children are underweight. In addition,
the survey reports that 7 percent of the
Map 1: Stunting in
children below 5 years are wasted.
children, 6-59 months, by
eco-development region
As can be seen from Map 1,
(NMSS 1998)
malnutrition is not evenly distributed
throughout Nepal. Instead there is wide
variation
both
ecologically
and
regionally throughout Nepal. Stunting,
underweight and wasting are all more
common in the mountain areas than in
> 70 %
60 - 69 %
the Terai. As with many other socio50 - 59 %
economic indicators, there is also a
40 - 49 %
marked geographical trend, with the
rates for all three indicators being
particularly high in the Mid- and FarWest Hills, as well as the whole mountain region. It should be noted from Map 1 that
although the prevalence of stunting is particularly high in the western mountain areas, it is
prevalent throughout the country with more than 40 percent of children stunted in all regions.
The 1998 survey also shows that children in urban areas are less likely to be stunted (36%)
than children in rural areas (56%). In spite of marked gender differences seen in many other
socio-economic indicators, the recent nation-wide surveys have not found any significant
From Ayad et al (1997) “Demographic and Socioeconomic Characteristics of Households” DHS
Comparative Studies, No. 26. quoted in Retherford, R.D and Shyam Thapa (1999) “The Trend of
Fertility in Nepal, 1961-1995”, Genus.
1
`
3
differences in malnutrition between girls
and boys below five years. Some
localised studies, however, have found
more malnutrition in girls.
(NMSS 1998)
70
60
Percentage
Age of the child is an important factor in
the levels of malnutrition. There is a
dramatic increase in malnutrition, for all
indicators, between 6 months and 2
years.
After the second year,
underweight and wasting begin to
decrease. Stunting, however, continues
to increase after the second year for
children in the Hills and Mountains.
Figure 1: Indicators of malnutrition by age,
children 6-59 months
50
40
30
20
10
0
6-11 months 12-23 months 24-35 months 36-47 months 48-59 months
Stunting
Underweight
Wasting
Trends in PEM
Stunting
In spite of the efforts made to address the problem of child malnutrition, and in spite of
significant reduction in infant mortality and increased GNP, there has been only limited
reduction in child malnutrition over the last 23 years.
Figure 2: Prevalence of stunting; 6-36 months,
<-2 SD, Nepal 1975-98
100
90
80
70
Prevalence
According to data from three national
level surveys having similar designs,
there has been a slight improvement in
the status of children, 6-36 months old, in
Nepal when measured by stunting
(height-for-age). There has been a 15
percentage point reduction since 1975,
from 65 percent to 50 percent (Figure 2).
On average, the rate of reduction was
0.65 percentage points per year, which
translates into a 6.5 percent reduction for
the 1990s.
60
50
NFHS
1996
NNSS
1975
NMSS
1998
40
30
20
10
0
1975
1980
1985
1990
1995
2000
The earliest national survey, the 1975
National Nutrition Status Survey (NNSS),
was originally analyzed using a different reference population and classification system. The
data have since been recalculated by the Center for Disease Control, Atlanta, to be
comparable with later surveys.
Underweight
When comparing prevalence of underweight in children 6-59 months in 1975 with the
situation in 1998, it can be seen that the reduction is slightly higher than for stunting. The
1975 National Nutrition Status Survey found 69.1 percent of the children to be underweight,
whereas the 1998 Micronutrient Status Survey registered a prevalence of 47.1 percent, a 22
percentage point reduction. However, as underweight is a sensitive indicator that quickly
responds to sudden changes, such as seasonal and temporary fluctuations, it is not a
reliable indicator for long-term trends.
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4
Goal 4:
Universal access to safe drinking water
Use of safe drinking water
Proportion of population who use any of the following types of
water supply for drinking: piped water; public tap;
borehole/pump; protected well; protected spring; rain water.
Drinking water received its due attention as a basic social service following the UN’s call to
declare the Eighties as the Drinking Water and Sanitation Decade.
Consequently, Nepal drew up a 10-year plan beginning November 1980 to provide drinking
water to 69 percent of the population by 1990. Although achievement was far short of the
rather ambitious target, this was the first time such a long-term plan, covering both the Sixth
and Seventh Plan periods, had been formulated in this sector. By the end of the decade,
according to the Nepal Family Health Survey (NFHS 91), 46 percent of the population had
access to drinking water
– 90 percent in the
Trends in Safe Water Supply Coverage
urban areas and 43
100
percent in the rural
90
areas.
80
In the 1990’s, drinking
water
coverage
improved significantly,
especially in the rural
areas. According to the
BCHIMES survey, in
2000 coverage stands at
80 percent – 92 percent
in urban areas and 78
percent in rural areas.
70
60
% 50
40
30
20
10
0
1990
91
92
93
Total
94
95
96
Urban
97
Rural
98
99
2000
DWSS
Safe water supply coverage
NFHS 1991
NFHS 1996
BCHIMES 2000









Rural – 42.8%
Urban - 89.9%
National -45.9%
Rural – 61.4%
Urban- 84.7%
National- 63.4%
Rural – 78.1%
Urban- 92.3%
National - 79.9%
However, figures released by the Department of Water Supply and Sewerage (DWSS),
which carries out projects related to drinking water and sanitation, are much lower. In 2000,
DWSS put coverage at only 67 percent. This could be because the information system is
incomplete and, thus, not fully accurate. There are many DDC, VDC, NGO-initiated water
supply schemes that have been built in response to popular demand.
None of the surveys carried out during the 1990s provide any information on the quality of
water being distributed in both the urban and rural areas.
`
5
The country hopes to achieve universal access to drinking water by the end of the Ninth Plan
period (1997-2002). However, meeting it will be a tall task for the following reasons:




Ambitious target
Frequent transfer of key officials from one district to another
Delay in the release of funds from the centre to the districts, making it difficult to meet
annual targets
Reduced funds from UNICEF and other agencies for drinking water due to increased
allocation of resources for sanitation
Goal 5:
Universal access to sanitary means of excreta disposal
Use of sanitary means of
compound :?
Proportion of population who have, within their dwelling
excreta disposal
toilet connected to sewage system; any other flush toilet
(private or public); improved pit latrine; traditional pit latrine
The overall situation of sanitation in Nepal is very poor. The NFHS survey in 1991 found
sanitation coverage was only 20 percent – 69 percent in the urban areas and 16 percent in
the rural areas.
Sanitation coverage
NFHS 1991
NFHS 1996
BCHIMES 2000









Rural-16%
Urban-69%
National -20%
Rural – 18%
Urban- 74%
National - 23%
Rural – 27.1%
Urban- 74.7%
National - 29%
In 1994, DWSS announced a new policy on sanitation that aimed at:
 bringing about changes in people’s sanitary and hygiene practices through health
education, information and community mobilisation;
 ensuring
community
involvement,
particularly
Trends in Sanitation Coverage
women,
in
water
management and hygiene
100
education;
90
 encouraging
the
80
participation of NGOs and
70
voluntary and community60
based organisations.
% 50
In 2000, sanitation coverage
stands at 29 percent, a nine
percentage point increase
since the beginning of the
decade,
which
means
sanitation has made little
progress over the years.
Sanitation coverage in the
`
40
30
20
10
0
1990
91
92
Total
93
94
95
Urban
96
97
Rural
98
99
2000
DWSS
6
rural areas is low, 27 percent, as against 75 percent in urban areas. In BCHIMES 2000, 51.5
percent of households (50.8% in rural areas and 66.5% in urban areas) report that they do
not have latrines because they lack the resources to build one.
During the current Ninth plan (1997-2002), the government has set a goal of increasing
sanitation coverage to 40%. Given the rate of progress in the past, the target will be difficult
to meet unless a different strategy is adopted to accelerate progress.
Goal 6:
Universal access to basic education and achievement of primary
education by at least 80 percent of primary school-age children through
formal schooling or non-formal education of comparable learning
standard, with emphasis on reducing the current disparities between
boys and girls.
Children reaching grade 5
Net primary school
enrolment ratio
Net primary school
attendance rate
Proportion of children entering first grade of primary school
who eventually reach grade 5
proportion of children of primary-school age enrolled in
primary school
Proportion of children of primary-school age attending
primary school
Net Primary School Enrolment
In 1995, the net enrolment ratio (NER) in primary school was 68 percent, four percentage
points up from 1990. However, wide disparity was seen in the enrollment of boys and girls,
with a 56 percent NER for girls as against 79 percent for boys. Nonetheless, the enrolment
ratio for girls shows remarkable achievement given that it was just 31 percent in 1990.
These official figures provided by the Ministry of Education are comparable to the data
collected by NMIS2 in 1995 which found 70 percent of children aged 6-10 enrolled in primary
school. The data when broken down by sex showed that 60 percent of girls and 80 percent
of boys were enrolled.
The NMIS survey also showed that more children in urban areas were enrolled than in rural
areas. Disaggregated data on NER by development region shows tremendous disparity, not
only among the regions but also between male and female enrollment. The Mid-West and
Far-West Regions had the lowest net enrollment rates and also the greatest disparity
between boys and girls’ enrollment.
Net Enrolment Rates (Source: NMIS Cycle 2, 1995)
National
Urban
Rural
East
Boy
79%
87%
78 %
75%
Girl
59%
76%
57%
57%
Central
75%
53%
West
89%
76%
MidWest
68%
37%
Far West
80%
57%
The most recent data from the MOES (Ministry of Education and Sports), though not official,
puts the NER at 72 percent in 1999. It shows little change in disparity over the 1998 data,
with the girls’ NER standing approximately 18 percentage points lower than that of boys.
NER in primary school in 1998 was 71 percent - 79 percent for boys and 61 percent for girls.
`
7
Net Enrolment Rates (Source: Ministry of Education and Sports 1998)
East
Central*
West
Mid West
Total
71%
69%
78%
67%
Boy
78%
81%
82%
78%
Girl
64%
58%
74%
55%
*This figure does not include the Kathmandu Valley.
Far West
62%
75%
49%
Kathmandu
84%
85%
83%
Over the decade, the net enrollment ratio has been rising, albeit slowly. The credit for this
goes to the Basic and Primary Education Project (BPEP) launched in 1992 to improve
access, quality of instruction and supervise primary education in 40 districts.
Nepal, however, fell short of its target of achieving a NER of 80 percent in 1998, as per the
Jomtien goal of achieving universal primary education by 2000. Inability to achieve the target
is attributed to the difficulty in reaching out to school children in the remote areas, gender
discrimination which keeps girls at home, language problem in a country where Nepali is the
mother tongue of only 52 percent of the population, poverty and low quality of education.
In 1999, BPEP II was launched throughout the kingdom to improve access and retention and
learning achievement. NER is expected to continue increasing, hopefully, at an accelerated
rate of 2 percentage points a year, with the BPEP II goal of having a NER of over 80 percent
by 2004.
Children Reaching Grade 5
Survival rates in Nepal can be calculated with reasonable accuracy starting only in 1994.
Survival rates in primary school were calculated in 1998 - the most recent date for official
figures - at only 34 percent without repetition and at 44 percent with repetition. The reason
for the low level of survival in the 5-year primary cycle is the high level of drop out and
repetition in Class One. According to most recent official figures from MOES, over 19
percent of children enrolled in Class One dropped out, with another 38 percent of Class One
students repeating the grade. This means only 41 percent of the cohort were promoted to
Class Two.
If we examine the trend from 1994 to 1998, we see a steady increase in survival rates of
approximately 1.5 percent per year without repetition, and greater increase for survival rates
with repetition. This can be attributed to several factors, including increased attention to
teacher training and the introduction of pre-primary programmes to reduce underage
enrolment. The survival rates are slightly higher for girls than boys, which means that
enrolled in primary school, girls are not being pulled out at a higher rate than boys. This
difference is greater for survival rate with repetition. Tables for survival rates (With Repetition
and Without Repetition) for boys and girls from 1994-1998 are given below.
If we look at the trends of the past five years, we are in a position to project survival rates
until 2005, shown in the two graphs below. At this rate of growth, however, survival without
repetition would still be well under 50 percent in 2005.
In terms of projected survival rates with repetition, the data until 2005 are calculated based
on the 1994-1998 trends in official data. As can be seen, girls’ survival rates with repetition
are considerably higher than that of boys and reach over 60 percent. It is possible, as a
result of the inputs from the Basic and Primary Education Programme 1999-2004, that
survival rates will increase above these projected levels. This could be especially true as
BPEP is focussing on teacher training and quality improvements in the classroom as key
components. Based on the existing trends, the rates below have been projected.
`
8
Survival Rates Without Repetition*
Year
Total
Female Male
1994
30
30
30
1995
31
31
31
1996
32
32
31
1997
34
35
33
1998
34
35
33
1999
35
37
34
2000
36
38
35
2001
37
40
35
2002
38
41
36
2003
39
43
37
2004
40
44
37
2005
41
46
38
*Rates from 1999 are projected figures
Survival Rates With Repetition*
Year
Total
Female Male
1994
38
38
39
1995
40
40
41
1996
40
41
40
1997
43
45
42
1998
44
45
43
1999
45
48
43
2000
46
50
44
2001
48
52
45
2002
49
54
46
2003
50
56
47
2004
52
58
48
2005
53
60
49
*Rates from 1999 are projected figures
Projected survival with repetition until 2005
SURVIVAL RATES WITHOUT REPETITION - 1994 TO 2005
50
40
30
20
10
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
0
YEAR
FEMALE
MALE
Net Primary Attendance Rates
No data are available in Nepal on net attendance rates. They have never been collected by
MOES, or by any surveys to date. There have been surveys that look at attendance rates in
primary schools, but these have not factored in the age of children. For example, the NMIS
Cycle Two data from 18,825 households in 1995, found attendance rates in primary school
to be 55 percent in Class One and 60 percent in Class Two. This was based upon
attendance registers in schools averaged over the previous five days. Boys’ attendance was
found to be slightly higher than that of girls. There was no analysis of differences based
upon age.
In early 2000, the BCHIMES survey covered 10,302 households. An average attendance
rate of 83 percent was found over the previous three days of school. Again, this was not
based on net enrolment, but on children of all ages in primary school (gross enrolment). The
main reasons for not attending were illness of the child, followed by household chores,
distance to school, poor quality of teachers, language problems and unwillingness of the
child for unspecified reasons.
`
9
Although the gross attendance rate shown by the BCHIMES study is encouraging, a trend
cannot be derived at as the methodologies used by NMIS2 1995 and BCHIMES are
different.
Goal 7:
Literacy rate
Reduction of the adult illiteracy rate (the appropriate age group to be
determined in each country) to at least half its 1990 level, with emphasis
on female literacy.
Proportion of population aged 15 years and older who are able, with
understanding, to both read and write a short simple statement on their
everyday life
Literacy Rate
The 1991 Census used reported literacy as its tool to assess literacy (i.e., based on the
feedback to the questions "Are you literate? Is each member of your family literate?"). The
1991 Census found 33 percent of Nepalese aged 15 years and above literate - 48.9 percent
males and 17.2 percent females.
In 1995, adult literacy rates were assessed in the NMIS Cycle Two survey. It found that the
reported national literacy rates for adults aged 15 years and above had risen to 40 percent,
with 57 percent for men and 23 percent for women. The main reasons given for the increase
was expansion of primary school education and the efforts of the national literacy campaign,
which had reached over 300,000 adults annually since 1993.
Disaggregated data on literacy shows tremendous disparity between male and female
literacy rates by development regions, with male literacy at four-times the levels of female
literacy in the Mid and Far West Regions. As can be seen from the chart below, female
literacy in the Mid and Far Western Regions is just a third of the 33 percent female literacy
for the Western Region.
Adult Literacy Rates by Development Region by percent
Far West
Female
9
Male
49
Source: NMIS2, 1995
Mid West
11
44
West
32
69
Central
16
51
East
21
53
In 2000, the BCHIMES Survey also looked at reported adult literacy as part of the household
data collected from 10,302 homes. It found adult literacy to be 51 percent, which was broken
down to 66 percent for males and 35 percent for females. The single factor most responsible
for the increase in literacy has been expanded primary education for girls. Of the 33 percent
women who are literate, 25.7 percent had undergone formal schooling while 7.2 percent
acquired literacy through informal channels, a pointer that the impact of the literacy
campaign has decreased.
Given the different modalities used in the NMIS and BCHIMES surveys, their figures are not
comparable, hence the actual literacy trend cannot be ascertained. Yet it is clear that over
the decade there has been a steady increase in both male and female literacy rates. Female
literacy is more impressive, having nearly doubled since 1991. The gap between male and
female literacy rates has also narrowed both in actual and percentage terms. In 1991,
female literacy was one-third the male literacy level, while in 2000, female literacy is half the
`
10
male literacy rate. The chart below shows the literacy figures as recorded by different
surveys over the past 10 years.
Adult literacy rate
Female
Male
Total
Goal 8:
1991 Census
17
49
33
1995 NMIS
23
57
40
2000 BCHIMES
35
66
51
Provide improved protection of CEDC and tackle the root causes
leading to such situations.
Total child disability rate
Proportion of children aged less than 15 years with some
reported physical or mental disability
Total child disability rate
This Situation Analysis on Disability in Nepal conducted in 1999/2000 found the prevalence
of disability among children below 15 years of age to be 1.01 percent. The study was
carried by New Era, a Nepali consultancy firm, under the supervision of the National
Planning Commission, with support from UNICEF.
In this survey “disability” is defined as: “a result of impairment where a person might not be
able to perform activities of daily life considered normal for his/her age, sex, etc.” A disability
describes a functional limitation in the categories of communication, locomotion, mental
development, as well as complex disabilities. Although the survey’s definition was formulated
based on the WHO international classification of impairment, disability and handicaps (ICIDH
1980), it is much narrower. The survey includes only those who are severely disabled, and
does not cover those with mild disabilities and cases with impairment. Furthermore, the
degree of disability was not clinically examined, and it was identified by non-medical although trained - enumerators.
The survey covered a sample size of 13,005 households with a population of 75,994,
accounting for 0.37 percent of the total population. Data quality management primarily
focused on proper data collection and recording them in the forms. No sampling error was
calculated
In this survey, prevalence of disability among the general population aged 0-70 years was
found to be1.63%. This is significantly lower that the global estimated prevalence rate of
moderate and severe disability of 5.5 percent2. This difference can be attributed to:




the narrow definition of disability used in the survey;
the age limit for the survey, i.e. 0-70 years old;
a non-clinical examination by non- medical enumerators who are not in a position to
identify mild and moderate types of disability;
non-inclusion of disability and death among children no longer present in the
household.
Disparities
2
`
Helander, E. “Prejudice and Dignity, an introduction to CBR”, UNDP 1999, p. 21.
11
Breakdown of the disability prevalence among children under 15 years is presented in the
table below. The survey found a higher disability rate among males than females under 15
years of age. This pattern is consistent with the findings of earlier sub-national studies
conducted in Nepal. In terms of regional differences, disability prevalence is lowest in the
mountains where socio-economic indicators tend to be the poorest. This suggests that in
areas where living conditions are harsh and access to quality basic social services is poor,
children with severe disabilities have a low chance of survival.
Table A:
Estimates of disabled persons below 15 years of age
Background
Characteristics
Total
Population
Persons
with
Disabilities
Prevalence
(%)
Percentage of
Disabled Persons in
Different Categories
(100%)
Age Group
0-4
5-9
10-14
10,772
10,908
9,644
97
103
117
0.90
0.94
1.21
28.7
30.5
40.8
Sex
Male
Female
16861
16151
199
139
1.18
0.86
58.9
41.1
Location
Urban
Rural
2712
30300
25
313
0.92
1.03
7.4
92.6
Ecological Belt
Terai
Hills
Mountains
Total
13377
10554
9081
33,012
140
108
90
338
1.05
1.02
0.99
1.01
41.4
31.9
26.6
100.0
Goal 9:
Special attention to the health and nutrition of the female child and to
pregnant and lactating women
Under-five mortality
Probability of dying between birth and exacetly five years of
age, per 1000 live births
rate- female/male – disaggregated by gender
Underweight prevalence
Proportion of under-fives who fall below minus 2 standard
deviations from median
female/male weight for age of NCHS/WHO reference
population-disaggregated by gender
Antenatal care
Proportion of women and aged 15-49 attended at least
once during pregnancy by skilled health personnel
Proportion of population aged 15-49 who are HIV positivedisaggregated by gender and age
HIV prevalence
`
12
Anemia
Proportion of women aged 15-49 years with
haemoglobin levels below 12 grams/100 ml
blood for non-pregnant women, and below
11 grams/100 ml blood for pregnant women
Underweight prevalence – girl/boys
Under 5 mortality rate
(male/female)
deaths per 1,000 live births
The Nepal Micronutrient Status Survey (NMSS), conducted in 1998, found that there was no
significant gender difference in the nutritional status of children below 5 years of age. The
survey found that 47 percent of children below 5 years are underweight (boys 46.8 % and
girls 47.4%). Fifty-four percent of under-five children are stunted (boys 54.4% and girls
53.7%), and 7 percent are wasted (boys 7.3% and girls 6.0%). In spite of marked gender
differences seen in many other socio-economic indicators, the recent nation-wide surveys
have not found any significant differences in malnutrition between girls and boys below five
years. Some localised studies,
however, have found more
Mortality Rates by Sex (1986-96)
malnutrition in girls. Please refer
200
to Goal 3 for a general
Boys Girls
discussion on malnutrition rates.
142.8 135.5
150
101.9
100
83.7
In the Nepal Family Health
56.5
Survey (1996), mortality rates
45.5
were calculated for a 10-year
50
period to assess disparities. The
infant, child and under-five
mortality rates by sex are shown
0
in the graph. We see that the
IMR
Child Mortality
U5MR
male IMR is higher than the
female IMR, as would be expected. However, the higher rate of female child mortality
(between 1-4 years) is not biologically expected, and suggests gender discrimination in child
rearing practices, such as feeding patterns and care seeking practices.
Antenatal care
Please refer to Goal 11 for the discussion on Antenatal care.
Proportion of Women 15-49 years with Anaemia
In 1998 the overall prevalence of anaemia in women of reproductive age was 67.7 percent.
Among pregnant women, the rate was 74.6 percent, with severe anaemia in 5.7 percent of
the pregnant women (NMSS 1998).
In spite of the magnitude of anaemia in Nepal, the problem has received little attention.
There have also been relatively few surveys. Anaemia was first assessed in the 1975 Nepal
Nutrition Status Survey, which only reported on children aged 6 to 70 months. In 1986, 71 to
95 percent of mothers with young children were found anaemic in five districts (Joint
Nutrition Support Project).3 And in 1997, the Nepal Nutrition Intervention Project – Sarlahi
(NNIPS) conducted a survey in Sarlahi District, which found 70.6 percent of pregnant
3
`
Joint Nutrition Support Project.
13
women, 81.6 percent of lactating mothers, and 57.5 percent of infants (3 months) with
anaemia.4
Field methodology may vary, and sample size and design certainly vary between these
surveys and the NMSS in 1998. It seems clear, however, that the anaemia rate has been
extremely high in women for at least the last twelve years and that there has been no
reduction. For a more detailed discussion on anaemia, please refer to Goal 13.
HIV Prevalence in Nepal
In the early 1990s, HIV prevalence in Nepal showed a slow, gradual increase among STD
patients and female sex workers (FSW). Beginning with the mid-1990s, HIV infection rate
among the FSWs shot up from 2.7 percent in 1996 to 17.3 percent in 1999/2000, and rose
exponentially from 2.2 percent in 1995/1996 to nearly 50 percent in 1999 among injecting
drug users (IDU).
Nepal has entered the stage of a concentrated epidemic, with a higher than 5 percent
seroprevalence among the sub-population such as the FSWs and IDUs. According to
WHO/UNAIDS estimates, some 33,500 Nepalese were living with HIV/AIDS by the end of
1999.
There are a total of 1,714 reported cases of HIV infection, including 18 children from
perinatal transmission, and 416 have progressed to AIDS, as reported by the National
Center for AIDS and STD Control (NCASC), as of Oct 31, 2000. The figures for men more
than double those for women: 1,206 men, 370 FSWs and 97 housewives. Blood transfusion
accounts for only three known cases and injecting drug use, a further 191. However,
HIV/AIDS cases could be vastly underreported due to irregularities in the reporting system.
No evidence of HIV infection was found among antenatal clinic attendees tested at 8 sentinel
surveillance sites in 1991 and 1992. But by 1999, HIV prevalence among antenatal clinic
attendees was an estimated 0.2 percent, which sends an alarming sign that HIV is foraying
into the general population.
In absence of effective interventions, HIV prevalence in Nepal may rise to 1-2 percent in the
15-49 age group over the next decade, according to Dr. James Chin, Clinical Professor of
Epidemiology, University of California, Berkeley. Translated into numbers, it would mean
between 100,000 to 200,000 young adults becoming HIV positive and 10,000 to 15,000 of
annual AIDS cases and deaths by the end of this decade.
If the trend is allowed to continue, by the end of the first decade in the 21st century, HIV may
become the Number One killer of Nepalese in the 15-49 age group. The stunning projection,
a conservative estimate of USAID/Family Health International, is based on Nepal's current
HIV prevalence among the adult population.
Injecting drug users
The relatively low HIV prevalence in Nepal's adult population masks a staggeringly high
prevalence of 50 percent among injecting drug users (IDUs). As of early 1999, there are
around 20,000 IDUs in Nepal. Half of all IDUs in Kathmandu, according to NCASC, test HIV
4
Dreyfus, ML, Shrestha, JB, Khatry, SK. The Prevalence of Anaemia among Pregnant and Lactating
Women and among their infants in Sarlahi District. For submission to the Journal of the Nepal
Medical Association.
`
14
positive. And half of the country's 50,000 drug users, including non-injecting drug users, are
in the 16-25 age group.
A national HIV seroprevalence survey in February 1999 showed that HIV prevalence among
IDUs increased markedly from 2.2 percent in 1995 to nearly 50 percent by 1998. Dr. Chin
attributed the rapid rise to a probable change in the type of drug used. There has been a
significant shift from heroin to the use of injectable buprenorphine (Tidigesic), he said in a
USAID-sponsored visit to Nepal in August 1999. Tidigesic is a prescribed pharmaceutical
product, a sedative that costs less than a hard drug like heroin. It is estimated that drug
users in Kathmandu spend an average of Rs 5 million (US$ 70,771) a day to sustain their
habit.
A rapid assessment in 1999 by the NCASC cited peer pressure, curiosity, frustration and an
uncertain job prospect as major factors that drive young people, mostly male, into drug use.
The NCASC said in a recent assessment that among HIV positive drug users are children of
middle-class families, students, street children, rickshaw pullers, vegetable vendors and odd
job holders.
Contrary to popular belief in the high correlation between HIV and illiteracy, the majority of
drug users in Nepal are educated. According to the NCASC, 36.5 percent have attained 9-10
grades, 17 percent 6-8 grades, almost 10 percent attended intermediate school, and only 7
percent are illiterate.
Another surprising fact is that almost 80 percent of IDUs associate the sharing of needles
and syringes with the risk of HIV infection. The high awareness points to their vulnerability of
not being able to access the means necessary for behaviour change, as national policies
and decision-makers still oppose 'harm reduction' interventions (e.g. access to clean needles
and syringes, and substitution therapy).
Migrant laborers and sex workers
HIV is also making inroads among migrant workers in Nepal. Between one to two million
Nepalese men and women cross the open border with India to find jobs in Mumbai, Calcutta
and other cities. Grim economic prospects - with the unemployment rate as high as 47
percent (1998 Human Development Report) - have triggered an exodus of cheap labour,
multiplying the real risk of HIV infection. Among them are girls trafficked or voluntarily
recruited to Indian brothels, exposing themselves to increased HIV risk unknowingly. A
recent UNAIDS survey of brothels in Mumbai shows an HIV prevalence of 60 percent among
FSWs. Data from a Family Health International (FHI) study in 1999 confirms a strong
correlation between sex work in India and HIV infection among returned Nepalese women.
Of the 410 FSWs surveyed, 70 had worked in India, and 12 of them (17.1%) tested HIV
positive. This compared to the 1.2 percent, or 4 women, who tested HIV positive in a survey
of 340 FSWs who had not worked in India.
Contributing to Nepal's HIV growth is also the large number of young Nepalese male
migrants who frequent brothels in India. The estimated numbers of HIV-infected Nepalese
FSWs and male workers returning from India may rise to a few thousand a year, according
to Dr. James Chin.
The number of sex workers in Kathmandu Valley varies from 5,000 - 25,000. Commercial
sex in Nepal is largely hidden. Many report serving at least three clients a day, and those
frequenting them include vegetable vendors, migrant workers, garment workers, local shop
owners and students. Most of their clients refuse to use condoms. According to UNAIDS, the
majority of male clients are married, or have other partners, which multiply the chances of
HIV spreading into the general population. The low socio-economic status of women and
`
15
relative inaccessibility of condoms also make hidden commercial sex an HIV fermenting
ground. Compounding the situation is the injecting drug habit among FSWs. In a recent FHI
sample survey of 300 FSWs in Kathmandu, 15 said they were IDUs and 11 of them (73.3%)
were found HIV positive.
Goal 10:
Access by all couples to information and services to prevent
pregnancies that are too early, too closely spaced, too late or too many
Contraceptive
prevalence
Proportion of women aged 15-49 who are using (or whose partner
is using) a contraceptive method (either modern or traditional)
Fertility rate for women
15 to 19
Number of live births to women aged 15-19 per 1,000 women
aged 15-19
Total fertility rate
Average number of live births per women who has reached the
end of her childbearing period.
Awareness about Family Planning
The percentage of married women of childbearing age, 15-49, knowing at least one family
planning method increased nearly five-fold, from 21 percent to 98 percent, during 1976-1996
(Figure 1). Awareness about family planning varied considerably by method: Sterilization
continued to be most widely known, while spacing methods were least known. Of all the
spacing methods, awareness about injectables and the condom increased by more than nine
and fifteen times, respectively. Awareness about the IUD and female barrier methods is the
lowest, while awareness about the pill increased more than two-fold. Overall, awareness about
any modern method of contraception has been nearly universal.
`
16
Figure 1 Women’s (15-49) Awareness of Modern
Contraceptive Methods, Nepal 1976-1996
100
Any modern method
90
Female sterilization
80
Injectable
Condom
70
Pill
Implant
Pe 60
rce 50
nt
40
IUD
Male sterilization
30
20
Female barrier
10
0
1976
1981
1986
1991
1996
Contraceptive Prevalence
Contraceptive use has also increased considerably over time (Figure 2). Current use of any
modern method of contraception increased from 3 percent to 29 percent among currently
married non-pregnant women of reproductive age - a 10-fold increase over the two decades.
This indicates an average increase of about 1.3 percentage points per annum. Female
sterilization is the most prominent method, accounting for 50 percent of the total prevalence.
Male sterilization is the second most popular method, representing one-fifth of the total
prevalence in 1996. Of the spacing methods, the injectable is the most popular method. There
has been an increase in the prevalence rate of injectables from 0.1 percent in 1981 to 5 percent
(a fifty-fold increase) during 1981-1996. The BCHIMES survey puts the contraceptive
prevalence rate at 37 percent, confirming the increasing trend of contraceptive use.
Figure 2 Trends in Contraceptive Use, 1976-1996
( currently married women, 15-49)
30
29
All spacing methods
Male sterilization
25
24
Female sterilization
9.6
Percent Using
4.4
20
15
15
7.5
6.0
2.0
Availability and Accessibility
10
8
6.2
2.2
5
3
3
3.2
12.1
13.4
6.8
1.9
0
1.0
1976
`
2.6
0.1
1981
1986
1991
1996
17
During 1976-1991, the percentage of women who knew of a family planning outlet (a measure
of service availability) increased from 6 percent to 74 percent (Table 1). This situation most
probably reflected a combination of the establishment of new service outlets and women being
more knowledgeable about the existing as well as new outlets. In contrast, there was only a
modest gain in accessibility, defined as women's perceived travel time to a known outlet, during
the period 1976-1991. Whereas about one-third (34%) of the women perceived the travel time
to be up to two hours in 1976, 50 percent of women thought so in 1991 - an increase of 16
percentage points.
Similarly, whereas in 1976, 66 percent perceived the travel time to be more than two hours, 50
percent thought so in 1991. The most significant increase in accessibility was in the category of
1-2 hours, where there was a 2.5 times increase during 1976-1991. Overall, accessibility
increased more during the 1976-81 period than during 1981-91; in 1976, about 50 percent of
women perceived the travel time to be one day or more, in 1991 only 18 percent. In spite of
these gains, however, only 25 percent of the women perceived access to an outlet within one
hour from their place of residence, while 50 percent of the women perceived the access to be at
least three hours.
Comparable data for all methods for 1996 are not available. However, among the current users
of modern contraceptive methods, 77 percent live within one hour of the nearest service
delivery outlet and 13.4 percent within a radius of 1-2 hours. These data indicate the
importance of bringing the services in close proximity to the potential users.
Table 1. Percentage of currently married women, 15-49 years, who know of a service outlet
for family planing and perceived travel time to a known outlet, Nepal, 1976-1991
Availability and Accessibility
Availabilitya
Accessibilityb
Up to one hour
1-2 hours
3-4 hours
1 day or more
a
b
1976
1981
1991
6
33
74
24
10
15
51
29
13
38
21
25
25
32
18
Refers to having knowledge of the availability of a service outlet.
Refers to perceived travel time to the nearest outlet among those who know of an outlet.
Supply Source
Both the 1991 and 1996 surveys collected data on the supply source for the methods currently
used. We present information from the 1996 survey in Table 2. For sterilization, injectables and
implants, the government continues to be the main source for the overwhelming majority of the
users; for the pill and condom, the private sector is an important source. Two of three women
using the pill and one of three women using condoms obtained the supplies from a private
source, mainly pharmacies. Within the public sector, the major sources, according to their
relative order of importance, are district hospitals/clinics and mobile clinics.
`
18
Public
District hospital,
district clinic, primary
health center
Mobile clinic/camp
Nor-plant
IUD
Condom
Inject ables
Pill
Total
48.2
31.7
8.3
18.8
6.5
56.7
52.3
34.5
38.7
49.8
0.0
3.9
0.0
4.7
0.0
29.1
0.4
0.1
49.4
63.2
34.1
26.2
8.6
17.0
0.0
0.0
27.0
2.1
45.4
0.0
0.0
5.3
9.1
10.6
10.1
11.4
5.6
12.4
29.2
9.8
3.7
7.8
5.2
0.6
8.2
0.0
10.0
4.5
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
Health post, Subhealth post, family
planning clinic,female
community health
volunteer and other
public sources
Private
Pharmacy/shop
Hospital, clinic,
community health
volunteer
Other
Friend/relatives and
source not specified
Total
Male
Sterilization
Source
Female
Sterilization
Table 2.
Percentage distribution of currently married women, 15-49 years, using
contraceptive methods by most recent source of the method, Nepal, 1996
Note: Some percentages may not add to 100 due to rounding. The percent distribution
shown in the table is partly from those reported in the 1996 survey report (MOH, 1997:64))
due to differences in classification of the source of supply. Total includes users of
diaphragm/foam/jelly.
Demand for Family Planning
There have been steady increases in unmet need, met need and total demand for family
planning services in the first half of the 1990s. However, the magnitude of the change varies for
the respective categories. The increase in unmet need is less than the met need. Unmet need
increased by only 0.74 percentage points annually, while met need increased by 1.16
percentage points annually.
`
19
The total demand for family planning services increased by over 9 percentage points, from
about 51 percent in 1991 to 60 percent in 1996. On the other hand, the met need (i.e.,
percentage using contraception) increased by 6 percentage points, from 23 percent to 29
percent. The total demand is, thus, higher by about 3 percentage points than the met need.
About two-thirds of the total demand is met by the increase in contraceptive use. Had the
percentage using contraception increased by 1.9 percentage points (in lieu of 1.16) annually,
the total increase in demand would have equaled the rise in contraceptive use. As of 1996, only
about half of the total demand is met, and fully 31 percent of the currently married women in
Nepal are in need of family planning services, either for spacing or limiting births.
Fertility
Emerging evidence suggests that fertility in Nepal has begun to decline. This change in fertility
represents a major social transformation underway in society; it indicates a transition in the lives
of women and their families and suggests the effectiveness of the population and family
planning programs in the country. This transition is indicative of the gradual changes in the
values, norms and practices. The pre-established cultural scripts are being transformed, and a
new culture of contraception and reproductive behavior is evolving. During the 20-year period,
1976-1996, five comparative national fertility surveys were conduct. In addition, censuses and
various other surveys provide further information for gaining insights into fertility change.
Life-time fertility, measured by the total fertility rate (TFR), for Nepalese women of 15-49
years was 6.3 in the mid-1970s. It declined to 4.6 in 1996 (Figure 3). Thus, there has been a
decline of 1.9 births per woman over a 20-year period. Life-time fertility for urban areas (2.9)
is about 2 children less than for rural areas (4.8). In urban areas, fertility has declined much
faster than in rural areas.
Contraceptive Use and Fertility
Contraceptive use is one of the four most important "proximate determinants" of the aggregate
level of fertility. Analysis of district-level data since 1991 shows that a 15 percent increase in
contraceptive use is associated with a reduction in one potential birth, or total fertility rate (TFR),
per woman in Nepal. By extrapolation, the 1996 contraceptive prevalence of 24 percent is,
therefore, associated with the reduction on average of about 2 potential births per woman in
Nepal.
Desired Family Size
The notion that the increasing demand for family planning is a relatively new phenomenon is
suggested by the data on desired family size. The average number of children desired by
currently married women is shown in Table 3.
Table 3. Average desired number of children among currently married women, age 15-49,
in Nepal, 1976-1996
`
Age
Group
1976
1981
1986
1991
1996
Difference
(1976-1996)
15-29
30-49
3.7
4.3
3.7
4.3
3.2
3.7
2.9
3.5
2.7
3.2
-1.0
-1.1
15-49
4.0
4.0
3.5
3.2
2.9
1.1
20
Over the 20-year period, the average desired family size declined by 1.1 children per currently
married woman. The data also suggest that the norm regarding family size began to change
sometime during the early 1980s. By the mid-1990s, the average number of children desired
declined to just below three. Of interest here also is that the change in fertility preference has
occurred between both the younger and older age groups.
Figure 3 Trends in Fertility & Contraceptive Prevalence 1976-2001
40
TFR
6
35
30
TFR per woman
5
25
4
20
3
15
Contraceptive prevalence
2
10
(modern methods)
1
5
0
0
1976
1981
1986
1991
1996
Percentage using contraception
7
2001
Knowledge and practice of family planning in Nepal have increased considerably during the 20year period, 1976-1996. As of 1996, the overwhelming majority of Nepalese women reported
being aware of modern family planning methods. Awareness of spacing methods is relatively
lower than that of permanent methods.
Of those who are aware of any modern methods, about 29 percent are currently using a
method. Use of modern contraceptive methods has increased by an average of 1.3 percentage
points per year during the 20-year period. This level of increment is lower than that of the
records of "established" programs, but higher than that of the "emerging" programs
internationally.
The private sector, mainly pharmacies, appears to be emerging as an important source of
supplies, particularly for the pill and condom. The private sector represents a new dimension of
the country's family planning program. For unlike in the public sector, the users of the private
sector would have to pay for the commodities, hence the beginning of the concept of "pay-forcontraceptives" in the country. It also signals the potential opportunity for introducing other
contraceptives through the private/ commercial sector.
While the private sector is not likely to be a substitute for public sector service delivery in the
foreseeable future, it certainly could play a larger role in expanding the service delivery capacity
of the country's family planning program. The recent introduction of the injectable contraceptive
through the social marketing sector in Nepal appears appropriate, particularly since the use of
injectables has been increasing in general, and pharmacies have become the main source in
the private sector.
Although the availability of services has increased over the years, for the majority (75%) of
women, service outlets continue to be at least one hour or more away from their place of
residence. The only spacing method that has recorded a relatively fast rate of increase in use is
the injectable. The main reason for this being its increasing availability. Actually, the injectable
`
21
is the only spacing method (aside from the pill and condom) that is currently available through
the majority (over 70%) of family planning outlets in the country.
The experience of the injectable contraceptive suggests that the use of other similar spacing
methods such as IUDs and implants may also increase, with wider availability of these
methods, accompanied by effective education, communication and motivation program inputs.
Evidence from Nepal and other countries suggests that availability of and accessibility to
services are directly related to increased use of family planning services. There is, therefore, an
urgent need to strengthen and expand service delivery outlets with the provision of regular
supplies of various contraceptive methods.
The data also reveal that about one-third of the women of childbearing age in Nepal do not
want to have any more children. The percentage wanting to limit childbearing is considerably
higher than the percentage wanting to space pregnancies. This pattern appears similar to the
experiences of several other countries in which contraception is initially adopted by older
women to terminate childbearing. At the same time, the role of spacing methods, particularly
injections and implants, in the overall contraceptive method mix has increased in more recent
years. The need to create more awareness for spacing methods with well-focused and
appropriate education-communication and motivation campaigns cannot be overemphasized.
The overwhelming majority of contraceptive users in Nepal do not switch between methods.
Further, the availability of each method has attracted a new pool of users. The current level of
contraceptive use is associated with a reduction of about 2 potential births per woman. These
results are in line with those based on cross-national studies.
After several years of effort, fertility transition appears to have begun in Nepal. Norms and
preferences regarding family size are changing. The demand for family planning, particularly for
limiting pregnancy, remains high and is probably increasing. The current level of contraceptive
use in Nepal may be considered to be at a critical stage in which further rapid spread is most
likely to occur, as has been the experience of other countries. The challenge is, therefore, to
expand and strengthen the provision of good quality services on a regular basis to meet the
increasing demand now and in the future.
Goal 11:
Access by all pregnant women to prenatal care, trained attendants
during childbirth and referral facilities for high-risk pregnancies and
obstetric emergencies
Antenatal Care
Childbirth Care
Obstetric care
Proportion of women aged 15-49 attended at least once during
pregnancy by skilled health personnel
Proportion of births attended by skilled health personnel
Number of facilities providing Comprehensive essential obstetric
care per 500,000 population
Number of facilities providing basic essential obstetric care per
500,000 population
Antenatal care
There are three national surveys that looked at antenatal care (ANC) in Nepal in the past
decade. These three surveys are essentially comparable. The differences in survey design
are that: (a) the NFHS (1996) only covered births in the three years prior to the survey,
whereas the other two surveys were for births in the previous five years; and (b) the
definition of a qualified ANC provider differs from one survey to another. There has been a
`
22
recent shift in policy on persons qualified to provide ANC. The figures and differences in
definitions are summarized in the table below.
The survey findings suggest that ANC coverage has been improving over the last decade in
Nepal. About a quarter of women now have at least one ANC visit with a skilled health
personnel during their pregnancy, compared to only 15 percent at the beginning of the
decade. It is also encouraging that among women who have at least one ANC visit, many of
them return for additional check ups. The 1996 survey found that the median number of
visits was 3. BCHIMES 2000 found that the number of visits was 3.6. A minimum of 4 ANC
visits are recommended for women with uncomplicated pregnancies.
Both the 1996 and 2000 surveys found that younger, educated, low parity women who live in
urban areas are more likely to have an antenatal check up. In terms of regional disparity,
women in the western parts of the country and the mountainous regions are less likely to be
seen by a health worker during pregnancy.
Proportion of women with at least one ANC visit during pregnancy
Nepal Fertility,
Nepal Family Health
BCHIMES (2000)
Family Planning
Survey (1996)
and Health Survey
(1991)
For all live births in
For all live births in
For all live births in
the last 5 years
the last 3 years
the last 5 years
% attended by
doctor, nurse or
15%
24%
27%
midwife (skilled
health personnel)
% seen by trained
15%
39%
40%
care provider
Doctor, trained
Doctor, nurse/ANM,
Same as 1996
midwife, nurse.
VHW, MCH worker,
survey definition
other health
Definition of
professional,
trained care
including health
provider
assistants, assistant
health worker, senior
assistant health
worker.
While the government policy on health staff who are eligible to provide antenatal care has
been expanded, much remains to be done regarding the training of health staff and
improving the quality of antenatal care provided. Further efforts are required to develop the
crucial link between antenatal care attendance and the ability to access lifesaving
Emergency Obstetric Care (EOC) services in health facilities for emergency complications.
Childbirth care
The table below summarizes the data available on assistance at delivery in Nepal. While the
data suggests that progress has been made over the decade, the proportion of births
attended by skilled health personnel remains low at only 12 percent. Furthermore, this figure
is more likely to be an overestimate, rather than an underestimate, because of the tendency
among rural women to consider paramedical health workers in health centers as doctors.
`
23
At the same time, the proportion of deliveries supervised by trained health personnel has
increased with each survey, from 6 percent in 1991 to 13 percent in 2000. However, a
distinction needs to be made between “trained” and “skilled” birth attendants. Training
programmes for health staff, community volunteers and traditional birth attendants are not
adequate for them to be considered “skilled” birth attendants.
The majority of women in Nepal deliver at home, with over half assisted by a relative or a
friend. What is also alarming is that the proportion of women who deliver on their own, with
no other person present, has not decreased over the decade: 10 percent in 1991; 11 percent
in 1996 and 12 percent in 2000.
Nepal Fertility,
Family Planning
and Health Survey
(1991)
For all live births in
the last 5 years
% of births at a
health facility
% attended by
doctor, nurse or
midwife (skilled
health personnel)
% attended by
trained health
personnel
For all live births in
the last 3 years
BCHIMES (2000)
For all live births in
the last 5 years
6%
8%
11%
6%
9%
12%
6%
10%
13%
Doctor, trained
midwife, nurse.
Trained personnel
involved in
providing delivery
services
Nepal Family Health
Survey (1996)
Doctor, nurse/ANM,
VHW, MCH worker,
other health
professional,
including health
assistants, auxiliary
health worker, senior
auxiliary health
worker.
Same as 1996
survey definition
As we have seen with antenatal care, younger, educated, low parity women are more likely
to have assistance at delivery. Also, births in urban areas are more likely to benefit from
medical supervision than those in rural and remote areas.
The low number of births attended by skilled personnel is clearly reflected in the high
maternal mortality in Nepal. There is compelling historical and limited epidemiological
evidence of a significant relationship between skilled attendance at delivery and reduction in
maternal mortality ratios. The low numbers reflect the lack of awareness among women and
communities in general, that every pregnancy faces risks. It also reflects the lack of skilled
personnel in rural areas of Nepal where 90 percent of the population resides, as well as the
lack of faith in the health system.
Obstetric care:
There has been no national survey to determine the number of facilities providing
comprehensive and essential obstetric care (EOC) in Nepal. The Health Management
Information System also does not collect this information from hospitals and health centers.
`
24
The most extensive survey to date has been the needs assessment conducted in 2000 for
the Women’s Right to Life and Health Project. The survey covered all the health facilities,
both public and private, in three of the five development regions in Nepal. Although the
selection of the three regions was based on the project implementation sites, the findings are
indicative of the national situation. The two development regions not covered in the
assessment were the Far Western and the Central regions. The Far Western region is
considered to be the most disadvantaged of the five regions in Nepal. The Central region
includes the Kathmandu valley, the largest urban center in Nepal, and therefore, is
considered to have the best maternal care facilities.
According to the Guidelines for Monitoring the Availability and Use of Obstetric Services
(UNFPA/WHO/UNFPA, October 1997, p. 27), the minimum acceptable level of
Comprehensive EOC is considered to be one facility per 500,000 people. The minimum for
Basic EOC is considered to be 4 facilities per 500,000.
From the table below, we see that in all the regions, EOC facilities were inadequate for the
population. For Comprehensive EOC services, the gap was the smallest in the Eastern
region with only one additional facility required, while the Mid Western region had only onethird of the required number of Comprehensive EOC facilities. Of greater concern is the
situation of Basic EOC facilities. The number of facilities with Basic EOC services is
drastically smaller than the number required. The data suggest that less than 10 percent of
the required Basic EOC services are actually available in these three regions.
Comprehensive EOC Services in the Three Regions Surveyed
Estimated
Required
Available
Region
Total
Comprehensive
Comprehensive
Population*
EOC Facilities
EOC Facilities
Eastern
5,316,150
11**
10
Gap between
Required &
Available
1
Western
4,509,076
9
6
3
Mid-Western
2,909,753
6**
2
4
All Regions
12,734,979
18
8
26
Basic EOC Services in the Three Regions Surveyed
Estimated
Required Basic
Region
Total
EOC Facilities
Population*
Eastern
5,316,150
43
2
Gap between
Required &
Available
41
Available Basic
EOC Facilities
Western
4,509,076
36
1
35
Mid-Western
2,909,753
23
2
21
12,734,979
102
5
97
All Regions
* Source: Annual Report, Department of Health Service 2054/55 (1997/98), HMG, MOH, p.297.
** The figure is rounded up to the nearest whole number.
The findings of the Nepal Needs Assessment Survey of the three development regions
showed that the high maternal mortality rates (MMR) in Nepal are reflected in the proxy
indicators for MMR - the process indicators for EOC. The Survey also found that the
situation in the Mid Western Region is poorer than in other parts of the country.
We see from the table below that the status of EOC services in the country is very poor.
Improving the status of Basic EOC services poses an even greater challenge than for
`
25
Comprehensive EOC services. The EOC facilities are underutilized, and may not be
performing the life-saving obstetric services.
Process indicators
Population
12,734,979
Facilities surveyed (Govt hospitals/ private hospitals/ PHCCs)
42/ 25/ 90
CEOC (Available/ Minimum acceptable for the said population)
18 / 26
BEOC (Available/ Minimum acceptable for the said population)
5 / 102
Proportion of births in EOC facilities (should be at least 15%)
5.2%
Met need for EOC (should be at least 100%)
5.4%
Caesareans as a proportion of all births (should be 5-15%)
0.7%
Case fatality rate (should be <1%)
1.9%
Goal 12:
Reduction of the low birth weight (less than 2.5 kg) rate to less than 10
percent
Birthweight below 2.5 kg
Proportion of live births that weigh below 2,500 grms
Current status
No nationally representative data on birth weights are available for Nepal. National surveys
on low birth weight have relied on the mothers’ subjective report on the baby’s size, ranging
from “very small” to “large”. A survey conducted in 4 hospitals in 1999 showed that 20 to 35
percent (mean 27%) of the babies are born with low birth weight (LBW Prevalence and
Associated Factor in Four Regions of Nepal, MIRA/UNICEF, June 2000). Previous hospitalbased studies have shown similar results. However, in Nepal, as few as 10 percent of all
deliveries take place in health facilities. Because of the bias involved in this, it is likely that
the real prevalence of low birth weight is much higher. This view is also supported by
unpublished data from an on-going study by the Nepal Nutrition Intervention Project –
Sarlahi (NNIPS). The study has found that in Sarlahi, a district in the Terai, about half of all
children are born with low birth weight.
It is unlikely that there has been any significant improvement in the prevalence of low birth
weight over the last decade.
Goal 13:
Reduction of iron deficiency anaemia in women by one third of the 1990
levels
Iron-deficiency
anaemia
`
Proportion of women aged 15-49 with haemoglobin levels below
12g/100ml for non-pregnant women, and below 11g/100 ml for
pregnant women
26
Current status
Al
l
40
Pr
eg
na
nt
No
npr
eg
na
nt
>
-3
9
30
-2
9
20
<
20
% anaemia
Iron Deficiency Anaemia is the most common nutritional problem in Nepal with profound
economic and social consequences.
Figure 1: Prevalence of anaemia in women
According to the Nepal Micronutrient
(NMSS 1998)
Status Survey (NMSS), in 1998 the
overall prevalence of anaemia (< 12
100
g/100ml) in women of reproductive age
80
was 67.7 percent.
Among pregnant
60
women, the rate (< 11g/100ml) was 74.6
40
percent, with severe anaemia (<
20
7g/100ml) in 5.7 percent of the pregnant
0
women. As seen in Figure 1, anaemia
rates decrease slightly with age.
Age Group (in years)
The NMSS also found distinct variation in
the prevalence of anaemia by ecological
zone, with highest levels in the Terai, followed by the Mountains (Map 1). In addition, rural
areas had higher rates than urban areas.
Map 1: Anaemia in
pregnant women
Trends
(NMSS 1998)
In spite of the magnitude of anaemia in
Nepal, the problem has received little
attention. There have also been relatively
few surveys. Anaemia was first assessed
80 - 89 %
in the 1975 Nepal Nutrition Status Survey,
70 - 79 %
only reporting on children aged 6 to 70
60 - 69 %
months. In 1986, 71 to 95 percent of
50 - 59 %
mothers with young children were found
anaemic in five districts (Joint Nutrition
Support Project). In 1997, the Nepal Nutrition Intervention Project – Sarlahi (NNIPS)
conducted a survey in Sarlahi District, which found 70.6 percent of pregnant women, 81.6
percent of lactating mothers and 57.5 percent of infants under 3 months with anaemia.
Field methodology may vary, and sample size and design certainly vary between these
surveys and the NMSS in 1998. It seems clear, however, that the anaemia rate has been
extremely high in women for at least the last twelve years and that there has been no
reduction.
Goal 14:
Virtual elimination of iodine deficiency disorders
Iodized salt consumption
Low urinary iodine
`
Proportion of household consuming adequately iodized
salt
Proportion of population (school age children general
population) with urinary iodine levels below 10
micrograms/100ml urine
27
Current status
Salt iodisation
The latest survey, BCHIMES 2000 (Figure 1), found 90.7 percent of the households using
salt with some iodine content, whereas 62.6 percent used adequately iodised salt (> 15
ppm). In Nepal, nearly all salt is iodised before being distributed on the market, yet popular
preference for large crystal salt is a
hindrance to universal iodisation, as
Figure 1: Iodine content in household salt
handling, trading and storage practices
by ecological zone
of large crystal salt cause considerable
loss of iodine.
100
The Terai has the lowest usage of
adequately iodised salt, probably due
to the cross-border trade in noniodised salt from India. Because of the
high use of packaged refined salt in
urban areas, adequately iodised salt is
more common in the urban areas
(87.5%) than in the rural areas
(58.9%). Iodine retention in packaged
salt is much better than in the large
crystal salt commonly used in the rural areas.
Urinary Iodine
80
60
40
20
0
Terai
Hills
0 ppm
Mou n tain s
< 15 ppm
Nation al
> 15 ppm
Source: BCHIMES 2000
Figure 2: Median Urinary Iodine Excretion
Women and School-aged Children
Med ia UIE (u g /l)
According to the findings of the 1998
(NMSS 1998)
Nepal Micronutrient Status Survey
300
(NMSS), Iodine Deficiency Disorders
(IDD) is no longer a problem of public
health significance in Nepal (Figure 2).
200
The median Urinary Iodine Excretion
(UIE) was 114.0 g/l among women and
100
143.8 g/l among school age children.
For both the groups this is just above the
0
cut-off point designated by WHO to
Terai
Hills
M ountains
National
indicate adequate iodine status (100
W om en
School C hildren
g/l). In spite of this overall good
situation, 43.6 percent of the women and
38.3 percent of the school age children had UIE below 100 g/l, indicating that further
progress is required.
Historically, IDD has been most severe in the Mountains. However, this is no longer the
case, with women and school age children in the Terai recording a lower UIE than in the
Mountains (Figure 2). In addition, median urinary iodine concentrations are higher in urban
areas compared to rural areas. There seems to be no differences by age or sex among the
school-aged children and no difference by age group among women.
`
28
Trends
Salt iodisation
The first nationwide survey examining salt iodine content at the household level was the
Nepal Family Health Survey 1996. In 1998, the Nepal Micronutrient Status Survey again
looked at salt iodine levels, as did BCHIMES 2000. As can be seen in Table 1, there are
slight differences in the findings from the three surveys. The differences, however, are more
likely to be due to differences in survey methodology than a reflection of any trend.
Table 1: Iodine Content of Salt Used in Households by Survey
Survey
NFHS 1996
NMSS 1998
BCHIMES 2000
No iodine
< 15 ppm
> 15 ppm
6.8%
93.2%
17.2%
27.7%
55.2%
9.3%
28.1%
62.6%
* The NFHS only reports on whether the
salt is iodised or not. There is no
information on the amount of iodine.
Figure 3: Prevalence of UIE < 100 μg/l
1985 - 1998
100
Urinary Iodine
UIE < 100 ug/l (percent)
90
80
70
60
HMG/UNICEF
1985
50
The first national IDD survey, conducted
40
in 1965-1967, showed a high goitre
30
20
prevalence, ranging from 60 to 90
10
percent, and also a high cretinism rate. A
0
1985
1990
1995
second IDD survey, jointly conducted by
the Nepalese government and UNICEF in
1985/86 in 15 randomly selected districts,
found significant improvements, with the total goitre rate reduced to 40 percent.
NMSS
1998
2000
The HMG/UNICEF 1985/86 survey also found a 52 percent prevalence of low urinary
creatinine excretion. In Figure 3, creatinine concentration has been converted to iodine
concentration on a 1:1 ratio based on WHO/UNICEF/ICCIDD recommendations.5 As seen
from the figure, there has been some additional progress since 1985, with a reduction of low
IUE from 52 percent to 39 percent in 1998.
Overall, with median UIE levels above 100 g/l for both women and school children, it is
clear that great progress has been seen in Nepal towards the elimination of IDD. However,
the prevalence of IUE < 100 g/l is still high, calling for further efforts in this area.
5
WHO/UNICEF/ICCIDD 'Indicators for assessing Iodine Deficiency Disorders and their control
through salt iodization'
`
29
Goal 15:
Virtual elimination of vitamin A deficiency and its consequences, including
blindness
Children receiving
vitamin A supplements
Proportion of children aged 6-59 months who received a high
dose vitamin A supplement in the last 6 months
Mothers receiving
vitamin A supplements
Proportion of mothers who received a high-dose vitamin A
supplement before infant was 8 weeks old
Low vitamin A
Proportion of children aged 6-59 months with serum retinol
below 20mcg/100ml
Current status
Vitamin A Supplementation
The Nepal National Vitamin A Programme
(NVAP) has been very successful. Aimed
at supplementing high dose vitamin A
twice a year for children aged 6-59
months, NVAP was initiated in 8 Terai
districts in 1993. By October 2000, the
programme had, after a gradual
expansion, been established in 69 of the
75 districts in the country. It is anticipated
that the whole country will be covered
during 2001.
Figure1: Vitamin A Capsule Coverage,
2000
100
80
60
40
20
0
Na tio na l
R ura l
Urba n
G irls
Boys
Source: BCHIMES 2000
Percentage
BCHIMES 2000 is the latest nation-wide
Figure 2: Age-specific prevalence of
survey examining vitamin A capsule
coverage in the six months preceding the
mild xeropthalmia in children 1-11
survey. Although the survey examined
years (NMSS 1998)
coverage in the whole country, including
3
those districts where the NVAP had not
Bitot's sp ots
2.5
yet been introduced at the time of the
Nig h tb lin d n ess
2
survey, the observed overall coverage is
1.5
very high at 89.5 percent (Figure 1). No
1
coverage differential was observed
between girls (89.8%) and boys (89.3%).
0.5
As in previous studies, the survey found
0
1
2
3
4
5
6
7
8
9
10
11
the coverage to be lowest in children
Child age in years
aged 6-11 months (75.2%). This finding
could be biased by the problem of
establishing the age of the children at the time of the last vitamin A supplementation round
as opposed to the age at the time of the survey. The coverage was higher in the rural areas
(90.3%) than in the urban areas (82.1%).
Vitamin A Status
`
30
In
1998,
the
prevalence
of
nightblindness
among
pre-school
children (12-59 months) was 0.27
percent. The prevalence of Bitot's spots
was 0.33 percent (NMSS 1998). Among
school-aged children, the prevalence
was 1.2 percent for nightblindness and
1.9 percent for Bitot's spots. This
indicates that while pre-school children
benefit from the NVAP, vitamin A
remains a public health problem in older
children. Figure 2 illustrates how clinical
vitamin A deficiency rates increase with
child age.
Map 1: Sub-clinical VAD in
children, 6-59 months
(serum Retinol < 0.70 mol/l, NMSS 1998)
 40 %
30 - 39 %
20 - 29 %
< 20 %
The NMSS did not find any significant differences in clinical vitamin A deficiency between
pre-school girls and boys. However, there was a noticeable difference between urban and
rural areas. While no cases of nightblindness were reported in urban areas, the prevalence
was 0.31 percent in rural areas. As for geographical distribution, the highest rates of clinical
vitamin A deficiency were seen in the Eastern and Central Terai.
Looking at sub-clinical vitamin A deficiency, NMSS found that 32.3 percent of the pre-school
children had serum retinol levels
below 0.70 mol/l, indicating that
children are still at high risk despite
Figure 3: National Vitamin A
on-going national efforts. The rates of
Programme Coverage
low serum retinol were higher in the
Children Receiving VAC and Estimated Coverage
2,400,000
100
Terai (40.0%) and the Mountains
90
(35.5%) than in the Hills (23.4%).
2,000,000
80
70
The 6-11 months age group had the
1,600,000
60
highest rates (41.2%), indicating that
1,200,000
50
the amount of vitamin A received
40
800,000
30
through
breastmilk
and
20
400,000
complementary feeding is insufficient.
10
0
Trends
0
1993/94 1994/95 1995/96 1996/97 1997/98 1998/99
Source: NTAG
Supplementation
Prevalence
After each of the biannual supplementation rounds, a coverage survey has been conducted
in some 15 districts. As shown in
Figure 3, these “mini-surveys” show a
Figure 4: Trends in the VAD Situation
consistently high coverage, with the
interventions reaching about 90
5
percent of the targeted children. The
4
mini-surveys also show that coverage
3
remains high in districts where the
2
programme has been implemented
for a long time, indicating that there is
1
no long-term fatigue. The high
0
1985
1990
1995
2000
coverage found by the mini-surveys
has been confirmed by two national
XN (N ation al)
X1B (Terai)
coverage surveys (NMSS 1998 &
BCHIMES 2000).
`
31
As mentioned above, BCHIMES 2000 estimated that vitamin A supplementation rounds
covered all the districts, regardless of the NVAP’s implementation status. So did the 1996
National Family Health Survey (NFHS), when the programme was implemented in only 27
districts. In 1996, NFHS found that 32.2 percent of all children aged 6-35 months surveyed
throughout the country had received a vitamin A capsule in the six months preceding the
survey. BCHIMES, conducted after the NVAP had expanded from 59 to 64 districts, found
the nationwide coverage of children aged 6-59 months to be 89.5 percent. This indicates that
the coverage in the actual programme districts is very high.
Vitamin A Status
Percen tag e
Figure 5: Impact of NVAP on
Limited data is available to discern
Nightblindness & Bitot’s Spots
change at the national level in the
(NMSS 1998)
status of vitamin A deficiency. It is
0 .5 7 %
0 .5 5 %
0.6%
known, however, from both national
and sub-national data, that vitamin A
0.4%
deficiency was a serious public health
0 .2 9 %
problem in the 1980s. It is also clear
0 .2 3 %
that there has been a significant
0.2%
decrease in nightblindness. Two
surveys conducted in 1995 and 1996,
0.0%
Nepal Family Health Survey and Nepal
N ig htblindne ss
B ito t's spo ts
Multiple
Indicator
Surveillance,
Receive VAC
Not receive VAC
reported nightblindness in children 2435 months at 0.9 percent. In 1998, the
prevalence for children in the same age group was 0.19 percent (Figure 4). It seems
reasonable to conclude that the significant improvement in vitamin A status is a result of the
implementation of the National Vitamin A Programme. Further evidence for this can be seen
in Figure 5 that compares the prevalence of clinical vitamin A deficiency between children
who had received and who had not received vitamin A supplements in the six months
preceding the NMSS.
With a national coverage rate of 89.5 percent, it is clear that the National Vitamin A
Programme is performing very well. The observed reductions in clinical vitamin A deficiency
over the last years also demonstrate the impact of the programme. Since vitamin A
deficiency no longer is a problem of public health significance in pre-school children, and
since almost 90 percent of the children nationwide are reached with supplements, Nepal can
be considered to have achieved the goal of virtual elimination of vitamin A deficiency. Even
so, 32.3 percent of pre-school children still have low serum retinol levels. Furthermore,
vitamin A deficiency is still frequent among school-aged children. In spite of the good
achievements, it is therefore clear that more needs to be done.
Goal 16:
Empowerment of all women to breastfeed their children exclusively for
four to six months and to continue breastfeeding, with complementary
food, well into the second year
Exclusive
breastfeeding rate
Proportion of infant under 4 months (120 days) who are
exclusively breastfed
Timely complementary
feeding rate
Proportion of infants aged 6-9 months (180-299 days) who
are receiving breastmilk and complementary food
`
32
Continued
breastfeeding rate
Proportion of children aged 12-15 months and 20-23
months who are breastfeeding
Number of babyfriendly facilities
Number of hospitals and maternity facilities designed as
baby-friendly according to global BFHI criteria
Current Status
Breastfeeding is universal in Nepal, with a 98 percent initiation rate (BCHIMES 2000). The
overall good breastfeeding situation in Nepal is reflected in Table 1, showing the standard
breastfeeding indicators.
Table 1: Breastfeeding Status 1996 (NFHS 1996)
Breastfeeding Indicator
Exclusive breastfeeding rate
Timely complementary feeding rate
Continued breastfeeding rate – 12-15 m
Continued breastfeeding rate – 20-23 m
Figure 1: Breastfeeding Status by Child Age
100
90
No breastfeeding
80
70
% of children
The relatively lower rates in “exclusive
breastfeeding”
and
“timely
complementary feeding” rates indicate
a wide range in the timing of the
introduction of complementary foods.
This is clearly seen in Figure 1, which
shows that complementary foods are
generally introduced too early – and in
some cases too late. It can also be
seen that water is introduced too early.
It is also clear from the figure that the
breastfeeding duration is very long,
with some 46 percent of 3-year-olds
still being breastfeed.
Rate (%)
81.8
70.8
96.6
87.7
Breastfeeding with
complementary food
60
50
Breastfeeding with
water only
40
30
20
Exclusive
breastfeeding
10
0
1
3
5
7
9
11
13
15
17
19
21
23
25
27
29
31
33
35
Age in months
Source: NFHS 1996
Trends
It is difficult to review overall trends in breastfeeding since earlier studies did not use the
present breastfeeding standard indicators. It is clear, however, that the initiation rate has
remained very high during the 1990s. In 1991 it was found to be 98 percent, in 1996 it was
97 percent and in 2000 it was again found to be 98 percent (NFHS 1991 & 1996 and
BCHIMES 2000).
Baby Friendly Hospital Initiative
In 1993, the Baby Friendly Hospital Initiative (BFHI) was started in Nepal. However, after an
initial assessment of the situation, when the need to increase health workers' knowledge,
attitudes and practices regarding breastfeeding and complementary feeding was fully
realised, and after a productive policy review meeting, very little progress has been seen. So
far only seven hospitals have been certified as 'Baby-Friendly'. To accelerate the
implementation of BFHI activities, additional partners need to be identified and a long-term
plan developed.
`
33
At the same time, we need to bear in mind that not more than 10 percent of births are
delivered in hospitals in Nepal. The proportion of deliveries in health facilities, including
hospitals, health centers, sub-health posts, etc., has only increased marginally over the last
ten years, from 6 percent in 1991 (NFHS) to 11 percent in 2000 (BCHIMES).
Goal 17:
Growth promotion and its regular monitoring to be institutionalised in
all countries by the end of the 1990s
No indicators
Current Situation
In accordance with the national policy of monitoring growth in the health facilities, a national
growth chart has been developed, which is based on the WHO standard chart. In spite of
this, the MOH’s institutional growth monitoring programme is not carried out properly. On
average, a Nepali child is weighed only 2.8 times in the first years of his/her life – far too
seldom for growth monitoring to make any difference. Generally, a child is weighed twice
during the first four months of life and a third measurement takes place about the age of nine
months – at the time for the measles immunisation.
This clearly indicates two things: that children are weighed when they come to the health
facilities for immunisation; and that no children come exclusively for growth monitoring. This
is not surprising, considering the low health service coverage and quality in Nepal.
For growth monitoring and promotion to work in Nepal, it has to take place at the community
level. In the UNICEF-supported Decentralised Planning for the Child Programme, presently
being implemented in 13 districts, growth monitoring data is used as an entry point to initiate
discussion in the community on the situation of children and women.
Goal 18:
Dissemination of knowledge and supporting services to increase food
production to ensure household food security
No indicators
Current Status
Data on household food security is not available in Nepal. However, with the very high
poverty rates seen in the country, many households face food insecurity. The Nepal Living
Standard Survey of 1996 found 42 percent of the population living below the absolute
poverty line. It seems unlikely that there have been any significant improvements during the
1990’s. Actual increases in food production have largely been offset by a rapid population
growth.
Goal 19:
Polio cases
`
Global eradication of poliomyelitis by the year 2000
Annual number of cases of polio
34
Although Nepal joined the global polio eradication initiative only in 1996, the progress
towards achieving the goal has been admirable. The number of confirmed polio cases has
decreased from 9 cases in 1995 (probably under-reported due to a weak surveillance
system then), to two cases in 1999 and one case in January 2000. All three cases were
found in the southern districts bordering India.
Since joining the initiative, Nepal has
conducted nine NID and three SNID
rounds, with each round covering more
Fig. 1: Confirmed Polio cases
than 92 percent of the total target
12
11
population, validated by post coverage
10
surveys. By sex, there was no difference
9
9
8
8
between boys and girls in the polio
6
vaccination coverage in the NIDs. In
4
order to enhance the epidemiological
2
2
impact,
the
NID
dates
were
1
0
synchronized with neighboring countries,
particularly India. OPV3 coverage in
1995 1996 1997 1998 1999 2000
routine immunization has stabilized at
around 76 percent. AFP surveillance,
started in 1996, attained WHO recommended standards in 1999 for the non-polio AFP rate
and in 2000 for the adequate collection of two stool specimens.
Until 1994, the sentinel site surveillance for vaccine preventable diseases from hospitals
provided little information. From 1995 onwards, the MOH, with WHO support, has made
extra effort to strengthen the system. In 1995, 15 AFP cases were reported, of which 9 were
confirmed as poliomyelitis. During 1996, 11 cases were reported, of which 8 were confirmed
as polio cases. In April 1997, the MOH established an Early Warning Reporting System
(EWARS) to complement the already existing HMIS system. As a result, the number of
reported cases increased. Altogether 35 cases were reported in 1997. Of them, 11 were
confirmed as poliomyelitis. Of these 11 cases, eight occurred in children aged less than five
years, and in one the wild poliovirus (type 1) was isolated from the stool.
In 2000, WHO estimates that 80 percent of global polio cases remain in South East Asia,
particularly in India and Bangladesh. Since Nepal shares most of its 500-mile open border
with the most polio indigenous Indian states of Bihar and Uttar Pradesh, Nepal is highly
vulnerable to cross border transmission. This makes Nepal critically important to the global
eradication initiative.
Experts believe that Nepal is on track to eradicate polio by 2005. This was demonstrated by
the fact that the expert group at SEARO/WHO advised the government to conduct only two
NID rounds in 2000 instead of three as planned by the MOH.
Goal 20:
Elimination of neonatal tetanus by 1995
Neonatal tetanus cases
`
Annual number of cases of neonatal tetanus
35
No accurate surveillance is currently in place to monitor neonatal tetanus (NT) cases, thus,
the magnitude of NT is unknown. The annual reports of the MOH, which are health facility
based data, indicate a sharply decreasing trend in NT cases. From 727 reported cases in
1995, they have decreased to just 50 in 1999. However, interpretation of these data calls for
caution as over 90 per cent of deliveries in Nepal take place at home under unhygienic
conditions, without the assistance of appropriate trained health care providers. Due to lack of
a community surveillance system, many of the cases from this cohort go largely unreported.
The MOH reports TT2+ coverage for all women of childbearing age (WCBA) as being in the
vicinity of 10 percent for the past 5 years.
This low coverage is due to inconsistency
Fig 2: NT cases in Nepal (Source: HMIS annual reports)
in the denominator which takes in all
women of childbearing age, whereas the
800
727
programme focuses on pregnant women
600
557
only. NFHS 1996 found that in about one
400
third (33%) of the births, mothers received
306
two or more doses of TT vaccine during
200
197
pregnancy. Similarly, the 1998 EPI
50
0
coverage survey indicated that 65 percent
1995
1996
1997
1998
1999
of mothers had two or more doses of TT
during the 3 years preceding delivery. This
means two out of every three children born are protected against NT at birth.
Programme status:
By endorsing the recommendation of the World Summit for Children, Nepal committed itself
to eliminating neonatal tetanus (NT) by 1995. However, for various reasons such as
competing priorities - mainly eradicating polio - and lack of resources, NT elimination
activities could not be initiated until recently. In 1999, with UNICEF and WHO support, the
MOH revised its National Immunisation Policy, providing a long-term vision and operational
strategies for a routine immunisation programme. It set the goal of eliminating NT by 2005.
Following the policy review, a national strategy to eliminate maternal and neonatal tetanus
(MNT) was developed, and eight high-risk districts were identified. In 2000, two rounds of
supplemental immunization covered 88 percent of all women of child-bearing age. The third
round is due for mid-2001. At the moment, work is under way to establish a community
surveillance system to sustain the coverage achieved in these pilot districts. The MNT
programme will ultimately cover all 75 districts.
Goal 21:
Reduction by 95 per cent in measles deaths and reduction by 90 per
cent of measles cases compared to pre-immunization levels by 1995.
Under-five deaths from
measles
Annual number of under-five deaths due to measles
Measles cases
Annual number of cases of measles in children under five
years of age.
Measles is a major cause of child mortality in Nepal, accounting for an estimated 13 percent
of all child deaths. Unfortunately at the moment, there is no reporting of active cases, making
it impossible to assess the impact of measles immunisation. No distribution of cases by age
group or previous immunization status is available.
`
36
The annual reports of the MOH show that
the measles incidence rate went up from
around 40 cases/100,000 population in
1996 to more than 50 cases/100,000
population in 1997, but gradually
decreased to 30 cases/100,000 in 1999.
Measles coverage in the routine
immunisation programme has remained at
over 81 percent, validated by the 1998
coverage survey and BCHIMES 2000.
The high number of reported cases in
1997 indicates a cyclical outbreak.
The reports, both the Ministry of Health’s
Management Information System (HMIS)
and various surveys, also indicate that
the measles coverage rate is higher than
DPT3 or OPV3. This signifies that
measles is a public health problem, and
people are more conscious about it than
other vaccines.
Fig.3: Mealses coverage and no. of cases annual
(source: HMIS annual reports)
90
15000
10000
80
70
coverage
No of cases
5000
1996
1997
1998
1999
87
88
89
81
7812
12677
5771
6874
0
Fig.4: comparison of measles and DPT3 coverage
100
82
80
60
57
65
54
40
Measles
DPT3
20
Of the four immunisation goals, Nepal
0
has lagged behind in the measles goal.
DHS 1996
BCHIMES 2000
Major reasons for this include a weak
management at the MOH, competing
priorities and lack of funds. However, the 1999 Immunisation Policy has given new impetus
to the programme. With the strengthened routine immunisation programme, the measles
goal will be achieved, hopefully, by 2005.
Goal 22:
Maintenance of a high level of immunization coverage (at least 90 per
cent of children under one year of age by the year 2000) against
diphtheria, pertussis, tetanus, measles, poliomyelitis, tuberculosis and
against tetanus for women of childbearing age.
DPT immunization
coverage
Proportion of one-year-old children immunized against
diphtheria, pertusis and tetanus (DPT)
Measles immunization
coverage
Proportion of one –year-old children immunized against measles
Polio immunizations
coverage
Proportion of one-year-old children immunized against
poliomyelitis
TB immunization
coverage
Proportion of one-year-old children immunized against
tuberculosis
Neonatal tetanus
protection
Proportion of one-year-old children protected against neonatal
tetanus through immunization of their mother
`
37
Immunisation programmes for the six primary series antigens were introduced in all the 75
districts only in 1989. In 1990, coverage, except for measles, increased to 80 per cent
through the UCI campaigns. However, the coverage achieved through these campaigns
could not be sustained. The following years saw a steady decline in coverage until 1994,
which began improving only from
1995. From 1998 the overall
120
coverage seems to have stabilized at
100
76 per cent.
80
60
40
20
0
The HMIS does not provide gender
disaggregated data. BCHIMES 2000
indicates no gender disparity in BCG,
DPT1 or OPV1. However, the
dropout rate for girls is slightly higher
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
than that of boys for both DPT3 and
OPV3, indicating that fewer girls
BCG
DPT3
OPV3
Measles
complete the full immunization
compared to boys. Though small, the
fact that the difference exists is a matter of concern. However, there seems to be no gender
disparity for measles, probably
Fig.4: Imm. status of boys and girls
because it is a more common
(BCHIMES 20000)
disease, and people are more aware
of the importance of immunizing
86 87
100
83 81
78
70
children against it.
67 64
80
60
Boys
40
The 1998 coverage survey conducted
Girls
20
jointly by CHD, WHO and UNICEF
0
showed that the programme has
BCG
DPT3
OPV3
Measles
accessed 92 percent of the total
target population with one or more
doses of vaccination. However, only 65 percent of children completed the full doses by age
one. The high drop out rate is attributed to lack of proper services and lack of parent's
knowledge about having to complete the course. Eight percent of the target population is not
reached mainly due to socio-economic conditions and remoteness of the communities.
Coverage in the southern Terai districts at 58 percent was much lower than in the
hill/mountain districts at 70 percent.
The same study reported that 64 percent of the babies are protected against NT at birth due
to a relatively high TT coverage for pregnant women. However, the coverage of the overall
target group i.e. women of child bearing age (15-45 years) was poor at 15 percent.
A large number of child deaths are due to vaccine-preventable diseases. However, the
immunization programme faces problems related to increasing coverage. This is due to staff
reduction, inappropriate training, unclear authority of the District Health Offices, late release
of funds, inadequate cold chain maintenance, poor supervision and incomplete data.
Currently, due to incomplete reporting of cases and inaccurate reporting of coverage, there
is a tendency to over-estimate the impact and the success of the immunization program.
The MOH has shown its commitment to improving the routine immunisation programme. In
1999, with UNICEF and WHO support, the MOH revised the National Immunisation Policy,
providing a long-term vision and operational strategies to improve the routine immunisation
programme. The new policy document outlines the objectives, targets and strategies for
Nepal’s national immunization program. It takes into account recent developments in
immunization strategies, and current limitations of the program.
`
38
The revised strategy for immunization programme has focused on the following major areas:
increasing accessibility to services, improving the quality of services, promoting safe
injection practices, high risk area approach for NT elimination, exploring the possibility of
introducing new vaccines, decentralized planning and community partnership in the
management of immunization sessions.
Goal 23:
Reduction by 50 percent in the deaths due to diarrhoea in children
under the age of five years and 25 percent reduction in the diarrhoea
incidence rate
Under-five death
from diarrhoea
Annual number of under-five deaths due to diarrhoea
Diarrhoea cases
Average annual number of episode of diarrhoea per child under
five years of age
ORT use
Proportion of children aged 0-59 months who had diarrhoea in the
last two weeks and were treated with oral rehydration salts or an
appropriate household solutions(ORT|)
Home management
of diarrhoea
Proportion of children aged 0-59 months who had diarrhoea in the
last two weeks and received increased fluids and continued
feeding during the episode
According to WHO, diarrhoea is defined as three or more watery, loose and effortless
motions within a 24-hour period. The peak season of diarrhoea in Nepal is from April through
July.
Under five deaths from diarrhoea: No reliable national data are available on the annual
number of under-five deaths due to diarrhoea. The Annual Report published by the
Department of Health Services, Ministry of Health, puts the number of diarrhoeal deaths in
1998/1999 at 655. This figure is based on reports from all the health facilities, and is
accepted to be grossly under-estimated.
The general impression is that diarrhoeal deaths among children under 5 years have
decreased substantially over the years. This is the view of the health workers and the
Female Community Health Volunteers (FCHVs). Many of them have not heard of diarrhoeal
deaths in the community for the last few years.
Current status of diarrhoea cases: The two most recent national surveys on diarrhoea
prevalence are BCHIMES 2000 and Nepal Micronutrient Status Survey (NMSS) 1998. These
two surveys are comparable in design, and covered two months of the diarrhoea peak
season (April/May).
`
39
Recent surveys on diarrhoea prevalence
Survey
% of children with diarrhoea
during the 2 weeks prior to
the survey, according to
mothers’ report
Age of children
NMSS 1998
BCHIMES 2000
25.4%
16.2%*
6 months – 5 years
0 – 5 years
Data collection months
December – May
* 16.8% for children aged 6 months to 5 years.
March – May
BCHIMES collected data from the beginning of March until the end of May 2000. The survey
found that 16.2 percent of children under five years had diarrhoea in the two weeks prior to
the survey. The 14-day prevalence of diarrhoea by children’s age follows a curvilinear
pattern. The prevalence increases for up to 12-23 months of age, after which it decreases.
The male/female difference is within the limits of sampling errors. In rural areas, the rate of
diarrhoea is about 17 percent, compared to 12 percent in urban areas. No difference in
diarrhoea prevalence has been observed between the Terai and Hill regions, while the figure
for the Mountain region is slightly higher. The 14-day prevalence is lower when mothers are
literate or better educated.
NMSS shows a 14-day prevalence of 25.4 percent in children of 6 months to five years. This
survey was carried out from December until May 1998. The age breakdown reveals that the
prevalence of diarrhoea is highest among the 6-11 months age group with rates decreasing
with increasing age. There were negligible differences by gender, with boys having a slightly
higher rate than girls. By ecological zone, diarrhoea was more frequent in the Mountains with
more than twice the 14-day prevalence.
While comparing the eco-development strata, the Central Mountains had a particularly high
14-day prevalence (45.7%). The population in the mountain region, especially in the MidWestern and Far-Western regions, is considered poorer and more isolated, with limited
accessibility to health services. This region also appears to bear a higher burden of
diarrhoeal disease.
Trends in diarrhoea prevalence: Despite the many national level surveys conducted in the
1990s to assess diarrhoea prevalence, it is difficult to ascertain a trend because of the
differences in survey design, target age group, and the season in which the survey was
conducted.
Surveys conducted during non-peak season
Survey
Survey months
Age group
Diarrhoea in 2 weeks prior to survey
Aug 1991 – Feb 1992
0 - 5 years
16%
15%
NMIS 1 1995
January – March 1995
0 - 3 years
NMIS 4 1996
August-November
1996
0 - 3 years
NFHS 1991
`
16%
40
Surveys conducted during the peak season (April/May/June/July)
Diarrhoea in 2 weeks prior to
survey
Peak season
Survey
Survey months
months
6 mos-5
0-3 yrs
0-5 yrs
yrs
NMIS 3 1996
February- April
April
18%
NFHS 1996
January – June
April/May/June
27.5%
December –
NMSS 1998
April/May
25.4%
May
BCHIMES
March – May
April/May
19.3%*
16.7%*
16.2%
2000
* recalculated from the raw data for the respective age groups.
Among the six national surveys1, NFHS 1991, 1996, NMSS 1998 and BCHIMES 2000 are
comparable in terms of survey design, but no two are comparable with regard to age group
and survey season. Furthermore, it is puzzling that the two comparable surveys that took
place only two years apart, NMSS 1998 and BCHIMES 2000, should show such different
rates, 25.4 percent and 16.7 percent respectively. From the above data, it is neither possible
to determine the trend in diarrhoea prevalence, nor ascertain if the end decade goal of
reducing the diarrhoeal prevalence rate by 25 percent has been achieved.
ORT use: A simple and effective response to a child’s dehydration is a prompt increase in
fluid intake, Oral Rehydration Therapy (ORT). ORT in Nepal includes recommended home
fluids, but the use of oral rehydration salts (ORS) is the main method being promoted.
Recommended home fluids, according to the Ministry of Health guidelines, include
breastmilk and other liquids, but sugar salt solution is no longer being actively promoted. The
policy has also seen a shift in recent years, emphasizing the importance of giving increased
fluid during diarrhoeal episodes, away from specifying the types of fluids to be given.
NHFS 1996 found that use of ORS or recommended home fluids was reported by 29 percent
of mothers. The use of home fluids, other than ORS solution, was small, contributing only
4.2 percent. BCHIMES 2000 found that a variety of fluids were given to the child during
diarrhoeal episodes. Among mothers who gave fluids to their children with diarrhoea in the
last two weeks, the most common fluids included breastmilk (60.6%), plain water (31.6%),
ORS (26.0%) and sugar salt solution (13.7%).
Trends in ORT use: The Government’s policy on what constitutes appropriate fluids for
ORT has changed over the years. Furthermore, the surveys have not been consistent or
clear on the definition of “home made solutions” or “recommended home fluids”. As a result,
it is also difficult to discern a trend for ORT use.
When limiting the analysis to ORS packages, there does not appear to be any improvement
over the decade. In three comparable surveys, only one in four mothers reported giving ORS
solution to their children with diarrhoea (see table below). In addition, NMIS 1 1995 and
NMIS 3 1996 both found similar figures (27% in NMIS 1 1995; 35% in NMIS 3 1996). This is
somewhat surprising since the use of ORS packets has been promoted through information,
1
A survey was also carried out jointly with Ministry of Health and WHO in 1990, Diarrhoeal Diseases
Household Case Management Survey, Nepal. This was not included in the analysis, since (a) the
sampling did not include the mountain regions, and (b) mothers were only asked about diarrhoea in
the last 24 hours.”
`
41
education and communication activities throughout the decade, withstanding changes in the
ORT policy.
The low rate of ORS use is, probably, not due to lack of awareness. A large majority of
mothers knew about ORS: 85 percent in 1991, 95 percent in 1996. And, according to the
1996 NHFS survey, about 63 percent of mothers reported having used ORS at one time or
another. Availability of ORS in health facilities has been ensured. The Health Ministry’s
Logistical Management Information System (LMIS) reports that ORS packets were available
in 73% of all health facilities in 1996. The figure in 2000 was 77%. ORS packets are
distributed at no cost at health centers and through the health staff, including community
based volunteers. ORS can also be purchased at pharmacies and shops. The correct use of
ORS may still be problematic in that only one in three mothers were found to be able to give
the correct amount of water for mixing ORS. NMIS 3 1996 found that only one in four
mothers could describe the steps for preparing the solution correctly.
Use of ORS during diarrhoea (1991-2000)
Survey
NFHS 1991
Use of ORS
Remarks
26.5%
Mothers with children
under 5 having
diarrhoea in the two
weeks prior to the
survey, were asked
whether ORS (Jeevan
Jal) was given to the
child.
NFHS 1996
BCHIMES 2000
25.9%
Mothers were asked
to list all the
treatments, including
recommended home
fluid, pill, intravenous
drugs, given during
diarrohea episodes for
all children under 3.
26.0%
Mothers were asked
to list all the liquids
given during diarrohea
episodes for all
children under 5.
Home management of diarrhoea: The MOH policy on home management of diarrhoea is to
give more fluids as well as to give the same amount or more food to the child. In the
BCHIMES survey, only 20 percent of mothers reported giving more fluids, compared to 35
percent in 1996. Continued feeding (same or more food than usual) during diarrhoea was
reported by 43 percent of mothers. The BCHIMES findings that only 20% of mothers gave
increased fluids and as many as 10% of mothers give no fluids to their children with
diarrhoea is of concern. A possible explanation is that mothers misunderstood the question
regarding liquids, since over 60% report on having given breast milk to their child with
diarrhoea. No figures are reported in BCHIMES for mothers who gave increased fluids AND
continued feeding, but NMIS-3 (1996) found the proportion to be only 4%.
Trends in home management of diarrhoea: Again, it is difficult to determine whether home
management of diarrhoea has improved or not over the past decade. Four national surveys
looked at different aspects of home management of diarrhoea. While there seems to be a
general trend towards increased fluid intake and continued feeding, this cannot be confirmed
by the data since the figures are not all comparable due to difference in survey design.
`
Survey
Increased fluids
(more liquids)
Same amount
of liquid given
No fluids given
Continued
feeding
(same amount
or more food)
NFHS 1996
January – June
0-3 years
35%
N/A
N/A
N/A
42
NMIS 3 1996
February - April
0-5 years
NMIS 4 1996
August – Nov
0-3 years
BCHIMES 2000
March - May
0-5 years
Goal 24:
24%
12%
47%
17%
N/A
N/A
N/A
24%
20%
41%
10%
43%
Reduction by one third in the deaths due to Acute Respiratory
Infections in children under five years
Under-five deaths from
acute respiratory
infection (ARI)
Annual number of under-five deaths due to acute respiratory
infections
Care seeking for acute
respiratory infections
Proportion of children aged 0-59 months who had ARI in the last
two weeks and were taken to an appropriate health provider
According to the WHO classification, a child with no cough or difficult breathing has no ARI.
A child represented with a cough or difficult breathing alone is defined as having an upper
respiratory infection without signs of pneumonia, while children who have a cough and/or
difficult breathing in addition to other specific symptoms have pneumonia of varying severity
or a very severe disease6.
Under-5 deaths from ARI
The Annual Report published by the Department of Health Services, Ministry of Health, puts
the number of ARI deaths in 1998/99 at 727. This figure is based on reports from all the
health facilities, and is believed to be grossly under-estimated.
Current status of ARI
The most recent survey, BCHIMES 2000, conducted from March till May 2000, shows a 29
percent prevalence of cough and cold in children under 5 years of age during the 14 days
preceding the survey.
Surveys on ARI prevalence
1995
NMIS
(Jan – Mar)
1998
NMSS
(Dec – May)
2000
(Mar – May)
6
`
BCHIMES
Cough or difficult breathing during past 2 weeks
(0-3 years)
ARI 14-day prevalence – 0-5 years (cough with or
without difficult breathing)
Maternal observation – 0-5 years (cough or
difficult breathing) at time of survey
Clinical observation – 0-5 years (cough or difficult
breathing) at time of survey
Cough and cold during past 2 weeks (0-5 years)
30%
48.8%
30.2%
19.3%
29%
IMCI (Integrated Management of Childhood Illness) training materials, WHO.
43
Another survey, NMSS7, conducted from December till May 1998, when the incidence of ARI
typically peaks, showed a prevalence of 48.8 percent of cough with or without difficult
breathing (ARI) during the two weeks prior to the survey. In this survey there were no
differences by gender, but there was a clear linear association with age, with the youngest
children being the most vulnerable. The highest incidences of ARI are in the Central Region.
Seasonality may have effected the outcome - the study was carried out starting in the Terai
in December and finishing in the mountains in May/June.
Current Status of Pneumonia
Surveys on pneumonia prevalence (cough and fast breathing)
1991
NFHS Cough and Fast Breathing in 2 weeks prior to survey in
(Aug-Oct 91)
children 0-5 years
(Nov-Feb 92)
1996
NFHS Cough and Fast Breathing in 2 weeks prior to survey in
(Jan – Jun 96)
children 0-36 months
17%
34%
For the classification of pneumonia, WHO uses the definition ‘cough or difficulty in breathing
with fast breathing’8. In the NFHS survey carried out from January till June 1996, the
prevalence of pneumonia was assessed by asking mothers if their children under three
years had been ill with a cough accompanied by short rapid breathing in the two weeks
preceding the survey. Reported was a prevalence of 34 percent.
Pneumonia prevalence varies according to age, decreasing from around 37-38 percent for
children 0-24 months to 26 percent after two years of age. Differences in pneumonia
prevalence by the child’s sex, birth order, urban-rural residence, ecological and development
regions are small.
Care seeking for ARI
The two surveys that report on care seeking behaviours for ARI - NFHS 1996 and BCHIMES
2000 - use different definitions of ARI. Therefore, strictly speaking the figures are not
comparable. According to NFHS 1996, 18 percent of caretakers reported taking their
children with pneumonia either to a health facility or a provider. BCHIMES shows a care
seeking of 26 percent for a child suffering from ARI, defined as “cough and cold”. Health
facilities and health care providers for both surveys include all public and private health
facilities, ayurvedic centers, village health workers and community health volunteers, but not
pharmacy shops and traditional practitioners.
Trends
Despite the numerous national-level studies on ARI and pneumonia, it is not possible to
discern a trend for their prevalence other than it is high. This is because the surveys have
used different age groups, ARI definitions, survey designs and seasons while collecting data.
Hence in all future surveys, definitions of ARI and pneumonia should standardized. It is also
recommended that standard questions be used in the same seasons for the same age
groups.
Community-Based Program for Management of Pneumonia
7
8
`
Nepal Micronutrient Status Survey, 1998.
IMCI (Integrated Management of Childhood Illness) training materials, WHO.
44
In 1993, even while using the lowest estimate of pneumonia prevalence (300 cases/1000
children under 5 years), MOH data revealed that only about 15 percent of suspected
pneumonia cases were brought by caretakers to a government health facility. That year the
MOH, USAID, JSI, UNICEF and WHO formed a working group to develop an approach, then
referred to as the ARI Strengthening Program, to bring much needed pneumonia diagnosis
and treatment closer to children. The primary strategy was to extend pneumonia case
detection beyond the health facilities through VHWs, MCHWs and FCHVs, collectively
known as Community Health Workers (CHWs). Initially, two different intervention models
were tested - “treatment” and “referral”, with each model established in two districts, to allow
time to determine the capability of the CHWs and their acceptability in the community as
care providers.
An external assessment was conducted in 1997 with technical assistance from
WHO/SEARO and WHO/Geneva, and the findings were very encouraging.1 The respiratory
rate was assessed in 95 percent of children, in agreement with surveyors in 81 percent of
the cases. Chest indrawing was assessed in 59 percent of children, in agreement with
surveyor’s assessment in 93 percent. For all cases of ARI assessed, the classification was
correct in 81 percent of the cases, and total case management was correct in 80 percent.
Only 2.6 percent of the children who should not have received antibiotics had been given
antibiotics by the CHWs. In addition, community-based treatment doubled the percentage of
identified and appropriately treated cases of suspected pneumonia.
Cautious expansion of the “treatment” model was recommended, as CHWs, particularly
FCHVs, were found capable of correct pneumonia case management. The original two
“referral” districts were converted to “treatment” districts in 1997/98, and two additional
districts were added. In 1998/99, five more districts were added in collaboration with four
international NGOs working in Nepal to maximize monitoring and to support the CHWs,
particularly the FCHVs. At the same time diarrhoea, nutrition/Vitamin A and immunization
were included in the training package, and the program was renamed the Community-Based
ARI/CDD (CBAC) Program. From July 1999, the experience of these previous programs
was combined with the Integrated Management of Childhood Illness (IMCI). Communitybased treatment of pneumonia is now available in 14 districts, representing 28 percent
(936,985) of all children under 5 years in Nepal. The Ministry of Health’s Logistics
Information System (LMIS) confirms that availability of Cotrimoxazole Pediatric tablets, used
to treat ARI in children, has also improved. In 1996 Cotrim P was available in 31 percent of
all health facilities, in 2000 it was available in 69% of health facilities.
To date, through all the Community-Based Child Health Programs, a total of 1,437 health
facility staff and 9,311 community
100
% of Expected Pneumonia Cases Treated by CHW
health workers, including 8,124
%
of
Expected
Pneumonia
Cases
Treated
by
HF
FCHVs, have been trained in the
80
standard case management of
57
pneumonia. FCHVs have provided
60
orientation to over 115,000 mothers
22
40
in the rural areas on pneumonia
symptoms, appropriate home care,
20
and on when and where to seek help.
Over 2,000 traditional healers as well
0
as 301 district-level and 7,524
Non-Intervention Districts
Intervention Districts
village-level leaders have also
received
orientation
on
the
community-based child health program and on their role in supporting FCHVs and saving
children’s lives. IMCI materials have been adapted from the original WHO materials and
translated into Nepali. Training, IEC and reporting materials appropriate for semi-literate
village women have been developed, and monitoring systems established.
`
45
By July 2000, the percentage of suspected pneumonia cases that were treatment in the 4
initial program districts had reached 57 percent, with the FCHVs treating over half the cases.
In the non-programme districts, only 22 percent of suspected pneumonia cases were treated
in the MOH’s facilities.
This 2.6 fold increase seen in the number of children reached and information on the quality
of case management strongly suggest that this program is having a substantial impact on
child mortality in Nepal.
Goal 25:
Elimination of guinea worm disease (dracunculiasis)
This goal does not apply to Nepal.
Goal 26:
Expansion of early childhood development activities, including
appropriate low-cost family and community-based interventions
Pre-school development
Promotion of children aged 36-59 months who are attending
some form of organized early childhood education
No data is available on pre-school net enrolment for children aged 36-59 months. The
Statistics Section of the MOES has only just included pre-school enrolment in its School
Monitoring Form and in the data collection process. So Nepal will have gross enrolment
rates in pre-school as part of the government’s regular data collection process in the future.
For the Education For All reporting process, Nepal did carry out a secondary analysis which
uses general data on enrolment to extrapolate pre-primary gross enrolment figures for 1997.
This Gross Enrolment rate for pre-primary school was calculated at just over 8 percent.
HMG/N has initiated new policies to expand pre-primary programmes through the MOES
structure, with the ambitious target of having 5,600 pre-primary centres established by 2004.
This should have the effect of greatly increasing the levels of pre-primary enrolment
nationally.
Underweight Prevalence
Please refer to Goal 3 for the discussion on underweight prevalence.
`
46
Goal 27:
Increased acquisition by individuals and families of the knowledge,
skills and values required for better living, made available through all
educational channels, including the mass media, other forms of modern
and traditional communication and social action, with effectiveness
measures in terns of behavioural change.
Overall information infrastructure
The information revolution has inched its way into Nepalese families in the decade after the
World Summit for Children. More families are able to access television in 2000 as TV
coverage expands from 18 percent in 1990 to 44 percent of the country’s geographic area.
Radio, the medium with the most extensive reach, is accessible in 90 percent of the districts
in 2000 compared to 75 percent in 1990. In Kathmandu Valley, FM radio services are
catching on, with a choice of 7 radio stations providing entertainment and a variety of
programmes to 1.5 million residents. The ownership of television has gone up from 2 per
1,000 people to 6 per 1,000, whereas radio ownership has climbed slightly from 34 sets per
1,000 people to 38 per 1,000 between 1900 and 2000. In general, the exposure of families
to TV, radio and print materials has increased, albeit at a slow pace, especially in rural and
remote districts.
The slow rate of progress is partly hampered by Nepal’s limited electricity coverage and
inadequate road infrastructure. According to the World Bank, only 15 percent of Nepal’s
population, mostly urban, currently enjoys electricity, and the rural poor live on the average
more than five hours away from the nearest dirt road. With 9 million people still surviving on
less than $1 per day, knowledge and information are, for the most part, a luxury rather than
a necessity.
Nepal’s transition to multiparty democracy in 1990 has given birth to a free press and an
active civil society. The number of registered periodicals and newspapers has risen four-fold
- from 423 in 1990 to 1,536 in 1999. However, high rates of illiteracy, especially among
women, have not enabled the print media to play a more effective role in promoting broadbased changes at the grassroots. Adult literacy, though surged from 33 percent in 1990 to
51 percent in 2000, conceals a staggeringly low literacy rate of 33 percent for women.
Gap between awareness and practice
The many constraints, notwithstanding, Nepal has made positive progress in child survival
and development since the World Summit for Children. Various evaluation reports show a
near universal knowledge of family planning and Oral Rehydration Salt among women. The
high rate of polio immunization - 92 percent of children in 1999 through NIDs -, the near
universal coverage of iodized salt, and the successful distribution of vitamin A capsules to 90
percent of children in almost all districts, are evidence of families’ improved awareness of
child health and nutrition. With HIV/AIDS a growing concern, 71 percent of urban women
and 35 percent of rural women said in the BCHIMES 2000 Survey they were aware of
HIV/AIDS. Colostrum feeding is also on the rise with 77 percent of mothers now giving their
first breastmilk to newborns compared to 64 percent in 1996. Meena, an animated character
advocating gender equality, has become a household name.
Though there has been no formal evaluation of the media’s impact on attitude and
behaviour, it is clear that families’ awareness is not put into practice. General knowledge of
ORS may be widespread among mothers, yet only 26 percent of children who suffer from
diarrhoea are given ORS, while a mere 4 percent receive recommended home fluids such as
breast milk, according to the 1996 Family Health Survey. The survey also shows that only 35
percent of children are given increased fluids during episodes of diarrhoea, and more than
`
47
half are not rehydrated with ORS or increased fluids. The practice shows a worrying decline
in 2000, with only 20 percent of children given increased fluids during episodes of diarrhea.
And among them, only 26 percent were given ORS, while the number taken to a health
facility has registered a negligible rise from 28 percent to 30 percent. The unmet gap in
practice places a large group of children at higher risk of severe malnutrition and mortality. It
also reflects a distressing lack of practical knowledge on the nutritional requirement of
children with diarrhoea, which remains a major child killer in Nepal.
The low level of awareness about sanitation and hygiene further compounds efforts to
reduce child mortality. According to BCHIMES 2000, 67 percent of Nepal’s households do
not have a toilet. Open defecation in crop fields, orchards, riverbanks, ponds and canals
remain a preferred practice in rural areas. A large majority of villagers, based on a 1994
KAP Survey on Water and Sanitation, do not associate human and animal excreta with
diseases. Though school children are somewhat knowledgeable, they have never tried to
educate their parents on how human waste can invite illnesses. More than half of the
families interviewed in 2000 said they are somewhat aware of the importance of latrines, but
are unable to afford it.
A more glaring gap between knowledge and practice confronts Nepal’s HIV high-risk group.
Over 90 percent of commercial sex workers report having heard of HIV/AIDS from radio,
according to a 1999 Family Health International (FHI) survey. They may be aware of its
mode of transmission, but sex workers lack the bargaining power to insist on a condom to
clients. A similar situation confronts girl children who are voluntarily recruited or trafficked to
Indian brothels. HIV education in source districts such as Sindhupulchowk has been
intensified through the work of NGOs such as CWIN. But girls who end up in Bombay
continue to face a sea of male clients who know little about safe sex.
Female illiteracy and gender biases
Gender discrimination cuts deep into Nepal’s development on all fronts, and poses
numerous obstacles in its efforts to achieve the end-decade goals for children. The net effect
of mother’s exposure to media on infant mortality, based on a 1999 FHI regression analysis,
is minimal. The analysis shows that mothers’ young age of pregnancy, short birth spacing
and malnutrition, compounded by the lack of antenatal care, tetanus immunization and
family planning are factors fueling Nepal’s high rate of infant death. Mothers’ exposure to the
media, nevertheless, has a higher impact on under-five child mortality. Improved knowledge
in detecting early signs of acute respiratory infections, diarrhoeal dehydration and child
immunization through the media and interpersonal communication, is contributing to
reducing child deaths.
However, the analysis also reveals that female children of 1-4 years are at significantly
greater risk of dying due to inferior care as opposed to the treatment given to boys. The
complete immunization of children is one such example. The BCHIMES 2000 report shows
that 58 percent of boys receive full immunization whereas only 51 percent of girls are
immunized against all of the six antigens. There is ample evidence to show education is the
most important determinant in a mother’s health seeking and reproductive behaviours.
Among the male and female children who were fully vaccinated in 1999, 66 percent are
children of literate mothers.
A similar pattern is observed for treatment of acute respiratory infections, the number one
cause of child death in Nepal. The BCHIMES 2000 survey shows that more boys than girls
are taken to a health care provider for treatment of cough and cold, with a difference of 28.2
percent for boys and 23.7 percent for girls. Literate mothers are also more likely to bring
their children to a health care provider. Over 70 percent of those who get treated for ARI are
children of literate mothers.
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48
Mass illiteracy among women as a result of gender biases also halts Nepal’s progress in
combating malnutrition. Poor maternal health is largely accountable for the high rate of low
weight births. Compounded by mothers’ poor knowledge of child nutrition, 70 percent of
children in 1994 and 47 percent in 2000 are moderately and severely underweight. The
prevalence of stunting among children aged 6-59 months has dropped only 15 percentage
points since 1975, from 65 percent to 50 percent in 1998. Female children, according to the
1996 National Family Health Survey, are more likely to be stunted (50%) or severely stunted
(22%) than male children.
Mothers’ awareness of infant feeding is also overridden by the enormous burden of farming
and housework. The BICHIMES 2000 shows that male members in as many as 57 percent
of households in Nepal have never made any trips to fetch water. Feeding and childrearing
practices are not likely to improve unless men’s role and responsibilities are addressed.
Interpersonal communication
Putting aside mothers’ education as a variable, any effective behavioural intervention in
Nepal will have to combine media outreach with interpersonal communication. Neighbours,
village leaders, street theatres and folk media are effective purveyors of information in the
rural setting of Nepal, and, perhaps, play a more important role in influencing behaviours.
Over the decade, government departments, aid agencies and NGOs have taken advantage
of a new rural force to provide health education and simple diagnosis of child ailments.
Known as the Female Community Health Volunteer (FCHV) programme, it was introduced in
1989 by the Family Health Division, Department of Health Services (DHS), with the support
of USAID, FINNIDA, UNFPA and UNICEF. Over 45,000 rural women are currently trained to
educate mothers on pneumonia, ORS, immunization, family planning, safe motherhood,
sanitation and control of communicable diseases.
Rural mothers often cite FCHVs as their source of information on children’s health care. A
DHS evaluation in 1997, based on household feedback, attributed an increase in primary
health care services in rural Nepal to the work of FCHVs. More than 80 percent of families
interviewed said FCHVs had taught them the importance of child immunization and the use
of Jeevan Jal (ORS). More than 60 percent said they learned about tetanus immunization,
use of contraceptives and antenatal services. More than half said they acquired knowledge
of childcare and nutrition from the volunteers, whereas 43 percent cited FCHV as a source of
knowledge on latrine construction.
Though the assessment does not look at FCHVs’ contribution to infant and child mortality
reduction, it is clear that they are fulfilling a dire need for health education and rudimentary
health services in Nepal.
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49
Additional indicators for monitoring children’s rights
Birth Registration
It was only in 1977 that birth registration programmes were initiated in the country, first in 10
districts and later expanding to all the 75 districts by 1990. Under the Birth, Death and Other
Personal Incidents (Registration) Act enacted in 1976, a baby must be registered within 35
days of being born, after which registration carries a penalty of Rs. 8–Rs. 50 (US$ 0.10 –
0.67).
The BCHIMES 2000 survey has found that only 34 percent of children below 5 years have
their births registered. However, given the late start, the figure implies that the vital
registration system is picking up. The study found little difference in the birth registration
between boys (17.3%) and girls (16.7%). Vital registration was found more effective in the
Hills (36%) and the least effective in the Mountains (18%). Registration is slightly better in
the urban areas (36.8%) compared to the rural areas (33.7%). The registration rate in the
Kathmandu Valley is quite low at only 25 percent.
Another survey carried out by Plan International, an NGO, in the 8 districts where it is active,
however, shows a much higher registration rate. It found 42.2 percent of the total sampled
child population below 18 years of age registered - 45.3 per cent for boys and 38.9 percent
for girls. The proportion of registered children in the Hills and Mountains was 29.1percent
and in the flat plains of the Terai 51.7 percent.
Official data furnished by the Ministry of Local Development (MLD) on the extent of birth
registration coverage during the 90’s also shows that in 2000 about 42 percent of children
under one year are registered.
Extent of birth registration coverage from 1991-2000
Year
Total
Populations
Pop and % of
children
under 1 year
Births
registered
(%)
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
18,491,097
18,937,160
19,393,984
19,861,827
20,340,957
20,831,644
21,331,362
21,843,068
22,367,048
22,903,598
565,413 (3.06%)
578,147
593,455
607,771
622,433
635,365
652,739
668,397
684,431
700,850
84,818
68,814
147,285
188,897
116,387
176,040
245,361
102,657
311,590
293,664
15.00
11.90
24.81
31.08
18.69
27.70
37.58
15.35
45.52
41.92

Projected population under 1 year has been calculated based on the past annual growth
rate of 3.06%.
Interpreting the data:
The End-Decade Review seeks information on the proportion of children 0-59 months whose
births are registered in 2000. However, neither the Ministry nor Plan International’s data are
for this age group.
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50
Plan International’s survey takes into account children up to 18 years. In Nepal, there is a
tendency to register births only when necessary. And many children are registered only
while enrolling in primary school, i.e., when they are more than five years old. Therefore, the
proportion of children registered would be expected to be higher for older children.
On the other hand, a cursory look at the data furnished by the MLD reveals that the
projected child population under 5 in 2000 is 3,341,782, i.e., children born between 19962000. Of them, 1,129,312 children have had their births registered in 2000, which is 33.79
percent of the total child population under 5 years – a percentage similar to the findings of
the BCHIMES survey.
According to BCHIMES 2000, the majority of the respondents said they had no time for
registration (39%), another 30 percent did not know about registration and 20 percent saw
no need for it. The findings suggest that advocacy and awareness creation on this issue will
go a long way in strengthening the system. But, of course, adequate and easy services for
registration must also be available.
Still other reasons cited by Plan International for not registering births include demand for
higher fees for delayed registration, inactive local registrars, long distance to the local
registration office, lack of necessary documents for registration, and a gender insensitive act
that does not allow a mother to register her child.
To enhance birth registration, Plan International has been adopting such approaches as
collaborating with local government bodies, local institutions, UNICEF, INGOS, NGOs and
CBOs; raising awareness through radio messages, hoarding boards, posters and pamphlets;
grassroots networking among all stakeholders such as NGOs, Plan staff, VDC members,
social workers, teachers and health workers; and organizing workshops cum trainings.
Unicef, on its part, has incorporated birth registration in the Parenting Orientation package
for caregivers of young children, and will establish the issue of birth registration in its Early
Childhood Development Project.
The government is committed to strengthening the vital registration system and promoting
birth registration in Nepal, as reflected by the adoption of the Kathmandu Declaration in June
2000 by all the concerned central and local government bodies. Other stakeholders,
development partners working in the area of birth registration, also signed the Declaration.
Following on from the Declaration, the training of local registrars has been initiated.
Children’s Living Arrangements & Orphans
The Children’s Act, 2048 (1992) has a provision for the establishment and operation of
Children’s Welfare Homes (Article 34), which are accessible to orphans as well as
unattended and abandoned children (Article 35). As per Article 36, children stay in these
homes until they are at least 16 years of age. Article 37 provides for vocational training
and/or employment assistance to the children in these Welfare Homes.
Provision for the establishment and operation of Rehabilitation Centres for children 0-14
years who are not living with their living parents has also been made under Article 42 of the
Children’s Act. These Centres provide living arrangements for children under judicial
custody, those addicted to drugs and runaways. The Centers are also open to children who
have been rescued after being trafficked for commercial sexual exploitation and forced labor
as well as victims of violence, rape, suppression and atrocity, and, therefore, compelled to
abandon their families and live on the streets.
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51
Although there is legal provision for living arrangements to be made for children, there has
not been any budget allocation from the Government. Hence, they have yet to be
established.
There are different forms of living arrangements established and operated by NGOs with
external funding. They include:



Rehabilitation Centres for working, trafficked, abandoned and/or street children;
Orphanages;
Educational centres like vocational training centres, boarding schools or hostels.
There are no exact figures available on the number of orphans nor on children not living with
their biological parents. NGOs operate a number of homes in the country for orphans and
abandoned children, but the data are not compiled and analyzed at the national level.
Although NGOs must register with the Social Welfare Council and furnish data regarding
living arrangements, they have not been done. However, different organizations are said to
provide rehabilitation to about 6,000 children.
Besides these institutionalised living arrangements, children aged 0-14 years also live with
their employers (including brothel owners), extended family members, step parents or with
relatives. There is no data for these categories of children either. Situation Analysis on Street
Children 1996 estimated there were 26,000 children on the street and 3,700 children of the
street. Based on CWIN’s information there has been a slight increase in the number of
children of the street, from 3,700 in 1996 to 5,000 in 2000. About 100 children are living as
dependents with their family members or guardians in jail.
Child labour
The Nepal Labour Force Survey 1998/99 (Central Bureau of Statistics, National Planning
Commission) had gathered information on children’s participation in the workforce. The key
concept used in the survey is current economic activity status. According to this survey,
children are considered to be “currently active” if (a) they worked for at least one hour during
the 7 days prior to the survey, or (b) they have a job to return to or (c) they are available for
work if work could be found.
The NFLS used a broad definition of work, consistent with the current ILO standard. For
example, “work” includes tailoring, making mats, collecting firewood or water for the
household. On the other hand, examples of “non-work” activities include cooking, serving
food, washing dishes and
Children's Work vs Schooling (5-14 yrs)
utensils or shopping for the
household, cleaning the house,
41%
minor household repairs, or
Currently
45%
working
caring for the elderly, the sick,
37%
or young children.
The population in the 5-14 age
group is estimated at 4.86
million for this survey.
20%
24%
16%
Usually working
71%
62%
80%
Going to school
Proportion
of
working
children: Over 40 percent of all
children 5-14 years, or 1.987
million children, were found to
`
0%
20%
Boys
40%
Girls
60%
80%
100%
Total
52
be currently economically active. According to this criteria, children’s participation in the work
force is significant. Since the proportion of unemployed among the economically active
population is very small among children, most economically active children could be
considered to be working children. Children in rural areas are more likely to be working, than
urban children, where even among children aged 5-9 years, 19.8 percent of boys and 25.4
percent of girls, are economically active. In addition, 60.9 percent of the boys and girls aged
10-14 are economically active. It is worth noting that the proportion of girls who work is
higher than that of boys, for all age groups.
Table 1: Proportion of currently working children (as % of age group population)
Total
Urban
Age group
Total
Male Female Total
Male Female Total
Rural
Male
Female
5 – 9 yrs
20.9%
18.3%
23.6%
7.3%
6.4%
8.4%
22.6%
19.8%
25.4%
10 – 14 yrs
60.9%
55.2%
67.1%
30.0%
27.5%
32.7%
64.9%
58.8%
71.5%
Total
40.9%
36.8%
45.1%
19.0%
17.3%
21.0%
43.6%
39.3%
48.0%
NLFS applied another definition of working children by determining their usual economic
activity status. “Usually active” working children are those who have worked or were
available for work during the 6 months prior to the survey. Compared to the 1.987 million
currently working children, children who are usually working number 974,000, or make up 20
percent of all children aged 5-14. Almost all “usually working” children are “currently
working”. Also among usually working children, similar patterns of gender disparity is noted,
where the rates for girls are much higher than those for boys. Rural children tend to be more
“usually active” than urban children.
Table 2: Percentage of usually working children (as % of age group population)
Total
Urban
Age group
Total
Male
Female Total
Male Female Total
Rural
Male
Female
5 – 9 yrs
7.5%
5.9%
9.1%
2.3%
1.5%
2.4%
8.2%
6.5%
9.9%
10 – 14 yrs
32.6%
25.9%
39.8%
15.5%
13.8%
16.4%
34.9%
27.5%
42.8%
Total
20.0%
16.0%
24.3%
9.1%
7.8%
9.7%
21.4%
17.0%
26.1%
Working children and schooling: Table 3 below shows the proportion of children who are
currently economically active, out of all children attending school. We see that even among
school going children, a little more than one in three children are working. This is possible
since currently economically active children are defined as those who have worked at least
one hour prior to the survey. It would be possible to work one or two hours a week and still
attend school full-time. More older children work than younger children, more girls work than
boys, and more rural children work than urban children.
Table 3: Percentage of currently active children among school-going children
Total
Urban
Age group
Total
Male Female Total
Male Female Total
Rural
Male
Female
5-9 yrs
19.1%
17.9%
20.7%
6.5%
6.1%
6.9%
21.1%
19.7%
22.9%
10-14 yrs
52.6%
50.2%
56.1%
24.3%
23.3%
25.5%
57.1%
54.0%
61.6%
Total
36.6%
35.2%
38.5%
15.8%
15.1%
16.7%
39.9%
38.1%
42.2%
Table 4 shows the proportion of currently working children among the non-school going
population. About half of all children who are not in school are currently working. As to be
expected, more children who are not in school are currently economically active: 36.6%
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53
among school goers, and 51.4% among non-school goers. Current economic activity in rural
areas is higher (25.3 percent) than in the urban areas (12.7 percent). More girls are currently
active than boys. As might be expected, a high proportion, 85 percent, of the non-school
going children aged 10-14 years are currently working. The proportion of currently active
girls is generally higher than that of boys.
Table 4: Percentage of currently economically active children not in school
Total
Urban
Age group
Total
Male Female Total
Male Female Total
Rural
Male
Female
5-9 yrs
24.7%
19.5%
28.3%
12.7%
9.0%
15.2%
25.3%
20.0%
28.9%
10-14 yrs
85.0%
82.7%
86.0%
74.3%
74.3%
74.3%
85.6%
83.0%
86.6%
Total
51.4%
43.4%
55.9%
41.4%
38.2%
43.5%
51.9%
43.7%
56.5%
Children’s work: Reflecting the pattern of the adult workforce, majority of the children
(84.3%) are engaged in agricultural work, mostly subsistence agriculture. Elementary
occupations, such as fetching water and collecting firewood, are also done by children.
NFLS did not collect information on working conditions. However, it is likely that some, if not
most, children engaged in manufacturing or construction industries may be exposed to
hazardous conditions in their workplace. Children at risk number about 36,000 according to
the NFLS.
Occupations (type of work)
Service Workers
- House Keeping and Restaurants
- Shop Sales persons
Agriculture
- Animal Producers
- Subsistence Agriculture
Craft and Related Trades
Plant and Machine Operators
Elementary Occupation
- Agricultural laborers
- Water Fetching
- Firewood collection
13,000
26,000
53,000
1,617,000
22,000
4,000
39,000
78,000
78,000
Industries (kind of goods produced or services supplied)
Agriculture, Hunting and Forestry
1,725,000
Manufacturing
26,000
Construction
10,000
Wholesale and retail trade
29,000
Hotel /Restaurants
16,000
Private holds with employed persons
165,000
All other categories
10,000
(2.0%)
(0.7%)
(1.3%)
(84.3%)
(2.7%)
(81.6%)
(1.1%)
(0.2%)
(9.84%)
(2.0%)
(3.9%)
(3.9%)
(87%)
(1.3%)
(0.5%)
(1.5%)
(0.8%)
(8.3%)
(0.5%)
Work hours: The 1.982 million children aged 5-14 years who are classified as “currently
active” work a total of 44 million hours a week. This works out to an average of 22.4 hours a
week for every child who is currently working. Boys and girls work about the same number of
hours, 22.1 and 22.7 hours a week respectively.
Paid work: Of the children who work, about 60,000, almost all aged between 10 and 14,
were reported as paid employees. About 50,000 children were engaged in activities
classified as elementary occupations, most of them in the agriculture sector.
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54
Non-economic activities of children: The NLFS also collected information on selected
non-economic activities. Many of these, such as taking care of younger children and cooking
and cleaning for the household, are performed by children aged 5 to 14 years old. The
survey found that about1.5 million children are involved in these tasks, working a total of 15
million hours. Reflecting the patterns found among adults, more girls (1million) are involved
in these tasks than boys (0.35 million), and girls work more hours than boys (12 million hours
versus 2.8 million hours).
Bonded child labour: Debt bonded child labour, under the Kamaiya system, is prevalent in
five districts in the Mid and Far Western region. A total of 4,778 children9 are working under
the Kamaiya system. These children are either working to pay the interest on the debts owed
by their parents, or working in lieu of their parents, or are in some way linked to the work the
bonded parents do.
Additional indicators for monitoring the Integrated Management of Child Illness (IMCI)
and malaria
Care seeking knowledge
BCHIMES 2000 was the first national survey conducted to collect data on care seeking
knowledge as defined above. BCHIMES found that among mothers of children under five
years of age, 50 percent were able to identify at least two symptoms for referral to a trained
health care provider. In this survey, an open-ended question “When would you refer your
child to a health care provider?” was asked. Where answers were not forthcoming,
interviewers were expected to probe for answers, and categorize the responses.
As with other indicators, there was a correlation between education levels and literacy, such
that the proportion of mothers who knew at least two symptoms increased with education
level and literacy level. For ecological zones, the highest proportion of mothers from the Hills
could list two symptoms with 53 percent and the lowest in the Terai with 48 percent. A higher
proportion of mothers in rural areas (51%), who tend to be less educated and less literate,
could identify the symptoms than mothers in urban areas (45%). A possible explanation is
that urban, educated mothers may have found the question too simplistic, or that because
information and education activities tend to target rural, illiterate women, they were better
able to recite the symptoms. A similar finding was also seen in mothers’ knowledge of the
immunization schedule, where more mothers in rural areas, compared to urban mothers,
were able to correctly give the immunization schedule for the six antigens.
Malaria
Malaria remains endemic in the southern Terai
belt and the forest fringes of the foothills and the
inner Terais. Ministry of Health estimates that 16
percent of the 22 million people of Nepal are at
malaria risk. The morbidity rate for the malariarisk area is estimated at 0.35 percent. Since
1995, the mortality due to malaria has remained
at less than two per year, except in 1996 when
an epidemic occurred in Kanchanpur district with
15 deaths.
9
`
Population
at risk
Blood slide
examined
Positive
detection
1995 12,298,141
338,189
9,718
1996 15,225,411
204,355
9,020
1997 15,619,053
160,293
8,957
1998 16,344,287
175,879
8,498
1999 15,879,497
132,044
8,540
Source: Ministry of Health, HMG Nepal
The Kamaiya System in Nepal, Shiva Sharma a.o., SAAT ILO New Delhi, 1998 page 46.
55
The beginning of the 1990s experienced periodic malaria outbreaks. Due to epidemics in
central and far-western regions the cases went up to 29,000 in 1991. With great effort,
especially through continued indoor residual spraying in the epidemic areas, the number of
cases was brought down to 9,700 by 1995. Since then, the malaria cases have remained
below 10,000 annually.
Of the 8,540 positive cases detected in 1999, 59 percent were male and 41 percent female,
or in other words, the male to female ratio was 10:7. Thirty percent of the cases were below
15 years, 6 percent below five years and 0.4 percent below one year of age.
Indicators for monitoring HIV/AIDS
Women and HIV/AIDS in Nepal
Knowledge of Preventing HIV/AIDS (main ways of avoiding HIV infection, and main
misconceptions about HIV/AIDS)
More women in Nepal are aware of HIV/AIDS today than they were five years ago, but the
majority of them are still ignorant about the lethal infectious disease. Among women aged
15-49 in Nepal, according to the latest BCHIMES 2000 survey, 39 percent have heard of
HIV/AIDS, a 12 percentage point increase from 27 percent in 1996. The knowledge gap on
HIV/AIDS between rural and urban women has also narrowed. In 2000, 35 percent of rural
and 71 percent of urban women have heard of AIDS, compared to 23 percent of rural and 67
percent of urban women in 1996.
HIV/AIDS education has also reached more illiterate and semi-literate women. In 2000, 35
percent of illiterate and 76 percent of literate women said they had heard about AIDS. This
compared to 1996, when a mere 16 percent of illiterate and 70 percent of literate women
were aware of HIV/AIDS.
In the 2000 survey, 67 percent of those who had heard of AIDS cited safe sex as the method
to avoid HIV infection, and 82 percent said condom use is effective. In 1996, only 31 percent
of those who had heard of AIDS were able to point out condom use as a preventive
measure. According to the BCHIMES survey, among those who had heard of HIV/AIDS, 60
percent knew that it was possible for a healthy-looking person to have HIV. Misconception
about the mode of transmission such as mosquito bites and kissing is low, less than 2.5
percent and 1 percent respectively.
Perception of Risk of HIV Infection
An increasing number of women are unsure about their risk of HIV infection. According to
the 1996 National Family Health Survey (NFHS), 66 percent said they faced no risk of being
infected, 16 percent thought there was a small chance, 6 percent a moderate chance, and 2
percent a big chance. In the BCHIMES study, 60 percent thought they faced no risk of HIV
infection, 14 percent said there was a small chance, 2 percent a big chance, while 23
percent were unsure.
Knowledge of mother to child transmission of HIV
Since 1995, HIV/AIDS education, including mother-to-child transmission (MTCT), has been
included in the training package of district-level health workers and female community health
volunteers (FCHV). However, MTCT has not been the focus of HIV/AIDS education because
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HIV prevalence among the general population is low, and the dominant mode of
transmission is heterosexual and injecting drug use.
In the 1999 FHI survey among FSWs, only 6 percent in 1998 and 11 percent in 1999 had
heard of mother-to-child HIV transmission even though over 90 percent are aware of
HIV/AIDS. FSWs have been the primary target of HIV intervention by NGOs in Nepal. The
lack of awareness of MTCT indicates a dire vacuum in HIV education among the general
population, especially among women with little education.
A more encouraging trend is found among teenagers, over half of whom, in a UNICEF 2000
Survey, were able to explain the mode of MTCT transmission, i.e., through pregnancy and
breastfeeding. The knowledge is derived probably from reproductive health lessons taught in
school, or through the mass media.
Women who know where to be tested for HIV and who have been tested for HIV
Women's knowledge about a place to test for HIV is low. In 2000, among those who have
heard of HIV/AIDS, only a quarter know where to go for an HIV test, and about 2 percent
have undergone such a test.
Poor awareness of a place to test for HIV is attributable to two factors. Firstly, very few
HIV/AIDS messages disseminated through the mass media actually provide information on
such a facility. Secondly, testing services are not available in all the districts. And where
available, the service is primarily offered by private labs and blood banks, with little or no
counseling to clients.
Attitude toward condom use
The condom has for long been promoted as a family planning method. However, it is only in
recent times that it is being promoted as a means of preventing STD/HIV infection. But many
families associate condom use with promiscuity. According to the 1996 National Family
Health Survey, 98 percent of the women who have heard of HIV/AIDS have also heard of
the condom. About 5 percent used it the last time they had sex, while another 4 percent
used it as a family planning method. According to the BCHIMES survey, condom use is 4
percentage points lower than all the family planning methods adopted by the general
population. Condom use is not prevalent partly because many families cannot afford one
regularly, and partly because of the misgiving that it reduces sexual pleasure. Most women
feel they are not in a position to influence their husbands on condom use.
A notable increase in condom use is, however, seen among the FSWs and their clients, due
to rigorous interventions by several agencies working on HIV prevention among high-risk
groups. A recent Family Health International (FHI) survey of sex workers, migrant workers
and truck drivers shows that consistent use of condoms by sex workers has increased from
33 percent in 1998 to 40 percent in 1999. An increased number of sex workers also reported
condom use with the immediate past client, from 60 percent in 1998 to 67 percent in 1999.
In the same FHI survey, consistent condom use by transport workers with their wives shows
a drop from 14 percent in 1998 to 8 percent in 1999, and by male labourers with their wives
from 26 percent to 7.8 percent. It is not clear what has brought about the decline. One
explanation is that these workers do not perceive a need for condoms now that they are
using them with sex workers. Given that 60 percent of the sex workers are not practising
consistent condom use, they are putting the spouses and partners of their male clients at
higher risk of HIV infection.
Attitude to people with HIV/AIDS
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People with HIV/AIDS are largely stigmatised in the Nepali society. HIV/AIDS is often
perceived as a nemesis for the promiscuous, a consequence of immoral sexual behaviour.
Sex workers who are HIV positive, in particular those returning from brothels in India, face
greater disapproval and contempt from their communities.
Families known to have HIV/AIDS patients find themselves isolated by the community in
which they live. Some families are so afraid of the stigma attached to the disease that the
infected member is confined to the home or thrown out of the house. It's not only the
community that discriminates against people with HIV/AIDS. They are also despised in the
hospitals and clinics. Many HIV/AIDS patients report being told to leave without proper
counseling and medical care. In a recent Nepal Red Cross survey of adolescents, a quarter
of them said AIDS patients should leave school and live in isolation, away from the
community.
Adolescent sexual behaviour
In a UNICEF survey of adolescents in 2000, 92 percent said they had heard of HIV/AIDS. Of
them, 10 percent felt that their friends were susceptible to HIV infection, either because they
frequent restaurants and hotels where sex is available, or because of their association with
drug addicts.
The high level of awareness among teenagers, however, does not translate into safe-sex
behaviour. About 20 percent of the adolescents who thought it was proper to have sex
before marriage did not always practise safe sex. Of the 9 percent girls who had had sex, 32
percent said that they had more than one sexual partner, 13 percent had contracted a
sexually transmitted disease (STD), and 14 percent had become pregnant. Among them, 74
percent said their partners use a condom, while 56 percent asked their partners to use one,
most of whom agreed. Of the 22 percent boys who had had sex, more than half had multiple
sex partners, 65 percent used a condom and 21 percent had contracted STD.
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