by Dr Rita Thapa (Chairperson, SAF Nepal chapter)
Nepal is one of the poorest countries in the world, wedged between China and India. With a total surface area of 147 square kilometers, the country is home to some 27 million Nepalis from more than a hundred diverse caste and ethnic identities. 86% of the Nepali people live in rural areas, with poor transport and communication facilities, and few health services. Public-private partnerships, which have steadily gained ground in Nepal, have highlighted one of the most important but neglected public health needs: safe pregnancy and childbirth.
|The country has come a long way since 1951, when it launched its first modernization drive. It has since transformed from a socially orthodox Hindu kingdom to a secular federal democratic republic, with women comprising 33% of its national assembly.
The Communist Party of Nepal-Maoist, which waged a decade-long insurgency in 1996, recently won elections, and a mandate to govern the country.
Having been a girl in pre-1951 Nepal, and having not been allowed to obtain formal schooling till I was 10 years old, I find these changes a bit dizzying, but recognize the huge gains for a country held back by centuries of feudalism, poverty, illiteracy, and discrimination, as well as a decade-long guerrilla war.
At present, Nepal is still in a period of transition, facing opportunity as well as danger, while the Maoists learn to adopt a democratic polity. In the words of the Buddhist teacher Vajra Regent Osel Tendzin “Transition is like going through a doorway. If you barge through without caution, you open yourself to disruption on the other side. In fact, you invite chaos.”
Community organizing among the disadvantaged women in Kapilvastu. Photograph courtesy of PAF.
Challenges in Health Services
Many people know that Prince Siddhartha Gautama, or the Buddha, was born in Nepal, but few know that his mother, Queen Maya Devi, died of complications arising from his birth.
Nepal’s Maternal Mortality Rate (MMR) has declined impressively in the last 10 years, going from 539 in 1996 to 281 in 2006. However, preventable complications during pregnancy and childbirth still remain the leading cause of death among women of reproductive age.
A high level of MMR indicates a high level of newborn mortality, mostly due to maternal health problems. 69% of the total infant mortality rate (48 per 1000 live births) in Nepal occurs among newborn babies, within the first 28 days of their lives. Preventing maternal deaths therefore also means saving babies, both born and unborn.
The 2005 World Health Report established that the presence of skilled health workers at childbirth can save the lives of mothers and newborn babies, which is why the Millennium Development Goals require 60% of all births to be attended by skilled birth attendants by 2015. In Nepal, only 19% of the total births are attended by skilled birth attendants, mainly because more than 80% of all births occur at home, in rural areas. Because health workers are reluctant to live and work in these areas, the government has found it difficult to remedy the problem.
A Public-Private Partnership Response
Since 2006, a three-partner initiative has responded to the challenge of providing skilled health workers at births in the rural areas, where the need for them is greatest. The South Asia Foundation (SAF), the Poverty Alleviation Fund of Nepal (PAF), and the Council for Technical Education and Vocational Training (CTEVT) are bound together by a shared commitment to the health and wellbeing of Nepal’s most excluded communities. Together they have reached out to the poorest of the poor in Nepal, namely the country’s women, its rural population, Dalits (its occupational and untouchable caste) and Janajatis (its ethnic minorities).
SAF, a non-profit and non-political voluntary organization, is a major funder in the initiative, having donated 100 Madanjeet Scholarships to participating women, each costing US$600 per year.
PAF is a self-governed organization, with Nepal’s Prime Minister chairing its Management Committee. Mobilizing its network, the organization channels the scholarships to the most excluded communities. Recently, it also committed to providing mentoring and financial support to help establish clinics for the ANMs in their own communities, so that they might work there after the completion of their training.
CTEVT, chaired by Nepal’s Minister of Education, has taken up the implementation of the scholarships into its overall institutional targets and recruits eligible candidates through its institutional network.
The partnership’s strategy has been to empower eligible candidates by offering them an 18-month vocational course, training them as Assistant Nurse Midwives (ANMs). The rationale is that with a single investment, communities see multiple benefits: income-generation and poverty reduction; the empowerment of women; and an improvement in women’s and children’s health. Assistant Nurse Midwives also serve as role models for young local girls, inspiring the next generation of trained health workers.
Trainees were selected from the six districts with the lowest Human Development Index in Nepal: Siraha, Rameshap, Kapilvastu, Mugu, Piyuthan, and Darchula. Candidates were selected based on academic, social, geographical and poverty factors, with special preference given to Dalit and Janajati groups. The training was conducted at the Jiri Technical School, located in Dolakha.
Nepal's map showing the districts where scholarship efforts are focused. Courtesy of PAF.
Success and Sustainability
To date, 90 young women have been recruited and trained. The first batch of 50 ANMs has already graduated, and the remaining 40 will graduate soon. 80% of the women trained are from Dalit and Janajati groups.
|A critical component to the initiative’s success is that each concerned partner did what it knew best without encroaching on the other’s responsibilities. By making use of each other’s competitive advantages, they formed a true partnership that demonstrates the great potential and benefit of collaborations between private, non-profit, and government institutions. But in order to bring about a larger impact, this initiative needs to be scaled up. Long-term plans should be made to help ANMs advance their careers with additional scholarships for higher education.
The trained Assistant Nurse Midwives must be engaged and retained in their own districts for at least a year or two after their training. At this point, we do not know exactly how many of those trained have returned to their respective communities. Follow-up and mentoring support would help them establish their services in their communities and would create a sustainable foundation for increased access to skilled birth attendants for the poorest of women and their children.
The results are encouraging. I feel inspired. But at the same time, this must not become yet another example of a successfully implemented pilot project that terminates with a good report. By truly investing in the prevention of maternal death, we can protect the human right to life, strengthen communities and foster much needed economic growth in Nepal’s impoverished areas.
The first 50 ANMs to graduate. Photograph courtesy of CTEVT-Nepal.
About the Author
Dr. Rita Thapa is a public health physician from Nepal who began her career in the 1960s as a medical officer in the Maternity Hospital at Kathmandu. Having observed too many preventable deaths and disabilities from lack of access to basic prenatal health care and family planning services, she became the first medical Officer-in-Charge of Nepal’s Maternal and Child Health and Family Planning Program, establishing a country-wide network of integrated primary health care delivery services. The program’s training of village health workers (VHWs) and female community health volunteers (FCHVs) at the ward level remains an important backbone of Nepal’s health system to this day.
Dr. Thapa joined the World Health Organization in 1986, working in the Manila, Geneva, and New Delhi offices. Dr. Thapa was the first woman Director in the WHO Regional Office for South-East Asia before retiring in 2001. She has since been a member of Nepal’s High Level Health Policy Advisory Committee, the National AIDS Council, the Poverty Alleviation Fund and the Country Coordination Committee for Global Fund to fight AIDS, Tuberculosis and Malaria. She also chaired the Nepal Chapter of the South Asia Foundation.
As a Nepal’s first national badminton champion in her teens, Dr. Rita Thapa remains an avid sportswoman, now a dedicated golfer.