92274 Knowledge Brief Health, Nutrition and Population Global Practice ACHIEVING MDGS 4 & 5: NEPAL’S PROGRESS ON MATERNAL AND CHILD HEALTH Seemeen Saadat, Rafael Cortez, Albertus Voetberg Sadia Chowdhury, and Intissar Sarker August 2014 KEY MESSAGES:  Nepal has made great progress in reducing maternal and child health outcomes, achieving its targets for MDGs 4 and 5a, ahead of the 2015 deadline.  Adopting a community-based approach to service delivery and bringing critical maternal and child health services closer to the most marginalized populations has been important to Nepal’s success.  Provision of subsidized or free care for maternal and child health services has been critical in the uptake of services, especially among poor households.  Improvements in socioeconomic status have also contributed to maternal and child health outcomes in Nepal through better access to services and reduction in poverty. Introduction heterogeneous society, with 125 caste/ethnic groups and Nepal has achieved its targets for MDGs 4 and 5a. 123 languages. At 59.6 percent, overall literacy is low, Maternal mortality declined from 790 to an estimated 190 and considerably lower among women than men (49 deaths per 100,000 live births between 1990 and 2013 percent vs. 72 percent, respectively). Free primary an impressive 76 percent decline. Under-five mortality education has contributed to a high enrollment rate (95 showed a similarly impressive decline going from 142 to percent), but it drops to 47 percent at the secondary 42 deaths per 1,000 births between 1990 and 2012. This school level, and tertiary enrolment is even lower at just HNP note explores the actions Nepal has taken to reduce over 7 percent. maternal and child mortality. MATERNAL AND CHILD HEALTH POLICIES Context Nepal has prioritized family planning and maternal and Nepal is a landlocked, low-income country with a per child health at the national level since the mid-1960s. capita GNI (PPP) of US$1,289 (2012), and an average More recent policies are the following: annual GNI growth rate of 4.4 percent (2003-2012). Headcount poverty declined from 60 percent to 25 National Health Policy (1991): This policy represents a percent between 1995/96 and 2010/11. Income inequality turning point, as it is the first in Nepal to adopt an also declined, with the Gini coefficient dropping from 43.8 integrative approach to health services. It strengthened in 2003 to 32.8 in 2010. Nepal has a population of 26.5 decentralization of service delivery to the district level, million, and a population growth rate of 1.35 percent per and encouraged community participation through annum. Fifty-seven percent of Nepal’s population is in the promoting female community health volunteers, traditional 15 to 59 years age group. Nepal has a very birth attendants, and inclusion of civil society. Page 1 HNPGP Knowledge Brief  National Reproductive Health Strategy (1997): This communities. Public health services are provided free of strategy focused on integrated reproductive health cost at health posts and sub-health post levels in Nepal, services to all. Several more specific policies and plans a right guaranteed under the 2007 Interim Constitution. on family planning, safe motherhood, and adolescents As a result, utilization of the health services has have their origins in this strategy, helping to catalyze increased, but it has also overburdened the health care policy into action. This includes the National Safe system with, for example, supply shortages in 25 percent Motherhood Plan (2002–2017). of facilities. Legalized Abortions (2003): A key development for Healthcare Financing: A significant portion of Nepal’s reproductive health rights in Nepal, the law allows women public health budget comes from donor support, to legally terminate unwanted pregnancies under certain coordinated via the Nepal Health Sector Program. Over circumstances. the past decade, public expenditure on health has averaged around 11.2 percent of total government More recently, the Government has sought to establish expenditure. At the same time, per capita expenditure on the right of citizens to free basic health care services. The health (PPP) has more than doubled (figure 1). Ninety 2008 Aama Surakshya Karyakram program is a step in percent of private expenditure on health represents out- this direction. of-pocket spending, which is also increasing (figure 2), driven by remittance-related increases in per capita MATERNAL AND CHILD HEALTH PROGRAMS incomes. Family Planning: Nepal’s family planning program Figure 1. Health expenditure per capita, PPP provides comprehensive coverage and services are (constant 2005 international $) provided at all tiers of the health system, as well as 100 through outreach clinics, and mobile camps known as 80 sibirs. Between 1990 and 2011 fertility declined rapidly 80 60 from 5.1 to 2.7 births per woman, and contraceptive 40 prevalence increased from about 24 percent to 50 percent. 20 37 0 Safe Motherhood Program: Initiated in 1997, the 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 program focuses on improving quality and utilization of services, especially emergency obstetric care. The Figure 2. Out-of-Pocket Health Expenditure program is implemented with support from donor partners (% of total expenditure on health) and in collaboration with NGOs. Between 1996 and 2011, 80 skilled attendance at birth increased from 9 percent to 36 percent and prenatal/postnatal visits went from 24 percent 60 70 to 58 percent. 40 49 Community-Based Integrated Management of 20 Childhood Illness (CB-IMCI): CB-IMCI supports the management of childhood illnesses, particularly diarrhea 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 and acute respiratory infections. The program has helped to double the number of pneumonia cases treated since its inception covering up to 69 percent of Nepal’s under- five population. The program also supports regular immunization and nutrition. Under the National Safe Delivery Incentives Program (SDIP): Piloted in Immunization Program vaccinations have increased, from 2005, the program offered demand-side cash incentives 46 percent to 92 percent for DPT, and from 57 percent to to women for having four ante-natal visits, skilled birth 88 percent for measles between 1991 and 2011. attendance, and a postnatal visit. It covered the costs of transport as well, with cash transfers based on region – HEALTH SYSTEM ranging from Nepalese Rupees (NR) 500 (approx. US$ 7.8) in the Plains (richer region) to NR 1,500 (US$ 23.4) in Service Delivery: The combination of a vast network of the Mountain districts (poorest region). The program also facilities and use of community health volunteers has provided incentives to skilled birth attendants for contributed to a strong public health structure at the managing home deliveries. Within a year of launch, village level and effective dissemination of health deliveries with trained birth attendants increased from 20 interventions in Nepal, especially for mothers and percent to 30 percent. children. Since more than half the women deliver at home, birthing centers have been established at the Aama Surakshya Karyakram (Aama): In 2009, the SDIP health post level to bring maternal healthcare closer to was rolled into the Aama program, which aims to provide Page 2 HNPGP Knowledge Brief  free delivery services in all public sector and partner of 6 districts shows that while overall institutional facilities. In addition to demand side incentives, program deliveries have increased from 17 percent to 33 percent, components include free institutional delivery care and there are disparities in utilization at the district level. supply-side incentives to health facilities for providing free care for normal deliveries, ranging from NR 1,000 to NR Human Resources: Female community health volunteers 1,500. Payments increase for complicated deliveries (NR (FCHVs) have played an important role in facilitating 3,000) and caesarean sections (NR 7000). A recent study access to services for maternal and child health in Nepal since 1988. The FCHV program covers mainly rural areas Figure 3. Nepal: Timeline of MDG 4 and 5 Interventions MDG 4: Under 5 Mortality 90 100 250 deaths per 1,000 live births 209 80 200 86 60 150 % 40 100 8 42 20 50 2 0 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 DPT Measles U5MR MDG 5: Maternal Mortality deaths per 100,000 live births 80 1200 1100 71.4 70 1000 60 54.8 800 50 40 46.1 600 % 30 510 400 20 10 200 6.9 0 0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Contraceptive Prevalence Rate Skilled Birth Attendance Maternal Mortality Ratio Pre-1990 1991–2000 2001–2012 1965–1970: Third Five-Year Plan prompts 1991: National Health Policy 2002–17: National Safe Motherhood launch of family planning, maternal, and Plan child health projects 1997: National Reproductive Health Strategy 2002: Education Regulation 1965: Immunization with DPT begins 1997–2017: Second Long-Term Health 2003: Abortion is legalized 1975–90: First Long-Term Health Plan Plan 2004: Safe Motherhood Plan revised to 1977: Expanded Program of Immunization 1999: Local Self-Governance Act include neonatal health (EPI) 1997: National Plan of Action (NPA) for 2005: Safe Motherhood Incentives 1979: National Commission on Population Gender Equality and Women’s Program established Empowerment 2006: Skilled birth attendance policy 1983: National Population Strategy 1998: Decentralized Action for Children and Women (DACAW) 2007: Interim Constitution 1988: FCHV program 2000: National Adolescent Health and 2009: Aama Surakshya Karyakram Development Strategy 2009: Community-Based Newborn Care Package Page 3 HNPGP Knowledge Brief  and has become pivotal for community-level service and children receive proper nutrition. provision in Nepal. It is linked to the increase in the intake of iron supplements during pregnancy, which increased  A large number of teenage pregnancies are from 23 percent to 59 percent between 2001 and 2006. unintended in Nepal, and use of modern Maternal and Child Health Workers and Auxiliary Nurse contraceptives is low compared to other age groups, Midwives are also important part of the strategy to provide even for married teens. Moreover, there are concerns maternal and delivery care services in communities. that contraceptive prevalence may be stagnating, highlighting the need for continued focus on Surveillance and Monitoring: Nepal has benefited from comprehensive family planning, especially for teens. the availability of timely and reliable data on maternal and  Income is a strong predictor of reproductive health child health for the last two decades. While the HMIS is outcomes in Nepal. For example, the total fertility rate not a perfect system (for example, vital registration data for women in the poorest households is 4.1 compared are incomplete because people simply do not register to 1.5 births per woman in the richest households. births), availability of information through Polio Continued poverty reduction efforts are essential, with Surveillance or the Maternal Mortality and Morbidity special attention to approaches that ensure benefits Surveillance has facilitated policy making and reach women and children in the poorest households. programmatic directions. Figure 3 shows a timeline of MDGs 4 and 5 interventions.  Further improvements in MCH require a systemic approach. Additional investment is needed for CREATING AN ENABLING ENVIRONMENT addressing shortage of human resources, improving  Reduction in poverty in the past decade due to logistics, referral systems and the quality of care. programs such as the Poverty Alleviation Fund (2004), Continued political tensions however pose a challenge. and remittances from migrant labor have contributed to Strong government leadership and accountability will higher spending on health. be important for maintaining the current momentum and planning for the future.  Caste and gender are major social barriers in Nepal. The 2007 Interim Constitution protects against References discrimination on the basis of caste, gender or race, Demographic and Health Surveys: www.measuredhs.com guaranteeing reproductive health rights and healthcare for all. Ghimire, M, et al. 2010. “Community-based Interventions for Diarrheal Diseases and Acute Respiratory Infections in Nepal.” Bulletin of the World  Nepal’s Education Regulation (2002) mandates free Health Organization 88 (3): 216–21. education to the poor, disabled, girls, and Dalits (lower Hanson, K., and T. Powell-Jackson. 2010. “Financial Incentives for Maternal caste population). The education policy also Health: Impact Evaluation of a National Programme in Nepal.” http://ssrn.com/abstract=1582863 emphasizes income-generating literacy and post- literacy programs for women. Ministry of Health and Population (MOHP) [Nepal], New ERA, and Macro International Inc. 2007. Nepal Demographic and Health Survey 2006. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and Macro Future Challenges International Inc  While cash incentives are alleviating some demand Upreti, SR, et al. 2012. “Rapid Assessment of the Demand Side Financing side barriers, what is harder to change are Schemes.” Aama Programme and 4ANC. Ministry of Health and Population; Nepal Health Sector Support Programme and HERD, Kathmandu, Nepal preferences, perceptions and mistrust of the public health sector, especially among the lower castes. The World Bank. 2011. “Implementation Completion and Results Report: Nepal government is taking concrete steps such as planned Health Sector Program Project.” Kathmandu: The World Bank. recruitment of Dalits and Janajits (lowest castes) to ______. 2010. “Nepal Public Expenditure Review.” Report No. 55388-NP. provide health services in underserved areas and Washington, DC: The World Bank. promote social inclusion. World Development Indicators: www.worldbank.org/data  Chronic malnutrition, an underlying cause of mortality for women and children, is pervasive even among higher wealth quintiles in Nepal. While there has been This HNP Knowledge Brief highlights the key findings from a study by the World Bank on “Maternal and Child Survival: Findings from Five Countries’ some progress, with 93 percent of children 6 to 59 old Experience in Addressing Maternal and Child Health Challenges” by Rafael months receiving the recommended doses of vitamin Cortez, Seemeen Saadat, Sadia Chowdhury, and Intissar Sarker A, more needs to be done to ensure that both women (forthcoming) The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4