Nepal is the poorest country in South Asia. The Nepalese have endured a 10-year insurgency, faces persistent political upheaval and the daily challenge of giving with some of the most challenging terrain in the world. So it would appear to be the last place to look for lessons on health improvements. Yet, Nepal shows us that rapid change is possible even in the most difficult circumstances.
Although Nepal is ranked 145th out of 187 countries on the Human Development Index, the country is one of the few in the world to have met, and exceeded, the international goals for the reduction of maternal mortality rates (MMR). As the global progress on MMR has lagged behind, Nepal has managed to achieve a striking reduction of 75 percent despite limited means.
While there is no bulletproof check list that every developing nation can adopt, here are 6 lessons that largely shaped Nepal’s rapid progress on reducing maternal mortality in the last 15 years.
1. PROGRESS IN HEALTH NEEDS POVERTY REDUCTION
It is statistically proven that maternal mortality rates are highest among the poorest households and even moderate poverty reduction shows progress on health indicators. Over the last 15 years, the poverty rate in Nepal has declined from 42% to 25% and this has largely been enabled by increased migration. More Nepalese people are working abroad and sending money back to their home country raising the number of Nepalese households receiving payments today to 56% compared to 23% in the 1990s. Increased incomes have allowed households to better address the nutritional and health issues related to giving birth. However, large improvements in MMR were also made during the 1990s and early 2000s, when migration and remittances had not reached their current scale, indicating that poverty reduction is only part of the solution.
2. BETTER DATA ALLOWS FOR BETTER DECISIONS
Effective response to maternal mortality has also enabled better data collection on the causes of maternal death. Lack of information has been the main barrier to seeking help and understanding key regional needs. In the 1990s, mid-level health ministry officials and a large-network of medical experts and civil society groups, who had previously gained field experience and saw the dire birthing conditions of women, started pressuring the Nepalese government to address maternal mortality. With the financial and technical support of donors, these officials commissioned in-depth research and qualitative surveys on the challenges to maternal health. This focus on getting the qualitative aspect of data to complement quantitative findings allowed for not only a broad but a deeper understanding of the key challenges while having only limited financial means.
3. ADDRESSING THE SUPPLY-DEMAND CHALLENGE IS KEY
For Nepal, like many poorer countries, the understanding of supply and demand trends remains key for effective policies on maternal health. Greater data collection and its subsequent analysis indicated that 67 % of all maternal mortality in Nepal took place when women delivered at home. The results also showed that it was the cost of deliveries in specialized institutions that prevented poor households from seeking medical help. As a result, Nepal embraced policies to incentivize poor households by gradually abolishing user fees and by paying small stipends to mothers who delivered at health centers.
A proper understanding of existing supply problems in the health sector has also led to improvements in infrastructure. It was found that MMRs were highest in rural areas where the provision of health posts had been insufficient. To address the increasing demand, the Nepalese government embraced policies to expand health services into more remote areas of Nepal. Over a period of 20 years (1991–2011), Nepal saw the expansion of health posts from 351 to over 1,200. The scaling up of birth centers along with increased provision of 24-hour delivery services, and the expansion of privately-run pharmacies, have allowed many mothers to treat illnesses that in the past may have proven fatal. Access to pharmacies has also broadened the availability of contraceptives — contributing to a reduction in unwanted pregnancies and a decrease in birth rates.
Finally, recognizing the physical constraints on access, the government has expanded the road and bridge network by 33 percent between 1999 and 2005. This has reduced transport delays and ensured that health supplies are available in remote regions. Paired with improved security and an expansion of facilities to many more villages, these strategies have given many mothers access to emergency obstetric care.
4. EDUCATING CAN CHANGE BEHAVIORAL NORMS
The higher a woman’s social status, the lesser the chance of maternal mortality. Better educated women are more likely to have fewer children, seek antenatal and postnatal care and have safer, institutional deliveries. A sustained policy focus on female empowerment through education is partly responsible for Nepal’s success. Over the past 2 decades, the government has consistently focused on increasing girls’ enrolment in education with remarkable results. Between 2008 and 2013, women achieving a secondary-school education, or higher, increased by 48%. Many of these women now seek better information, medicines and treatments related to giving birth.
In addition, active efforts to change the norms and behavior around many of the country’s traditional patriarchal family structures through a volunteer network of educators has enabled further female empowerment. Recognizing the power of social norms, the government has increased the number of female community health volunteers by 50,000. They serve as a source of education on maternal health, continuously advising mothers on health related risks and ways to avoid them. These policies were complemented with a conceptual reframing of basic health ‘needs’ into health ‘rights’, and many government strategies related to safer motherhood, nutrition and gender have become anchored in the principles of ‘human rights’ altogether.
As a result, more than 50 % of expectant mothers sought the World Health Organisation (WHO)-recommended four antenatal visits in 2013, a fivefold increase since the 1990s. With better educated women, Nepal’s contraceptive demand also doubled. Women now give birth to an average of 2.6 children as compared to almost 6 children in 1990s.
5. SUSTAINED FUNDING AND POLICY COMMITMENT REMAIN CENTRAL
The changes described above could not have been possible without a sustained financial commitment from both the government and international donors. The Nepalese government dramatically increased funding for maternal health, nearly doubling the spending from $33 per person in 1995 to $66 per person in 2011. As international donors grew more confident about the government’s commitment to health, they too scaled up their funding, allowing the government to further increase its services. The support to health as a share of aid rose from just under 2 percent in 1990 to almost 14 percent in 2011 and international aid has been responsible for the coverage of 40 percent of public health expenditure. Hence, Nepal’s example illustrates the importance of showcasing early progress and sustained financial commitment to policy implementation.
6. COOPERATION AND COORDINATION TO FILL IN THE GAPS
Finally, Nepal’s rapid progress would not have been possible without cooperation between the government and various local, national and international health actors. The country’s dense network of NGOs has filled many gaps where the system failed to provide in certain areas. Community-based organizations and NGOs have worked closely with the government to establish “mother groups” in almost every village to serve as a source of innovation and education for women, such as the development of the Birth Preparedness Packages. The coordination of activities and cooperation between a multitude of actors were key in ensuring that the limited resources of some could be effectively complemented by the resources of others.
Nepal has made tremendous progress in reducing MMR and provides useful lessons for others. Yet it is now facing a different set of challenges brought about by the devastating 2015 earthquake. It has already shown what a poor nation with limited means can achieve in a brief period of time given the right conditions, sustained commitment and international support. However, the devastation caused by the earthquake has stretched beyond breaking point the already limited resources of the Himalayan nation. Public and private international aid is coming under greater pressure due to the other crises around the world that need attention. Many people worry that Nepal is falling out of the global agenda. Yes, there are other challenges around the world but we cannot let the recent crisis in Nepal undermine the remarkable results of decades of concerted effort.
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