Friday-Sunday, Octobet 5-7, 2007, Ottawa, Canada
“Altogether 22 people have died following an outbreak of gastro diseases in southern parts of Humla district over the past few days.” (www.ekantipur.com, August 31, 2007)
“Beshi Shahar locals padlocked the Health Service Post, protesting against the Health Ministry’s dillydallying to renew the community health posts.”(www.ekantipur.com, July 9, 2007)
The above are news reports that describe widely occurring health-related incidents in communities across Nepal, where most of the population is rural, poor, and disadvantaged. These accounts show how easily life, especially that of children, can be ended by preventable diseases even in the 21st century, when there are simple ways of preventing, controlling, and treating these diseases. The prevalence of enteric diseases across the country has been attributed to poor water supply and sanitation (Pokhrel and Viraraghavan, 2004). The second quote above describes “have-nots” protesting against a system that provides inadequate facilities for the rural poor, yet at the same time provides state-of-the-art, well-run health care facilities in Kathmandu city for the rich and influential “haves”.
During my over 20 years of civil service in Nepal, I had experienced countless instances where the “haves” would have direct access to many free-of-cost publicly funded goods and services. This applies to health cares services as much as anything else due to the feudal basis of the state’s public affairs. Health care continues to remain less accessible to disadvantaged people like the poor, women, children, rural and remote groups, and Dalits, Madheshi, and Janajati ethnic groups. This paper attempts to bring new insight into these issues through the analysis of public data from the health sector and personal field experiences. The paper also provides ideas about future restructuring of Nepal.
The Early Efforts
A systematic approach to population-based health care in Nepal was started in early 1950s in the aftermath of a democratic movement that resulted in the transfer of government from the autocratic Rana regime to a monarchial limited democracy. With international cooperation, most notably from the United States (Moore and Moore, 2005), small-pox vaccination campaigns and malaria eradication programs were launched across the country and brought encouraging successes. Nepal has come some way since then, and with bilateral and multilateral international cooperation a countrywide network of health care is now in place. However, the one thing that was apparent from the beginning was that only those people who could be called “haves” by Nepalese standards were the ones to access the bulk of publicly funded health services. The “have-nots” (i.e. those who earn less than one dollar per day) have meanwhile become sicker and receive fewer health care services. These findings differ from a Canadian study that found that while people in poorer neighborhoods are sicker, they also use more health care services (Diener et al, 2007). Nepalese inequities in health – like other socio-economic inequities – have been taken for granted for decades even in the modern era.
Population Health Assessment
The World Health Organization’s (WHO) population based health assessment showed that only 27% of the population has access to adequate sanitation, and 30% lack access to safe drinking water (The WHOIS, 2001). Not surprisingly, the main health problems in Nepal still continue to be communicable diseases such as acute respiratory infections, encephalitis, diarrheal disease, dysentery, cholera, and typhoid fever. Preventable diseases such as diarrhea continue to be a common killer of rural children.
Demographics and Health Infrastructures
Figure 1 shows the population distribution of Nepal in its 75 districts. Morang and Kathmandu have populations over 800 thousand. Kaski, Kavre, and remaining Terai districts have populations between 400 and 799 thousand. Most other districts have populations between 100 and 399 thousand, while six districts in the north-west part of the country have less than 100 thousand people per district. Other than two parts of the Kathmandu and Pokhara valleys, the part of the country’s population that demands significant health care services dwells throughout the lengthy stretch of Terai belt. The distribution of middle hill populations is fairly uniform.
Figure 1. The population distribution in Nepal by district in 2004-05 (Source: Ministry of Health, Nepal)
While the majority of the population lives in rural areas, most of the health infrastructure and human resources are clustered in urban areas, especially the Kathmandu valley. Figure 2 shows the distribution of health care facilities in Nepal. The largest cluster is in Kathmandu valley, with other facilities concentrated in the middle part of the eastern Terai belt and around Pokhara valley. On the other hand, the high health risk districts of the western Terai belt are less concentrated. To add to this anomalous distribution, there are huge gaps in the quality of health services provided by these facilities across districts. For instance, the facilities categorized as Government Hospitals (84 in total) are not uniform. They range from a large facility in the capital city with hundreds of doctors, to a district hospital in Humla without one qualified physician or the position lying vacant for several months in any given year. Thus, the quality of services are not uniform and do not conform to the same standard from post to post. Thus, primary health care means different things in different geographic and population groups.
Figure 2. The distribution of health facilities in Nepal by districts in 2005. (Data Source: Ministry of Health, Nepal).
Clearly the two maps (Figures 1 & 2) do not match up. There are gaps in health care facility distribution for many population based risk areas. Given that all lives are equal, there is no reason to concentrate all the health care services in the Kathmandu valley unless the goal was to provide easy access for the rich and influential. If population was a major criterion, the Morang district should have more health care resources than it has today (notwithstanding the that the location of the BP Koirala Institute of Health Sciences in Dharan is a very appropriate one and that this will enhancing access to health care for needy rural populations). Kathmandu valley is not even a strategically important location for delivering health care to the rest of the country. In my opinion, there should be a ‘Remote Area Access First’ policy. This is a necessary consideration for any further expansion of health care facilities in the Kathmandu valley. Otherwise the country will not be able to say that it is concerned with providing new health care infrastructures in locations that are strategically important for the rest of the population.
Startling Scenarios of Health Disparities
There are rampant disparities in health across the population. In a repeat survey of health equity in the hill valley of the western region in 1999 after a 50-year interval, Johns Hopkins School of Hygiene and Public Health found community groups saying, “the poorest just die…” because their needs are unmet even where health facilities are present. This study confirmed government data that showed only a fraction of the population uses the government system each year; 28.1% in 1996-97 compared to 32.8% in 1997-98 (Taylor et al, 1999). Health inequities and disparities are illustrated in the infant and maternal mortality rates of the rural poor.
Differences in institutional births and professional care of newborns across populations (Figure 3) indicate inequity in the availability and quality of perinatal health care. Despite the fact that an exorbitant maternal mortality in Nepal (850 per 100,000 population) (Bhattarai, 1993) demands higher professional perinatal health care across the country, urban newborn babies represent a disproportionately larger share of institutional births and delivery by a skilled birth attendant compared to rural newborns. The finding that the babies born in the Hills eco-zone and Central development region (located in the Kathmandu valley) ranked highest in the share of both institutional births and delivery by a skilled birth attendant means that much of the long stretch of the Hills is largely deprived of these services.
Figure 3. Institutional births in the last 5 years (top bars) and delivery care by a skilled birth attendant (bottom bars) in Nepal, by area, eco-zone, and development region in Nepal (Data Source: NDHS-Nepal, 2006).
Against this backdrop of unequal distribution of health services across the country, common health status indicators have shown large rural/urban, eco-zones, or development region splits. Infant mortality was the highest in rural, mountain and mid-western regions, as was the under-5 mortality rate (Figure 4). The rates of both these indicators were nearly double what occurred in urban areas. The gaps in the rates of both these indicators from the highest eco-zones and development regions were more than double the lowest ones. These are not good signs for Nepal’s future, which needs healthy and well-nourished children that can attend school and become productive adults capable of contributing to the economic growth and development of their communities (Franco-Paredes et al, 2007).
Data on infant and child deaths are available from the National Demographic and Health Surveys (NDHS-Nepal, 2006). However, more detailed data on disease-specific causes of these deaths, as well as the distribution and trends of critical diseases across the country, are required in order to better understand the disparities that affect disadvantaged populations. It is important that society also address the fundamental human needs of autonomy, empowerment, and human freedom because the lack of these same is a potent cause of ill health (Marmot, 2006).
Figure 4. Infant mortality rates (top) and under-5 year old mortality rates (bottom) in Nepal, by rural/urban areas, eco-zones and development regions, 2006 (Data Source: NDHS, Nepal, 2006).
Figure 5 shows health determinants such as geographic area (rural vs. urban), wealth (lowest quintile vs. highest quintile), and level of highest education for mothers (lowest vs. highest) that influence various measurable health outcomes and that can provide us with further insights into population level health inequalities. The mortality rates of children aged under 5 years per 1,000 live births in Nepal are more or less double in rural, lowest wealth quintile and lowest level of mother’s education groups, as compared to urban, highest wealth quintile and highest level of mother’s education groups. Similarly, the percentage of under-5 children having stunted growth was more than 50% higher in rural (51.5%) than in urban (36.3%) areas. The corresponding percentages in lowest wealth quintile and lowest educational level of mothers were much higher than in the highest wealth quintile and highest educational level.
Figure 5. The under-5 year old mortality rate (top) and the stunted growth of children (bottom), by area, wealth quintile and level of mother’s education in Nepal in 2001 (WHOIS, 2001).
Caste based discrimination & health disparity
Many population health indicators such as infant mortality rate, under-5 year mortality rate, total fertility rate, and life expectancy rate have shown substantial national improvement over the past few decades. However, a study of the BP Koirala Institute of Health Sciences (BPKIHS) in Nepal indicates that health services utilization by marginalized groups within the population is low, and that health disparity is evident among various groups (BPKIHS, 2008).
Dalits make up approximately 15% of the country’s population, yet they are the most marginalized group in Nepal. The age-old societal practice of caste discrimination and the statutory provisions of “high” and “low” treatments meted to them by the law ever since the Muluki Ain (Civil Code) from 1854-1992 (Nepaldalitinfo) has meant that they comprise the lowest societal stratum. Dalits continue to be victims of caste discrimination which negatively affects their socio-economic standing and health status. The Word Bank found low health status among Dalits when compared to the whole population and any other group in Nepal (The World Bank/DFID, 2006). The World Bank/DFID (2006) following 2001 Nepal Census data reported that the under-5 mortality rate was 171 per 1,000 live births in the Dalit population was 171 compared to the national average of 105 per 1,000. Infant mortality was 117 per 1,000 live births as opposed to 105 in the total population, and life expectancy was 51 years in Dalits compared to the national average of 59 years.
Table 1 shows that in 1996 Brahman and Newar caste groups ranked the best in the under-5 mortality rate, infant mortality rate, and life expectancy, while the Dalit group was at the bottom of the list of all three indicators. Therefore, a special attention to the plight of this segment of the population is warranted.
Table 1. Disparity in mortality rates and life expectancy by caste/ethnic group in Nepal, 1996.
|Caste/ Ethnicity||Under 5 Mortality
Rate (per ‘000)
Rate (per ‘000)
|Life Expectancy at
Data Source: UNDP 2001: Nepal Human Development Report (NHDR) as cited by The World Bank/ DFID (2006). * Disaggregated data by gender and caste is unavailable.
Nepal faces real challenges in breaking the barriers placed by traditional feudalism. In order to lift the masses out of the vicious cycle of poverty, the inequalities and disparities at social, political, and organizational levels must be addressed. Economists advocate faster pace of growth even if it comes at the cost of high inequity. Their primary motivation comes from a belief that growth initiates from people at higher income standings as they can take greater risks on their investments. However, a country cannot make great economic strides unless the productivity of its whole population increases. A country like Nepal can therefore gain much by fostering growth that is pro-poor, pro-rural, and pro-disadvantaged. My assertions are similar to those made by the British Commission on Social Determinants of Health which said,
The time for action is now, not just because better health makes economic sense, but because it is the right and just. The outcry against inequity has been intensifying for many years from country to country around the world (Marmot, 2001).
In the Nepalese context, where the majority of the population is poor, rural, and disadvantaged, this may be the only option for progress and prosperity. The challenges that Nepal faces in the health sector are as follows:
• To ensure equitable access to health care on the basis of need, not on the basis of the ability to pay as a means to address the problem of health inequity.
• To ensure utilization of health care proportional to the population by age, sex, geographic, and socio-economic-ethnic group as a means to address the problem of health inequality.
• To minimize health disparities in terms of health outcome and status across the population groups as a means to address the problem of health disparity.
The following policy directions are proposed in order to meet the identified challenges:
• A political will to break the regressive cycles of poverty, inequality, and health disparities.
• Fostering pro-poor and pro-disadvantaged growth towards overall prosperity.
• Regional autonomy and self-determination.
• Having a universal health care system in place.
• Equal treatment as Janata Janardan (meaning that the people are the “God”) at all levels of health care.
• Delivering health care to the masses with a quality comparable to that in Kathmandu.
• Completely evolving health services to areas proportional to population distribution, with this responsibility bestowed to local governmental jurisdictions. The only exception to this rule would be for research, policy, and programs to combat diseases from national and international fronts.
• Providing regional autonomous authority in health care fund mobilization, supplies and services, education, and recruitment.
• Managing health sector performance based on an evidence-based population health approach, by way of developing the capacity to monitor the population’s health and the functionality of the public health network using measurable developing indicators.
The vast majority of the population in Nepal is rural, poor, and disadvantaged. Today, poorer and disadvantaged communities are not only sicker at the alarming rate, but they are also less likely to receive health care services from publicly funded health facilities compared to their richer and advantaged counterparts. The existing structure of the state’s public affairs is based on feudal practices which favor the “haves” rather than the “have-nots”. Without fundamental reforms in the way the health care system provides health care to the masses, health care will continue to be inaccessible to disadvantaged groups such as the poor, women, children, rural and remote groups, and Dalits, Madheshi, and Janajati ethnic groups.
Since majority of the population lives in rural areas, clustering most of the health infrastructure and human resources in urban areas, especially the capital city, is counterproductive to the broader interest of the country. Restructuring the state machinery for regional autonomy and accountability may prove to be a way forward for bringing equity in health care distribution. Implementing a universal health care system with uniform standards across the country could make health care accessible to the masses. Closing the gaps of existing health inequities, health inequalities, and health disparities among populations could be a way forward in the new era of Nepal.
The author thanks Dr. Mary Cameron, Associate Professor of Anthropology at Florida Atlantic University and Dr. Damodar Pokhrel, Environmental Health Engineer for their suggestions relating to diarrheal diseases in children of Nepal. Thanks are also due to Dr. Pramod Dhakal, Executive Director of the Canada Forum for Nepal for his constructive comments on this paper. The opinions expressed in this article are the author’s own, and cannot be attributed to any agency/organization of his past or present employment or affiliation.
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