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					                                           Foreword


This National Report on Follow-up to the World Summit for Children is being submitted to the
Secretary General of the United Nations for his report to the Special Session of the General
Assembly for Follow-up to the World Summit for Children in September 2001.

In September 1990, at the World Summit for Children, His Majesty‟s Government of Nepal
signed the Summit Declaration and the Plan of Action for Children. A National Programme of
Action was prepared under the auspices of the National Planning Commission in January 1992.
Nepal was one of the first countries to ratify the Convention on the Rights of the Child in 1990.
Since then, Nepal‟s commitments to fulfill the promise of “First Call for Children” have been
reflected in the subsequent National Development Plans.

This report summarizes the findings of the End Decade Review, an assessment of the
commitments made at the beginning of the decade. The Review has involved consultations with
government line ministries, development agencies, both bilateral and multilateral, civil society
partners including both national and international non-governmental organizations, as well as
the children of Nepal.

During the decade, His Majesty‟s Government has undertaken many initiatives aimed to
improve the status of children and women and to realize their rights. Restoration of democracy
at the beginning of the decade provided a special opportunity for legal reform in light of Nepal‟s
new Constitution based on the principle of human rights. New policies and institutional
arrangements have been established to give priority on the issues concerning children and
women. A broad range of activities has been taken up to operationalize the laws and policies of
the country. The progress seen in the end-decade goal indicators is a result of these concerted
efforts by His Majesty‟s Government, and support from all development partners.

Nepal has made substantial gains in some areas during this decade. The National Campaign to
eradicate Polio through the National Immunization Days has resulted in high coverage rates and
a reduction in polio cases. The distribution of vitamin A capsules has been successfully
implemented in most parts of the country, again with high coverage rates. Nepal is close to
achieving universal coverage in water supply. The Sector Investment Plan established though
the Basic Primary Education Programme is a model of donor coordination in a sector, resulting
in a more effective use of resources.

Nevertheless, much remains to be done to fulfill the rights of all children and women in Nepal.
The UNGASS will provide a welcome opportunity to renew our commitments for the coming
decade. Nepal‟s National Movement for Children will help to promote broad participation from all
segments of society, but particularly the children and youths, to ensure that our commitments to
children – our country‟s future – are met.


                                                    (signed)
                                                    Dr Nirmal Pasad Pandey
                                                    Member
                                                    National Planning Commission
Singha Durbar
Kathmandu, Nepal
December 2000



                                                                                                1
Steering Committee for End-Decade Review
Chairperson
   Dr. Nirmal Prasad Pandey
   Honourable Member
   National Planning Commission

Members
  Mr. Ram Krishana Tiwari
  Joint Secretary
  National Planning Commission Secretariat

   Mr. Prem Nidhi Gyawali
   Joint Secretary
   Ministry of Information and Communication

   Mr. Pratap Kumar Pathak
   Joint Secretary
   Ministry of Women, Children and Social Welfare

   Mr. Sundar P. Shrestha
   Chief , Planning Division
   Ministry of Education

   Mr. Vidhan R. Yami
   Chief , Planning Division
   Ministry of Physical Planning and Works

   Mr. Yuba Raj Bhusal
   Chief, Budget Division
   Ministry of Finance

   Mr. Arjun Bahadur Singh
   Joint Secretary
   Ministry of Health

   Mr. Upendra Prasad Adhakari
   Under Secretary
   Ministry of Population and Environment

   Mrs. Padma Mathema
   Under Secretary
   National Planning Commission Secretariat

   Mr. Stewart McNab
   Representative
   UNICEF
   Nepal Country Office

   Ms. Eriko Onoda
   Planning Officer
   UNICEF-Nepal Country Office

Member Secretary
  Mr. Durga Prasad Khatiwada
  Section Officer
  National Planning Commission Secretariat


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3
           National Report on Follow-up to the World Summit for Children


A. Introduction and background

In September 1990, the then Prime Minister Krishna Prasad Bhattarai led the Nepalese
delegation to the World Summit for Children at the United Nations in New York, and signed the
Summit Declaration and the Plan of Action aimed at achieving the survival, protection and
development goals for children, on the principle of "First Call for Children".

In Nepal, the Summit provided the unprecedented opportunity for the Government, NGOs,
communities and individuals to mobilize for children. Radio programmes, newspaper articles,
television features, information kits and publications about the Summit were produced, which
contributed significantly to promoting the spirit of the World Summit. These activities were
instrumental in having the rights of children and women reflected in Nepal‟s new Constitution
that was being drafted at the time.

In response to the Summit Declaration, which was later ratified by Nepal‟s Parliament, a 10-year
National Programme of Action for Children and Development (NPA) was formulated in January
1992. The cost of implementing the NPA's programmes in the priority social sectors – primary
education, basic health and low cost drinking water and sanitation - was estimated at NRs. 56
billion (about US$ 1.3 billion). The NPA‟s mid-decade and end-decade goals were incorporated
into the Eighth (1992-97) and Ninth National Development Plans (1997-2002) - an indication of
the Government's seriousness in achieving the social sector targets.

For the periodic reviews of the NPA, a steering committee headed by a member of the National
Planning Commission (NPC), Social Sector Division, was formed in 1992. All the line ministries,
including the Ministry of Finance, were represented on the committee. In 1996, the NPC, in
collaboration with the Ministry of Women and Social Welfare and UNICEF, conducted a mid-
decade review of the NPA. The review concluded that while significant progress had been
made, the majority of targets in health, nutrition and education had not been achieved. Infant
and maternal mortality rates continued to be among the highest in South Asia, immunization
coverage had declined since 1990, and the nutritional status of children had not improved.
Gender discrimination remained widespread, with girls and women doing excessive labour, but
getting inadequate food and limited access to health and education. Despite these difficulties,
the review noted that mid-decade goals for water supply and sanitation had been met.

The mid-decade review identified many factors that affected progress towards the goals,
including political instability, poverty, population growth, and widespread gender and caste
discrimination as well as low levels of economic growth.

Nepal was among the first countries to ratify the Convention on the Rights of the Child (CRC) in
1990. In February 1995, the Government submitted its initial report on the implementation of the
Convention to the CRC Monitoring Committee. Based on the initial observations, Nepal
submitted an Additional Country Report to the Committee in May 1996. The reports noted that
poverty, conservative beliefs and lack of awareness of children's rights were constraints to the
effective implementation of the Convention. Implementing the CRC, the reports added, would
depend on better use of scarce resources and strict enforcement of laws.

The CRC Committee commended the Government for being self-critical about the difficulties
encountered in implementing the CRC. It appreciated Nepal‟s openness to international


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guidance and technical assistance to implement the Convention. The key areas of concern
raised by the Committee were; the gap between legislation and enforcement, insufficient
measures to curb discriminatory practices towards, and the absence of specific laws and
policies to combat the trafficking of children and child prostitution.

In 2001, Nepal will submit its second CRC report that will highlight the developments over the
last five years. The Ministry of Women, Children and Social Welfare (MWCSW), in collaboration
with Save the Children Norway and UNICEF, is preparing the report. Children are being
extensively consulted, for example through Children‟s Camps and through the Consortium of
Child Clubs. Civil society organizations, particularly NGOs involve with children, will also be
consulted. Before being finalized, draft reports will be shared in public hearings.


B. Process established for the End-Decade Review

The End-Decade Review (EDR), led by the National Planning Commission in close cooperation
with the Ministry of Women, Children and Social Welfare (MWCSW), has been based on many
studies, surveys and policy discussions on children and women‟s issues in Nepal. The Common
Country Assessment, conducted jointly by the Government and UN agencies in 1999, is one
such document.

Also contributing to the review were government officials, former bureaucrats, academics, staff
of UN organizations, bilateral organizations, INGOs and NGOs. For instance, as part of
celebrations for Children‟s Day in November 2000, a workshop was organized by a local NGO
to review the progress made in CRC implementation. The EDR also received inputs from
children at Children‟s Camps organised by the MWCSW to discuss child rights and their vision
of the future.

To fill in data gaps for the end-decade goal indicators, a national survey was conducted by the
Central Bureau of Statistics, with support from UNICEF. The survey findings were compared
with figures from different data sources, and discussed to determine which figures should be
included in the EDR report.

The EDR findings will be disseminated in 2001 through various forums to ensure that they lead
to future action in areas where progress has been slow. The dissemination will be integrated
with the preparation of the CRC report and the Global Movement for Children.


C. Action at the National and International Levels

Child-specific actions cannot be implemented in isolation and have, therefore, been integrated
into the broader national development policies and programmes. Poverty alleviation is now a
long-term national policy, with the current Ninth Plan (1997-2001) shaping a 20-year vision to
reduce the proportion of people living below the poverty line to 10 percent by 2017. The
decentralization process, though in its early stages, is being institutionalised to ensure that
children and women have not only access to the basic social services, but that they also have
the right to fully participate in the development process. Democracy, though still in its nascent
stage, is beginning to instill civic responsibility with greater participation and contributions from
the civil society, including NGOs, the media, children and youth in the development process.
With these broad objectives in mind, the following actions at the national level were taken during
the „90s.


                                                                                                   2
In 1992, a National Programme of Action for Children was formulated in close cooperation with
the line ministries and NGOs. Earlier in March 1991, a national seminar attended by 108
national and international NGOs prepared an action plan that envisaged wide participation of
NGOs to supplement the Government‟s limited human and financial resources.

The NPA goals were incorporated into the Eighth National Development Plan (1992-97) and
were carried over into the current Ninth Plan (1997-2002). As a result, government spending on
the basic social services increased from 10 percent in 1993 to 14 percent in 1996. Increased
allocations to these sectors were possible largely due to a budget restructuring study conducted
in 1994 by the Government with UNICEF support. As part of the Ninth Plan‟s vision of reducing
poverty, long-term targets have been set for the social services sector.

The advent of multi-party democracy in the country in 1990 has given birth to an active civil
society and a free press. There are more than 10,000 NGOs, many of them dedicated to the
promotion of human development and human rights. NGOs, the media and the society at large
have been mobilized throughout the decade, especially in the advocacy of children and
women‟s rights. National and international NGOs have come together to support the Child Clubs
of Nepal, to help ensure that children‟s voices are heard and reflected in the development
process.

To monitor relevant social indicators for the NPA, the NPC, with UNICEF assistance, developed
the Nepal Multiple Indicator Surveillance (NMIS) system in 1994. In 2000, the BCHIMES survey
was carried out to assess progress on the end-decade indicators.

During the decade, Nepal has participated in a number of world conferences and committed
itself to the rights of children and women. It has ratified more human rights instruments than any
other country in South Asia. Nepal has been reporting to the treaty bodies on time. The quality
of the reports and the high degree of participation involved have been well appreciated.

A summit organized by South Asian Association of Regional Cooperation (SAARC) has
endorsed the Goals for children and development and declared the 1990s as the Decade of the
Girl Child. In 1993, the Seventh SAARC Summit held in Dhaka endorsed the plans of action
prepared by the SAARC countries. In 1996, the SAARC countries endorsed the Riwalpindi
Declaration on Child Labour.


D. Specific Actions for Child Survival, Protection and Development

a. to disseminate and promote the earliest possible ratification of the Convention on the
Rights of the Child and, thereafter, to promote its implementation and monitoring of the
CRC.

Even before the CRC was ratified, non-governmental organizations (NGO) were actively
advocating children's rights. In 1988, Nepalese NGOs took the initiative to organize a regional
seminar to discuss child labour issues in South Asia. Its outcome was the establishment of a South
Asian forum on the rights of the child.

Soon after the adoption of the CRC by the UN General Assembly in November 1989, Nepalese
NGOs began actively engaging in building public opinion in support of ratifying the Convention. The
CRC document was translated into Nepali and widely circulated at seminars and among the NGOs


                                                                                                 3
and university students. Talk programmes and photographic exhibitions on child rights were held in
the capital. All these activities were crucial in generating support for the CRC‟s ratification. The
Save Alliance played a key role in supporting the NGOs and in advocating for the ratification.

On September 14, 1990, Nepal was among the first 20 countries to ratify the Convention. The
ratification has helped to place the cause of children on the national agenda, and to promote the
principle that their well-being is a responsibility of the family, society and state.

In the decade following the ratification, legal provisions have been amended, repealed and new
ones enacted to harmonize Nepalese policy, laws and regulations with the provisions of the
Convention. The Children‟s Act, the most comprehensive law on the rights of the child
guaranteeing their right to education, maintenance and survival, was enacted in 1992. The
Children‟s Regulation to implement the Act followed three years later.

Other instruments enacted to safeguard the rights of the child and ensure their protection and
development include the Labour Act (1992), the Breast Milk Substitutes Act (1992) and the Social
Welfare Act (1992). The long-awaited Act to regulate and control child labour was passed by
parliament in 2000. And in April 2000, the Government gave directions to set up a juvenile bench
in all the 75 district courts to deal with cases related to children who are in conflict with the law.
More recently, the Government is in the process of amending laws and acts that contradict one
another or with the principles of the CRC.

To implement the provisions in the acts, the Government has worked out a number of
institutional mechanisms. To begin with, a Children and Women's Development Section was
created in the NPC in 1993 to formulate policies to enhance their status. A Central Child
Welfare Board to (CCWB) to implement, report and monitor on the CRC was also formed. To
decentralize the implementing and monitoring process at the grassroots level, District Child
Welfare Committees (DCWC) have been set up in all the 75 districts. Since 1998, Save the
Children Norway and UK have been involved in efforts to strengthen the DCWCs.

In June 1994, the Government constituted the National Council for Woman and Child Development
headed by the Prime Minister. Its purpose is to formulate national policies for the development of
children and women and to monitor progress towards the World Summit goals. A year later, the
Ministry of Women and Social Welfare was created. In May 2000, the Ministry was renamed as the
Ministry of Women, Children and Social Welfare, indicating the Government‟s sensitiveness
towards children‟s issues.

Other initiatives taken by Nepal in the light of the CRC include:
 setting up of Nepal‟s first organization set up and run by children, Bal Chetana Samuha, as well
   as child clubs and groups at various levels;
 formation of a National Human Rights Commission in 2000 which is expected to contribute to
   protecting the rights of children and women;
 abolishing bonded labour in 2000 that has emancipated more than 30,000 bonded and semi-
   bonded child labourers in Nepal.

However, all these initiatives, good as they are, do not guarantee the rights of the child. Much
work remains to strengthen the institutions and implement the provisions. This, compounded by
conservative social beliefs, poverty, illiteracy, inadequate financial and human resources,
administrative challenges and Nepal's difficult terrain, make the CRC‟s implementation a
challenging task.



                                                                                                    4
Against this backdrop, it is apparent that the Government cannot ensure the rights of the child on
its own. Supplementing the Government‟s efforts are NGOs and INGOs. To facilitate dialogue with
the Government both at the policy and program implementation levels, civil society has formed a
Federation of Child-related NGOs. While the sheer number of child-related NGOs is impressive,
most of them are concentrated in the capital. This has made reaching out to the more
disadvantaged children in the remote, rural areas difficult.

Implementation of the CRC may have been slow, but there is little dispute about the growing
awareness about the need to improve children‟s conditions. The credit for this goes to the
Government, NGOs and the media. NGOs have proved themselves particularly adept in advocacy.
Promotional activities included organizing essay, poetry and song contests, publishing brochures,
pamphlets and posters, producing radio and TV programmes and holding seminars and training
programmes on the CRC.

The Government, on its part, has included texts on the rights of the child in the textbooks of
Classes 5 and 8. Children too have been involved in this endeavour. For example, children working
on behalf of children in various “child-to-child” activities, such as street dramas, seminars and wall
newspapers, have been advocating children‟s and women‟s rights as well as promoting hygiene
and health for children. Child clubs have also been formed to enhance the capacity of children to
become involved in community issues.

Institutions not directly associated with children have also been joining in to generate awareness
about child rights. In 1998, for instance, more than 1,000 institutions and organizations across the
country participated in the Global March Against Child Labour. In December 1999, the Police
Headquarters organized awareness programmes for district level police officers on sexual
exploitation of children and on women trafficking. In 1999, a postage stamp was issued with the
call 'let's end child labour'.

The media, both state-owned and private, have been supporting the free expression of children on
television, radio and in newspapers. In 1995, the draft of the country's initial report on the CRC was
widely discussed and shared with the public through the media. Similarly, that year, human rights
organizations initiated educational programmes on human rights and child rights on the radio for
the first time in South Asia.

UNICEF has been assisting in the making of telefilms and cartoon series that have messages on
health, child care, discrimination and other related issues. However, children in the rural areas
have limited access to both the print and broadcast media.

b. to combat childhood diseases through low-cost remedies and by strengthening primary
health care and basic health services; to prioritize the prevention and treatment of AIDS; to
provide universal access to safe drinking water and sanitary excreta disposal; and to
control water-borne diseases.

While much has been achieved to improve the health status of the Nepalese population over the
last decade, high fertility, low literacy levels and unabated population growth are undermining
efforts to reduce poverty and improve health care. Infant and under five mortality has steadily
decreased from 102 and 165 respectively in 1991 to 79 and 118 in 1996. However, as many as
78,000 children aged 0-60 months are estimated to have died in 2000.

With an annual growth rate of 2.4 percent, Nepal‟s population is expected to double from 22.4
million in 1999 to 44 million in the next 29 years. Although the total fertility rate has come down


                                                                                                    5
from 5.6 in 1991 to 4.6 in 1996, the decrease is not keeping up with declines in child mortality.
From 1987 to 1999, the crude death rate decreased from 14.9 to 10.3 per 1,000 population,
against a decline in the crude birth rate from 41.6 to 34.1. A 1996 survey found that only 29
percent of married women use contraceptives, with an unmet demand of 31 percent. A more
recent survey in 2000 found the contraceptive prevalence rate to be 37 percent.

Infectious diseases, maternal and perinatal ailments, and nutritional deficiencies are the leading
causes of morbidity and mortality in Nepal. Hospital data indicate that intestinal infectious
disease, bacterial diseases, measles, pneumonia and perinatal factors account for 80 percent of
deaths among children. Malnutrition and other nutritional deficiencies contribute to 54 percent of
all young child deaths.

Early marriage among females is responsible for the high fertility and maternal and infant
mortality rates in Nepal. In 1996, the average age of marriage, among women between 20 and
49 years old, was reported to be 16.4 years. Among women 15-19 years, 44 percent are
already married, and 24 percent of this adolescent group are mothers or pregnant.

A national study on maternal mortality and morbidity (1998) reported the leading cause of death
among women of reproductive age as pregnancy, childbirth and puerperium, accounting for 20
percent of all deaths in this group. Postpartum haemorrhage accounted for 43 percent of all
maternal deaths, obstructed labour 16 percent, eclampsia 14 percent and sepsis 11 percent. In
Nepal, most women deliver at home, and only 9 percent are attended by a skilled health worker.
The estimated maternal mortality rate in 1996 was 539 per 100,000 live births.

Access to basic health services for the population has steadily increased during the last decade.
According to the Ministry of Health (MOH)‟s 1998/99 Annual Report, the national health service
system comprises 74 hospitals, 137 primary health care centers, 747 health posts and 3,195
sub-health posts. Primary health care services are provided by an estimated 46,000 Female
Community Health Volunteers (FCHVs) through 13,500 primary health care outreach sites.
Primary health care centres, staffed by a doctor, are coming up in each of the 205 electoral
constituencies.

Specific child survival interventions, particularly National Immunizations Days (NIDs) for polio
and vitamin A distribution, the control of diarrhoeal diseases and acute respiratory infections
(ARI), have helped to significantly reduce child mortality and morbidity during the 1990s. While
proper oral rehydration therapy is not widely practiced, over 90 percent of all mothers know
about oral rehydration salts. Mortality rates among children suffering from ARI have been
significantly reduced through the mobilisation of FCHVs to administer antibiotics at the
community level. Community-based treatment of pneumonia is now available in 14 districts,
representing 28 percent of all children under 5 years of age.

The immunization programme for the six primary antigens were introduced in all 75 districts only
in 1989. In 1990, coverage, except for measles, had increased to 80 percent through the
Universal Child Immunization campaigns. However, the coverage level declined steadily in the
first half of the decade. From 1998, the overall coverage seems to have stabilized at 76 percent.

Although Nepal joined the global polio eradication initiative only in 1996, experts believe it is on
track to eradicate polio by 2005. This was demonstrated by the fact that WHO advised the
Government to conduct only two NID rounds in 2000, contrary to the MOH‟s plan for three.




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A large number of child deaths in Nepal is caused by vaccine-preventable diseases.
Immunization coverage could be further increased. Currently, due to incomplete reporting of
cases and inaccurate reporting of coverage, there is a tendency to overestimate 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 that
provides a long-term vision and operational strategies. The revised strategy focusses on
increasing access to services, improving the quality of services, promoting safe injection
practices, adopting a high risk area approach for neonatal tetanus elimination, exploring the
introduction of new vaccines, and decentralized planning and community partnership in the
management of immunization sessions.

Total public expenditure on health care remains low in Nepal. Per capita public health spending
increased from only US$1.5 in 1991/1992 to US$ 2.3 in 1996/97. If health spending in 1991/92
accounted for 3.5 percent of the total public expenditure, it increased to 5.4 percent in 1996/97.
But, according to World Bank figures, budget allocations to primary health care decreased from
76.8 percent in 1991/92 to 57.2 percent in 1997/98. On the other hand, allocations to hospitals
increased from 14.6 percent to 37.5 percent during the same period.

Private sector spending on health care is significantly high in Nepal. With total per capita annual
health spending estimated at US$ 10.50, private out-of-pocket spending accounts for US$ 7.40
and government spending US$ 1.7 per capita (1995/96).

Although the prevalence of HIV/AIDS is still relatively low in Nepal, indications are that the
disease has rapidly spread among high-risk groups, threatening to spread to the general public.
Twenty percent of female sex workers tested in Kathmandu are HIV positive. As are 50 half of
of all injecting drug users in the capital. Other high-risk groups include migrant workers,
transport workers and their spouses, as well as children who are trafficked. According to
UNAIDS, in 1999, about 34,000 people were living with HIV/AIDS, and 2,500 people are
estimated to have died of AIDS.

Access to water supply has been increasing steadily in Nepal over the past decade. The
progress in the rural areas is more dramatic, where surveys found that coverage nearly doubled
from 43 percent in 1991 to 78 percent in 2000. The increase in coverage is attributable to the
increasing number of water supply schemes executed by NGOs, local government bodies and
the communities themselves. In urban areas, however, it appears that water supply coverage
has not been able to keep pace with the rapid population growth.

The most recent survey suggests that Nepal is close to achieving the goal of universal access to
water. However, the country still faces the enormous challenge of ensuring sufficient quantities
of water on a regular basis. According to the survey, a quarter of the households in Kathmandu
Valley, the largest urban centre, reported insufficient and/or unreliable supply of water. Water
quality is also an issue of concern, given the serious outbreaks of water-borne diseases year
after year.

On the other hand, access to sanitary excreta disposal remains low, at 29 percent, which is a
mere 13 percentage point increase over 1991 levels. Access is also uneven between urban
(75%) and rural households (27%). Unlike drinking water, there is relatively less popular
demand for sanitation facilities.



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The low sanitation coverage and slow progress is all the more disconcerting since the majority
of ailments, such as worm infestation, diarrhoea, dysentery and gastritis, are attributable to poor
sanitation. Among children, diarrhoea is the second leading cause of death, accounting for more
than 38,000 child deaths each year. Poor sanitation and frequent episodes of diarrhoea also
affect nutritional status. Worm infestation is another symptom found among children and women
in Nepal. A study has found1 that three quarters of school children are infested with hookworm,
which also causes iron deficiency among pregnant women.

c. to overcome malnutrition, including by ensuring household food security and by
developing strategies that include employment and income-generating opportunities;
dissemination of knowledge; and support to increased food production and distribution.

There has been only a slight reduction in the overall child malnutrition rates in Nepal in the last
23 years. Hence, half of all young children still suffer from malnutrition. From 65 percent in
1975, stunting prevalence in children aged 6-36 months decreased to 50 percent in 1998. This
means an average annual reduction of 0.6 percent, which for the 1990s is an overall reduction
of only 6 percent, far below the 50 percent reduction goal.

The improvements seen in child nutrition are more likely a result of general improvements in the
socio-economic factors, such as GNP, infrastructure and health services, than a result of
concerted efforts to reduce malnutrition. In fact, there have been limited efforts in the last
decade to reduce child malnutrition. Until very recently, growth monitoring in a health facility was
the Government‟s central programme aimed at reducing malnutrition.

One of the constraints to improving child malnutrition in Nepal is the deep-rooted belief that
malnutrition cannot be reduced in a country as poor as Nepal with the present low levels of
income and food production. Unfortunately though, increased food production has not led to
significant reductions in child malnutrition. This is partly because increased food production has
been offset by rapid population growth. More importantly though, increased food production
does not improve the most important cause of child malnutrition - inadequate care as a result of
the mother‟s heavy work burden.

The past few years have shown that community level involvement is the key to drastically
reducing child malnutrition in Nepal. In just two years of its implementation, the Decentralized
Planning for the Child Programme (DPCP) has halved malnutrition in many communities. The
DPCP was implemented in 1998 by the Ministry of Local Development and district level
authorities in seven districts with the goal of improving child survival, growth and development
through community level discussions on ways to improve child care. The positive deviance
model, being successfully implemented by a number of INGOs and NGOs, is also implemented
at the community level to reinforce good feeding and care practices.

As for micronutrient malnutrition, significant achievements have been seen in Nepal during the
1990s. The goal for vitamin A has been reached: about 90 percent of the children receive high
dose supplements twice a year, and clinical deficiency has decreased to levels that are of no
public health significance. Some 90 percent of the households use iodized salt, with nearly two
thirds of households using adequately iodized salt. With median urinary iodine excretion levels
above 100 µg/l for both school children and women, Nepal is also close to eliminating iodine
deficiency disorders (IDD).


1
    Quoted in Sanitation Report 99/00, p 45.


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On the other hand, anaemia remains a significant problem, and there has been little, if any,
improvement during the 1990s. This is not surprising. Unlike vitamin A and IDD, anaemia
cannot, at present, be addressed through national level interventions. There is no fortification
vehicle to be used, as for iodine. Neither is it possible to provide iron a few times a year, as for
vitamin A. On the contrary, anaemia prevention requires daily care, in the same way that
general malnutrition requires daily care.

However, it is possible to reduce anaemia through community level action. An operational study
conducted in Nepal in 1998 showed that the percentage of pregnant women accepting iron
supplements increased from about 10 percent to more than 50 percent in less than a year. This
drastic improvement was caused by three main factors: the pregnant women understood better
the importance of the supplements; a support structure existed to encourage the women to take
the supplement; and the supplements were more readily available. These lessons are being
translated into action in the DPCP with very promising results. In some communities virtually all
pregnant women take iron supplements daily.

d. to enhance the status of girls and women and ensure their full access to health,
   nutrition, education, training, credit extension, family planning, pre-natal, delivery,
   referral and other basic services.

Nepal has a patriarchal society that is prevalent in most castes and ethnic groups.
Discrimination against women is widespread and pervades all spheres of life. It begins from the
birth of a child, with sons clearly being preferred to daughters. Girls are seen as a financial
burden on the family, requiring a dowry to be eligible for marriage in some communities.
Daughters are considered to contribute little to their family of birth, as ultimately they will
become a member of their husband‟s household. Household workloads assumed by children
are unequally shared to the detriment of girls. Girls are taught from early childhood that they
should be less visible, less mobile and always subordinate to male relatives.

Women have very little decision-making powers, having to refer relatively simple matters
concerning the family to their husbands or other members of his family, even regarding their
own health, fertility and income. Much of their work, which far exceeds that done by men, is
unrecognized and undervalued. Even when they must assume responsibility of the household -
while their husbands and other male family members are away as migrant workers - they are
not recognized as head of the household. They take very little part in public life: there are only
three Village Development Committees (VDCs), out of 3,914 VDCs throughout Nepal, with a
woman as chairperson. While Nepal has had a woman Deputy Prime Minister, at present, no
women hold cabinet rank, although there is one woman Minister of State.

Nepal thus scores very low in UNDP‟s gender-related development index (GDI): 0.449,
compared to 0.542, the average for South Asian countries, and 0.634, the average for
developing countries2. In the gender empowerment measure (GEM), it stands at 0.191,
compared to the global average of 0.418. In South Asia, only Pakistan has a lower score3.

At the Beijing Fourth World Conference on Women in 1995, Nepal made six commitments to
advance the status of women, which strongly reflected several of the most important articles
mentioned in the Convention on the Elimination of all forms of Discrimination Against Women
(CEDAW). They include integrating women‟s concerns in all policy frameworks, reviewing legal

2
    UNDP Human Development Report 2000.
3
    Nepal Human Development Report 1998.


                                                                                                  9
provisions relating to violence against women, prioritizing initiatives at assisting impoverished
women, improving the health and educational status of women, and to plan and implement
development programmes within gender frameworks. Recently, discussions have been initiated
to amend the bills on abortion and property rights to eliminate the discriminatory practices
against women.

Health: Despite the expansion of the health system over the years down to village level, the
general health status of women remains low. In 1996, life expectancy for women was found to
be 53.5 years, as opposed to 55 years for men. Only in few countries do women have a lower
life expectancy than men.

Women‟s access to health services is highly limited due to the existing social norms that restrict
her mobility. Either the health facility is too far away, or she is unable to leave her household
and other chores, or her treatment is considered unimportant. These norms equally affect girls
in the family, for whom health care is sought less frequently than for boys. Also women have
severe difficulties in discussing reproductive and other health issues with the male staff, who
predominate in health institutions.

As evidence of this, currently only 40 percent of women receive any antenatal care, though this
is up from 15 percent in 1991. Almost all deliveries take place at home, with only 9 percent of
deliveries assisted by a skilled birth attendant, resulting in one of the highest maternal mortality
ratios in the world: 539 per 100,000 live births.

Knowledge on family planning among married women is almost universal, but only 37 percent
currently use contraceptives due to both supply-side and access constraints. Sterilization is the
most commonly used method, which means that contraception is used to limit, rather than
space, births. Their knowledge of HIV/AIDS on the other hand is little, leaving them vulnerable
to contracting HIV, particularly in areas with high male migration.

Nutrition: In Nepalese households, women eat last and least, and girls are systematically fed
less than boys. Almost all children in Nepal suffer from both protein-energy malnutrition and
micronutrient deficiencies.

The high level of iron deficiency anaemia among women in the reproductive age group (67
percent) is alarming, and this figure rises to 75 percent among pregnant women. Although extra
nutrition and rest should be available to women in pregnancy, they are not generally seen as
necessary. This results in additional risk to the women during pregnancy and childbirth, and in
the high incidence of children born with low birth weight.

Education: Enrolment of girls in primary school has more than doubled since 1991. However,
disparities still remain with the girl:boy ratio still standing at 40:60. Participation of girls in school
decreases as they get older with lower enrolment and girl:boy ratios in secondary and higher
education. Schools also are not sensitive to the particular needs of girls, including separate
bathroom facilities for girls who have attained puberty. The vast majority of teachers are men,
which increases the concerns of parents about sending their daughters to school. One
presumes also that gender-biased treatment in interactions between teachers and students is
as prevalent as it is between parents and children. Women‟s literacy rate is only half that of
women, greatly limiting women‟s access to information, training and more gainful areas of
employment.




                                                                                                       10
Economic activities: Economic activities for women still tend to have low added value. For
instance, women are socially permitted to involve themselves in raising buffaloes, but
commercialization of their milk is the exclusive preserve of men. However, for the first time, the
upcoming census is taking into account the work done by women, an acknowledgement that
their work has economic value.

The Production Credit for Rural Women and other micro-credit projects for women now cover all
75 districts, though the coverage of VDCs within districts is limited. Credit is provided on a group
liability basis and complemented by skill training, exchange visits and literacy programmes.
While micro-credit programmes have reported successes, their sustainability is constrained by a
reluctance of commercial banks to extend their facilities to poor women.

e. To ensure support for parents and other care-givers in nurturing and caring for
children; To prevent separation of children from their families and, where such
separation takes place, to ensure appropriate alternative family care and institutional
placement.

Although Nepalese laws do not require the state to provide any financial assistance to parents
and guardians of children under any circumstances, different acts enacted in the past ten years
have included provisions for child care services and facilities:

   The Labour Act requires a company with 50 or more employees to provide a day care centre
    with toys and a caregiver for children of employees. Women employees must be given
    adequate time to breastfeed their children.

   The Local Self-Governance Act stipulates that VDCs have the responsibility of carrying out
    programmes for the benefit and welfare of children and women in their area. About 25
    percent of the VDC budget is expected to be allocated to social development.

   The Children's Act has provisions for District Child Welfare Committees (DCWC) to
    encourage the development of child care facilities and services at the community and village
    levels, alongside local NGOs.

Despite these provisions in the acts, much remains to be done to translate them into action. For
instance, only over half of the 75 DCWCs are believed to be functioning, and the majority are
said to be unclear about their role and responsibility.

In Nepal, there is still low awareness among both policy makers and families in Nepal about the
importance of proper care during the crucial early years of children, so necessary for their
holistic development. Much can be done at the family level, as a recent study on child rearing
and caring practices in certain ethnic groups attest.

To improve child care in the household, non-formal parenting education for caregivers is being
conducted in 12 districts. The participatory, discussion-based course helps parents and parents-
to-be to understand how they can improve child care in their family. The course covers topics as
diverse as feeding practices, sanitation, birth registration, immunization, etc..

Nepal offers limited specialized health services for children, apart from the provision of free
basic medical services. The Kanti Children‟s Hospital in Kathmandu is the largest of its kind
and provides a wide range of specialized pediatric services. However, services to address the
special needs of children with disabilities are limited in Nepal. According to a situation analysis


                                                                                                 11
of disabilities conducted in 2000, 1 percent of children under 15 years were found to be severely
disabled.

In principle, Nepalese legislation does not allow a child to be separated from his/her parents
against his/her will. Separation is possible under the following circumstances:
 When competent authorities deem a separation necessary in the best interest of the child;
 When the child is abused or neglected by the parent/s;
 When a marriage dissolves, resulting in the child‟s separation. In this case, the child living
    with one parent has the right to spend time and visit the other parent. If this cannot be
    amicably settled between the parents, the court will decide.

A woman in jail can keep her child until he or she reaches two years of age. There are currently
about 100 children living with their parents or guardians in jail. Even when the child is not living
with the parents, he or she has the right to visit them in prison. Adopted children have the right
to maintain contact with his/her natural family.

The Children‟s Act provides for the establishment and operation of Children‟s Welfare Homes
for orphans, unattended and abandoned children. However, due to lack of a budget, the Welfare
Homes have not yet been established. NGOs operate various types of living arrangements such
as homes for orphans and unattended children, rehabilitation centres for working, trafficked,
abandoned and street children and institutions for education or vocational training.

Most children living outside the family environment do not have access to protection, services
and facilities. The most visible of them are the street children who are estimated to number
about 5,000 in 2000. There are some centres for street children which provide non-formal
education as well as rehabilitation.

f. To ensure priority for early childhood development; universal access to basic
education; reduction of adult illiteracy, vocational training and preparation for work; and
increased acquisition of knowledge, skills and values through all available channels.

The Basic and Primary Education Project (BPEP) launched in 1992 tried to address the high
rate of dropouts and students repeating Grade One due to the enrolment of underage children
accompanying elder siblings. Based on research findings that early intervention on children
make a lasting impact on their development, especially in completing the first years of primary
school, pre-primary classes were started to provide children aged 3 to five years age-
appropriate education in a child development centre. By 2000, BPEP was running
approximately 1,900 child development centres, mostly in the rural areas. The success of these
centers lies in training care givers and in raising community awareness and support. NGOs are
also active in this field, implementing another 1,000 such centres. Individuals or private groups
run pre-primary schools, Montessori schools, nurseries, kindergartens and day care centres
mostly in the urban and semi-urban areas. There are also community based child care centres.

Since the global initiative of Education for All in 1990, there has been a visible impact on the
development of primary education in Nepal. By 1997, a primary school was within a 45-minute
walk for 65 percent of the children. The net enrollment of girls in primary school has been
growing at a fast rate, to more than double in 1999 - 64 percent according to the Ministry of
Education - from a 31 percent low in 1990.

The Government spends about 13 percent of its budget on this sector, half of it going to primary
and basic education. Primary education, including textbooks, is free, while girls and


                                                                                                 12
disadvantaged groups are provided incentives. To encourage girls' enrolment, it is now
mandatory for every primary school to have at least one female teacher. The Primary School
Food Programme, supported by WFP, has been launched in 12 food deficit districts where
enrolment of girls is below the national average. In addition, girls and children from
underprivileged communities in 18 pilot districts are provided cash and school uniforms by the
Government.

The BPEP was launched in 1992 to improve access, improve quality of instruction and
supervise primary education in 40 districts. The Project has evolved into a Programme and has
been extended throughout the 75 districts of Nepal to improve access, retention and learning
achievement. UNICEF has been an active partner throughout the decade in the multi-donor
BPEP. The current BPEP is a Sector Investment Plan, supported jointly by 5 major donors using
a 'basket' approach to funding. While not in the 'basket', UNICEF support for technical
assistance is considered a key element in teacher training, monitoring, early child development
and in maintaining donor and HMG/N relations and coordination.

Despite these efforts, however, the end decade review shows that net primary school enrolment
is just 66 percent in 2000. Gross enrolment in primary school is over 120 percent, creating one
of the largest gaps between Net and Gross enrolment in the world. Dropout and repetition rates
are high. As a result, only 45 percent of the children enrolled in Class One reach Class Five.
Learning achievement is also very discouraging, largely because teachers are not adequately
trained and are poorly motivated. Less than 50 percent of primary school teachers have had
basic teacher training. The failing physical infrastructure in the school is equally to blame.
Overcrowding is a problem in Class One where enrolment of underage children is estimated at
20 percent.

BPEP has also failed to close the gender disparity seen in the net enrolment of girls and boys in
primary school, with girls lagging some 20 percentage points behind the boys.

Non-formal education (NFE) is seen by HMG/N as one of the keys to improving Nepal's adult
literacy rate, which is estimated at just a little over 50 percent in 2000. In 1992, the Ministry of
Education adopted a strategy to integrate literacy with village development programmes to
eradicate illiteracy within a certain time frame. Priorities have been given especially to
programmes that address illiterate women through community health volunteers and mothers‟
clubs. The Chelibeti programme targets girls 8-14 years, while Women‟s Education under BPEP
focusses on women in the age group 18-35.

Both NGOs and the Government have been conducting non-formal literacy classes of various
duration, ranging from three to nine months, for both adults and out of school children in the 10-
14 age group, with little measurable impact. The Central Bureau of Statistics estimates there are
two million illiterates among the children of 10-14 years, or about 34 per cent of the total
children‟s population in this age group.

Inability to halve the 1990 adult illiteracy rate (60%) by 2000 shows a shortcoming on the
approach and a lack of resources. Unless women are educated, they are unlikely to see the
importance of learning for their children, especially their daughters. Currently, women's literacy
rate is just 35 percent, about half the male literacy levels.

For a limited number of young adults entering the job market, vocational training is provided by
the Council for Technical Education and Vocational Training (CTEVT) through 13 technical
schools and affiliated training institutions as well as by the different ministries. NGOs as well as


                                                                                                 13
the private sector are equally active in providing skill training. However, most of the vocational
schools lack the necessary infrastructure, qualified teachers and adequate instructional
materials. Unfortunately, the chances of finding employment after training remains low, with
over 80 percent of the country still engaged in agrarian work.

Given Nepal's difficult topography, the most effective means of promoting distance and media
education has been the radio. To this end, state-run Radio Nepal have been very active
nationally, broadcasting programs for children, as well as interactive radio instruction for early
childhood development and teacher training. Private radio stations are increasing in recent
years and are limited to semi-urban areas. Nepal Television's tele-serials 'Devi' and "Chetana'
were very effective in conveying messages on discrimination, community and family
responsibility, participation and health care concerns. Carrying similar themes, the Meena
cartoon series are being promoted through the radio, video, TV and posters.

g. To ensure special attention to children living under especially difficult circumstances;
including by ending their exploitation through labour; and by combating drug, tobacco,
and alcohol abuse among young people.

Nepal has ratified a series of international instruments specifically concerning child labour and
child trafficking. The International Program on Elimination of Child Labour (ILO-IPEC) was
started in Nepal in 1995. A year later, Nepal signed the Stockholm Declaration against
Commercial Sexual Exploitation of Children. The Amsterdam Declaration on Child Labour and
the Oslo Declaration on Child Labour were both signed in 1997. Also that year, it ratified ILO
Convention 138 on the minimum age for employment. And in June 1999, it adopted Convention
182 on the worst form of child labour, including trafficking. All these international instruments
oblige Nepal to address seriously the issue of child labour.

In September 2000, Nepal also signed the Optional Protocols to the Convention on the Rights of
the Child on the involvement of children in armed conflict and on the sale of children, child
prostitution and child pornography.

It is along the spirit of these instruments that Nepalese laws and acts have been formulated.
The Constitution of Nepal forbids the engagement of minors in a factory, mine or in a dangerous
workplace. The Children's Act prohibits the employment of children below 14 years in
manufacturing industries. It also provides for protective and safety measures for children aged
14-18 years. The Act also requires employers to send photographs and particulars of all child
labourers to the District Child Welfare Committee (DCWC).

Despite these laws to protect the child, controlling and preventing child labour are difficult in
Nepal since children work to supplement the family income. The Nepal Labour Force Survey of
1998/99 found that over 40 percent of all children 5-14 years, or 1.987 million children, were
currently economically active. More girls work than boys and the proportion of working children
in the rural areas is greater than in the urban areas.

A dearth of alternatives for child labourers is hindering progress in this field, as has been the
case with the thousands of child bonded labourers who were freed together with their parents in
July 2000. Although their emancipation was a progressive step, without adequate arable land to
feed the family, it will be difficult for the ex-Kamaiyas to be economically viable.

There are many NGOs working with children in especially difficult circumstances such as street
children and child workers in carpet factories. However, given the sheer number of such


                                                                                               14
children requiring rehabilitation, the actual number that has benefitted from NGO assistance is
relatively small.

Girl trafficking: Another issue of concern is girl trafficking, which continues unabated despite
efforts by the Government, NGOs and the police. While the actual number of girls sold to Indian
brothels is not known, some estimates place the figure at about 5,000-7,000 annually. The
market has now extended to Hong Kong, Japan, Korea and the Arab world. In one instance,
NGOs succeeded in repatriating 128 minors from Mumbai, India in July 1996. The rescued girls
are being rehabilitated in different NGO-run centres. Activities to prevent girl trafficking include
community mobilization and peer counseling through child clubs and women‟s groups.

In 2000, ILO-IPEC launched a 2-year programme to combat child trafficking for exploitive
purposes. The programme will initially benefit 2,000 families and about 400 children who have
been rescued from exploitive situations, in addition to strengthening the national institutions in
combating trafficking of children.

Drug abuse: Drug abuse among young people may be a relatively new phenomenon in Nepal,
but it is a growing problem. As of early 1999, there were an estimated 50,000 drug users in the
country, half of whom were in the 16-25 age group. With hard drugs becoming more easily
available in Nepal, there has been a rise in intravenous drug addiction. There are today about
20,000 injecting drug users (IDUs) in the country.

With HIV/AIDS now a growing problem in Nepal, increasing intravenous drug use amongst
young people is raising concern. Half of all IDUs in Kathmandu, according to the National
Centre for AIDS and STD Control, test HIV positive.

NGOs run a number of treatment and rehabilitation centres, but they are mostly concentrated in
the capital. As a preventive measure, NGOs and the Government have been creating
awareness about the issue through the media.

To discourage the use of tobacco and alcohol, the Government in 2000 banned all
advertisements of cigarettes and alcohol on radio and television, and has plans to do so in the
print media as well.

h. to ensure special protection of children in armed conflict and to build a foundation for
a peaceful world by promoting the values of peace, tolerance, understanding and
dialogue.

Under the 1962 Royal Army Recruitment Rules, anyone under 18 is not eligible to join the Royal
Nepalese Army, although Nepalese can enlist for military training from the age of 15. For
Nepalese youths from the hills, joining the British and Indian armies is a lucrative prospect,
considering the limited job opportunities available in Nepal.

The Maoist insurgency that started in 1996 has, to date, claimed more than 1,500 lives, and
injured many others. There are reports that Maoists have been recruiting children and youth into
their movement. Detailed information of the situation and the number of children involved,
however, is not available. Although the insurgency originated in Nepal‟s western and mid-
western regions, an increasing number of districts are being affected by disruptions and
insecurity. Development activities have been adversely affected in some areas.




                                                                                                 15
Refugee children: There are more than 100,000 Bhutanese refugees of ethnic Nepalese origin
living in UNHCR-administered camps in east Nepal for the past 10 years. While talks continue
about repatriation, the Government has been providing food, education, health and other
services to the refugees. A number of NGOs and INGOs such as the Save the Children UK,
World Lutheran Service and Oxfam as well as UN bodies have been assisting in this endeavour.

i. to prevent the degradation of the environment by pursuing the World Summit goals, by
inculcating respect for the natural environment, and by changing wasteful consumption
patterns.

The decade following the restoration of democracy in Nepal in 1990 saw a number of positive
initiatives to address environmental concerns, although most of them lack the crucial aspect that
shows results – enforcement. The lobbying by environmentalists contributed to a state directive
on the environment being included in the democratic new Constitution framed in 1990. That
year, a high-level council to handle environmental issues was also created at NPC.

If the establishment in 1993 of the Environmental Protection Council under the chairmanship of
the Prime Minister was a notable event, the creation in 1995 of a Ministry of Population and
Environment was an even bigger milestone. On the legislative side, the Environment Protection
Act and Regulations, effective for the past three years, requires certain categories of industries
to conduct an Environmental Impact Assessment (EIA) before the project can be approved.

Since the mid-90s, measures have been taken to tackle Kathmandu valley‟s growing air
pollution. Vehicular emission standards were fixed in 1994. All vehicles failing the test are
refused entry on selected routes in the capital. In 1999, polluting three wheelers were banned
from the valley. Since then there has been a visible increase in the number of indigenously
manufactured electric vehicles. Since January 1999, all imported vehicles must meet Nepal
Emission Standards for vehicular emission. More recently, an announcement has been made to
ban vehicles older than 20 years from the valley.

The Government also announced plastic bags had to be of a certain thickness, to discourage
their haphazard use and the resultant implications on solid waste disposal. However, a solution
to Kathmandu‟s waste management problem remains elusive. Despite all these measures to
check environmental degradation, enforcement has been weak.

The „90s saw a growing environmental NGO movement, with many NGOs acting as pressure
groups. The Government is working closely with the NGOs and has set up an Environment
Support Fund to assist NGOs to take up projects related to natural resource management and
other activities.

As environmental issues become more and more complex, the need for specialized human
resources in different fields is being felt. In response to the situation, educational institutions
have introduced environment subjects in their curricula.

The restoration of democracy in 1990 has given the much needed impetus to people‟s
participation at all levels, including in the management of resources. The Forest Act 1993 and
Forest Regulations 1995 have given local communities, comprising a million people, the right to
make management decisions over some 632,000 hectares of forests.




                                                                                                16
j. to address poverty and debt; mobilize development finance; halt the net transfer of
resources from developing to developed countries; establish an equitable trading
system; and ensure children are given priority in economic and social development.

Despite more than four decades of planned development efforts, poverty in Nepal is high,
pervasive and deep-rooted. In 1996, the Nepal Living Standard Survey and the NPC estimated
the incidence of poverty at 42 percent, up from 31.5 percent in 1977. Over half of its 22 million
people live on less than one dollar a day. The incidence of poverty is greater in the remote rural
areas and among the lower castes and ethnic minorities.

Some would argue that poverty in Nepal is a direct result of the growing debt burden. The
country‟s total outstanding loans in US dollar terms grew by a third from US$ 2 billion in 1990 to
US$ 3 billion in 1998. Rupee-wise, it jumped three-fold, from Rs. 74 billion in 1990 to Rs. 208
billion in 1998.

The quantum leap is attributed to the depreciation of the Nepalese currency by more than 50
percent between 1990 and 1997, and a further depreciation by 29.6 percent under the impact of
the Asian currency crisis. As a percentage of GDP, Nepal‟s total outstanding loans hovered at
around 63 percent during the „90s, with foreign debts accounting for 50 percent. Based on 1998
figures, every man, woman and child in Nepal carries a debt burden of Rs 7,772 (US$ 113).
Total debt-servicing already claims 13-14 percent of the total budget.

Economic reforms initiated in the 90s have generated substantial amounts of surplus revenue to
finance the development expenditure, which accounted for 24 percent in 1999. The yield,
however, is still low. This, compounded by a growing debt servicing burden and swelling
administrative expenses have increased Nepal‟s dependence on foreign aid - from 52 percent in
1990 to 57 percent in 1998. At the same time, the contribution of grants has declined from more
than 35 percent in 1993 to less than 26 percent in 1998.

While servicing foreign debts, we see a significant proportion of capital transfer to the donor
community. In 1999, US$ 95.8 million was set aside to service foreign loans, which is 9 percent
of the total government expenditure. The amount is equivalent to a quarter of the US$ 394.6
million Nepal received in aid under the development budget.

Against this backdrop, there is a need to halt the transfer of resources from the country. It is
understood that most bilateral donors have already cancelled Nepal‟s debts. In a welcome step,
the World Bank and the IMF have launched the Initiative for Heavily Indebted Poor countries
(HIPC) to reduce overall poverty. At the Annual Meeting of the World Bank-IMF in 1999, Nepal‟s
Minister of Finance, Mahesh Acharya, had appealed for the wider inclusion of poor countries
like Nepal under this initiative. He again raised this issue in 2000 at the Joint Annual Discussion
of the World Bank and IMF held in Prague.

Since the adoption of an open market economy at the beginning of this decade, Nepal‟s total
trade turnover has grown significantly, from US$ 0.83 billion in 1990 to US$ 2.32 billion. India is
Nepal‟s principal trading partner, accounting for 36 percent of the total trade. The export-import
ratio also improved from 28 percent in 1990 to 41 percent in 1999. Although Nepal has enough
foreign exchange reserves to sustain imports for over 10 months, the country must maintain
huge amounts of foreign exchange reserves for the amortization of foreign loans, repatriation on
foreign investments and to attract foreign capital. This, however, is not possible without
diversifying the export trade.



                                                                                                17
Nepal is banking on the South Asia Free Trade Agreement (SAFTA) to boost exports. SAFTA is
expected to relax tariffs and non-tariff barriers among the seven South Asian member countries,
facilitating trade as well as social development.

Nepal‟s entry into the 139-member World Trade Organization (WTO) by 2001 is also expected
to open up opportunities for exports and speed up global integration of the Nepalese economy.
But there are fears Nepal‟s principal exports, garments and carpets, will not be able to compete
once the WTO regime sets in. In a bid to boost efficiency and increase exports, the Government
has been privatising state-owned enterprises and wooing foreign investments. But political and
economic instability in the country is holding back foreign investment.

Since the launch of the Eighth Plan in 1992, high priority has been given to the survival,
protection and development of children. As a result, government spending on the basic social
services increased three fold, from NRs. 3.5 billion (US$ 82 million) to NRs 10.9 billion (US$
159 million) between 1992/93 and 1999/2000. The development outlay on the social sector, the
activities that directly address problems of social development and poverty, has also been
raised significantly from 29.5 percent in the Seventh Plan (1985-90) to 31.5 percent in the Eight
Plan and 33.3 percent of the total development outlay in the Ninth Plan (1992-97). Nearly two-
thirds of the social sector expenditure in 1999 was spent on basic social services, that include
basic education, basic health and low-cost water supply and sanitation.


E. Lessons Learned

In Nepal, the beginning of the decade coincided with the restoration of multi-party democracy.
Since then, the country has been experiencing difficulties in adjusting to the new political
system. Political instability due to the frequent change of governments has not been conducive
to national development. However, democracy is beginning to bear fruit with greater
participation and contributions from the civil society, including NGOs, the media, children and
youths in the national development process.

The 1990s were also marked by fluctuating macroeconomic stability. GDP fluctuated widely,
and the fiscal deficit remained high, despite the Government‟s commitment to mobilize
additional revenue. Nepal‟s dependence on foreign aid to finance the development budget, its
limited absorptive capacity and the large debt burden have not enabled the allocation of
necessary resources for the basic social sector.

Slow progress in reducing poverty can also be traced to weaknesses in controlling population
growth, which at present is growing at 2.4 percent. The rapid population growth has largely
dwarfed the achievements made, particularly in the social sector.

Starting with the Constitution, Nepal has seen many positive changes in its laws. However, the
promulgation of laws and regulations has not necessarily resulted in the realization of women
and child rights in Nepal. Enforcement of these laws is equally important. Efforts are also
required to ensure that there is consistency between the related laws and regulations, and in
their implementation.

Widespread gender and caste discrimination impact social, political and economic development.
Women have very little powers of decision making, even on matters relating to their own health,
fertility and income. While there has been progress in some areas, as in the growing number of
girls enrolling in primary schools, these ingrained patterns are often slow to change.


                                                                                              18
Most indicators show similar patterns of disparities across regions, castes and ethnic groups.
These disparities, if not addressed, will continue to reinforce the cycle of poverty and
discrimination in future generations.

The decentralization process, promoted through the Local Self Governance Act (1999), is a very
positive development. However, it can be made more effective through a systematic delegation
of financial and administrative authority to the districts. A coordinated effort among the central
and local governments will be the key factor to ensure the effective implementation of the Act.

Community mobilization has proved to be an effective strategy in the success of the vitamin A
supplementation programme and the national campaign on polio eradication. Notably the
contribution of the Female Community Health Volunteers has been acknowledged by the health
sector. Similarly, the strategy to promote community ownership of rural water supply schemes
and forestry suggests great potential. The success of the programmes employing community
mobilization strategies will provide valuable lessons for other development activities.

Many NGOs have been providing a valuable service to promote the rights of the children and
women, particularly in the area of child protection. At the same time, their concentration in
mostly urban centres is hampering efforts to reach out to the more disadvantaged children and
women in the rural areas. A better coordination between the Government and the NGO sectors
would also enhance the effectiveness of both sectors.

The growing Maoist insurgency during the mid-90‟s in the country threatens the country‟s peace
and security, so vital for social and economic development. The conflict has affected the
delivery of basic social services in the some areas. Children are at additional risk of being
victims of the insurgency. The increased government spending on internal security could further
squeeze the development budget for basic social services.


F. Future Action

Since the restoration of democracy in 1990, people have become increasingly conscious about
their right to participate in the nation‟s development. They have become more organized and
are voicing demands for development and social justice. They are exercising their right to
dissent by publicly protesting against development strategies that are antiquated and ineffective,
which should be taken positively.

These democratic exercises have provided opportunities to correct shortcomings and lapses.
However, fulfilling children and women‟s rights in Nepal is still an unfinished agenda. In the
context of realizing them, the following plans and programmes will serve as a basic guide for the
future course of action:

1. The Ninth Plan (1997-2002) has a long-term vision of reducing the proportion of people living
below the poverty line to 32 percent by the end of the plan period and to 10 percent by 2017. As
part of the plan, long-term strategies for the child and a plan of action will be developed.

2. The Government‟s commitment to poverty alleviation is reflected in the comprehensive reform
agenda presented at the National Development Forum held in Paris in April 2000. It proposes a
three-pronged strategy:



                                                                                               19
 Creation of more opportunities and access to productive assets for the poor by fostering an
  environment that promotes growth, employment and income;
 Ensuring effective delivery of basic goods and services like education, health and drinking
  water to the poor;
 Designing and implementation of programmes for the development of special areas, regions
  and targetted social groups.

3. A Poverty Alleviation Fund (PAF) has been created with the aim of generating resources and
enhancing institutional capabilities to directly facilitate poverty alleviation programmes. Donor
funding is expected for the PAF that will be utilized to integrate and coordinate all poverty
alleviation programmes.

4. The Government has issued a foreign aid policy to ensure that donor support is consistent
with the country‟s development priorities and national interest. This is expected to improve the
utilization of aid money. A national modality to execute the policy has been developed. It will see
that the donor community plays the role of facilitator and promoter rather than implementer.

5. The 20/20 initiative has been a declared government policy since 1996/97. However, Nepal‟s
spending on the basic social services does not yet conform to the internationally recommended
norm. Continued attention to allocating resources to the basic social services is needed, both by
Government and its development partners.

6. The public-private sector mix modality will be used to overcome financing as well as human
resources constraints in the social sector. Similarly, an effective government-NGO partnership
will do much to accelerate the progress on children and women‟s goals in the coming decade.
For example, in the field of health, private sector and NGOs could be allowed to practice in
government health institutions to improve service delivery in the health sector.

7. Efforts to devolve authority to the local government bodies under the Local Self-Governance
Act will continue in the Tenth Development Plan (2002-2007). A human resources development
plan will accompany the devolution process to ensure that local governments have the capacity
to deliver basic social services to the people. The plan will cover aspects related to institutional
development, plan preparation, information management and delivery of services. A
decentralized approach to child development should be adopted in line with the Decentralization
Act. District Child Welfare Committees must be strengthened to implement the CRC.

9. The Tenth National Development Plan will build on the lessons learned from the Eighth and
Ninth Plans. One of the key strategies, therefore, will be the promotion of community
participation in and ownership of development initiatives.

10. Consistent with the principle of the Constitution that guarantees basic human rights to all
Nepali citizens, Nepal is committed to the principle of non-discrimination. Addressing the
disparities based on gender, caste, ethnic group and geographical region will require a
concerted     effort   and      specific   attention    to    the    disadvantaged    groups.




                                                                                                 20
                                        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
(1992-1996) 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.
                Trends in Infant Mortality in Nepal (1969 -1994)              Findings
from                                                                            earlier
                     200
                                                                         surveys are
plotted                                                                  in the graph
below.               150

                        100

                            50

                            0
                                 1969     1974          1979   1984   1989   1994
                   NFS 1976       156      140
                   NFFS 1986                             90    103
`                                                       123    115     80
                                                                                                     1
                   NFHS 1991
                   NFHS 1996                                   127    108     79
To determine disparities in                                            U5MR by Place of Residence (1986-96)
IMR and U5MR, rates were
calculated for a 10-year                                       250


                                deaths per 1,000 live births
period to increase the                                                                   208
number of cases. The                                           200                                                                                           178 179
disparity pattern for IMR and                                                143.4                             139                       138
U5MR is the same, although                                     150                                      127
                                                                                                                           113                     119
they differ in the magnitude.
                                                               100 82.2
IMR and U5MR are higher in
rural areas than they are in
                                                                50
urban areas. Mortality rates                                                                                                                                                       in
the Mountains are much                                           0
higher than they are in the




                                                                                                                                                   Western
                                                                                                                               Eastern




                                                                                                                                                                        Far-West
                                                                                                                                         Central



                                                                                                                                                             Mid-West
                                                                                                        Hill

                                                                                                                Terai
                                                                              Rural
                                                                     Urban




Terai or the Hills. The Mid-                                                                 Mountain
Western and Far-Western
regions have the highest
mortality rates.

The IMR for boys is                                                           Mortality Rates by Sex (1986-96)
typically higher than that                                     200
for girls. However, the                                                      Boys       Girls
                                deaths per 1,000 live births




higher    rate    of  child                                                                                                                 142.8 135.5
                                                               150
mortality (between 1-4
years) is not biologically
                                                                             101.9
expected, and suggests                                         100                    83.7
discrimination against girls                                                                                                                                                       in
child rearing practices,                                                                                                56.5
                                                                                                               45.5
such as feeding patterns                                        50
and care seeking.

                                                                 0
                                                                                 IMR                    Child Mortality                            U5MR




Goal 2:       Reduction of maternal mortality rate




`                                                                                                                                                                                  2
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 Demographic
Health Surveys.4 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 children                                 Map 1: Stunting in
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

4
  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.         > 70 %
                                             60 - 69 %
                                                50 - 59 %
                                                40 - 49 %
`                                                                                                      3
variation both ecologically and regionally throughout Nepal. Stunting, underweight and wasting
are all more common in the mountain areas than in the Terai. As with many other socio-
economic indicators, there is also a marked geographical trend, with the rates for all three
indicators being particularly high in the Mid- and Far-West 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


differences in malnutrition between girls
and boys below five years. Some                               Figure 1: Indicators of malnutrition by age,
localised studies, however, have found                                    children 6-59 months
more malnutrition in girls.                                                                     (NMSS 1998)


                                                          70
Age of the child is an important factor in                60
the levels of malnutrition. There is a
                                             Percentage


                                                          50

dramatic increase in malnutrition, for all                40
                                                          30
indicators, between 6 months and 2                        20
years.       After the second year,                       10

underweight and wasting begin to                                0
                                                                         6-11 months 12-23 months 24-35 months 36-47 months 48-59 months
decrease. Stunting, however, continues                                               Stunting       Underweight       Wasting
to increase after the second year for
children in the Hills and Mountains.

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.

According to data from three national
level surveys having similar designs,                                   Figure 2: Prevalence of stunting; 6-36 months,
                                                                                    <-2 SD, Nepal 1975-98
there has been a slight improvement
in the status of children, 6-36 months                                 100

old, in Nepal when measured by                                         90
                                                                       80
stunting (height-for-age). There has                                   70
                                                                                                                            NFHS
been a 15 percentage point reduction                                                                                         1996
                                                          Prevalence




                                                                       60    NNSS
since 1975, from 65 percent to 50                                      50
                                                                             1975

                                                                                                                                    NMSS
percent (Figure 2). On average, the                                    40
                                                                                                                                     1998
                                                                       30
rate of reduction was 0.65 percentage                                  20
points per year, which translates into                                 10

a 6.5 percent reduction for the 1990s.                                  0
                                                                         1975        1980        1985         1990       1995           2000


The earliest national survey, the 1975
National Nutrition Status Survey (NNSS),


`                                                                                                                                              4
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.



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               Trends in Safe Water Supply Coverage
to drinking water – 90       100
percent in the urban
                              90
areas and 43 percent
                              80
in the rural areas.
                               70
                               60
In the 1990‟s, drinking
water            coverage    % 50
improved significantly,        40
especially in the rural        30
areas. According to the        20
BCHIMES survey, in             10
2000 coverage stands at         0
80 percent – 92 percent             1990   91   92   93   94   95   96     97    98    99    2000
in urban areas and 78                           Total     Urban          Rural        DWSS
percent in rural areas.




`                                                                                                   5
                                          Safe water supply coverage

NFHS 1991                            NFHS 1996                                    BCHIMES 2000

   Rural – 42.8%                        Rural – 61.4%                                   Rural – 78.1%
   Urban - 89.9%                        Urban- 84.7%                                    Urban- 92.3%
   National -45.9%                      National- 63.4%                                 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.

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 Proportion of population who have, within their dwelling compound :?

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



                                                              Trends in Sanitation Coverage

                                            100
                                             90
                                             80
                                             70
                                             60
                                          % 50
                                             40
                                             30
                                             20
                                             10
                                              0
`                                                 1990   91     92      93   94       95     96     97    98   99   2000   6

                                                                Total        Urban                Rural        DWSS
   Rural-16%                             Rural – 18%                           Rural – 27.1%
   Urban-69%                             Urban- 74%                            Urban- 74.7%
   National -20%                         National - 23%                        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 women, in water management and hygiene
    education;
 encouraging the participation of NGOs and voluntary and community-based organisations.

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 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            Proportion of children entering first grade of primary school
                                     who eventually reach grade 5
 Net primary school                  proportion of children of primary-school age enrolled in
enrolment ratio                      primary school
Net primary school                   Proportion of children of primary-school age attending
attendance rate                      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.


`                                                                                                                   7
Net Enrolment Rates (Source: NMIS Cycle 2, 1995)
         National    Urban     Rural        East      Central     West    MidWest    Far West
 Boy      79%         87%       78 %        75%        75%        89%       68%        80%
 Girl     59%         76%       57%         57%        53%        76%       37%        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.



Net Enrolment Rates (Source: Ministry of Education and Sports 1998)
              East          Central*       West         Mid West      Far West    Kathmandu
Total         71%             69%           78%           67%           62%          84%
Boy           78%             81%           82%           78%           75%          85%
Girl          64%             58%           74%           55%           49%          83%
*This figure does not include the Kathmandu Valley.

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



`                                                                                                 8
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.




`                                                                                                  9
Survival Rates Without Repetition*                                   Survival Rates With Repetition*
Year      Total    Female Male                                        Year      Total     Female Male
1994      30       30        30                                       1994      38        38         39
1995      31       31        31                                       1995      40        40         41
1996      32       32        31                                       1996      40        41         40
1997      34       35        33                                       1997      43        45         42
1998      34       35        33                                       1998      44        45         43
1999      35       37        34                                       1999      45        48         43
2000      36       38        35                                       2000      46        50         44
2001      37       40        35                                       2001      48        52         45
2002      38       41        36                                       2002      49        54         46
2003      39       43        37                                       2003      50        56         47
2004      40       44        37                                       2004      52        58         48
2005      41       46        38                                       2005      53        60         49
*Rates from 1999 are projected figures                               *Rates from 1999 are projected figures



Projected survival with repetition until 2005
                       SURVIVAL RATES WITHOUT REPETITION - 1994 TO 2005


    50

    40

    30

    20

    10

    0
         1994


                1995


                        1996


                               1997


                                      1998


                                               1999


                                                             2000


                                                                      2001


                                                                             2002


                                                                                    2003


                                                                                           2004


                                                                                                  2005


                                                      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.



`                                                                                                             10
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:         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.


Literacy rate    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     Mid West    West     Central     East
     Female    9            11          32       16          21
     Male      49           44          69       51          53
    Source: NMIS2, 1995

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,


`                                                                                         11
female literacy was one-third the male literacy level, while in 2000, female literacy is half the
male literacy rate. The chart below shows the literacy figures as recorded by different
surveys over the past 10 years.

Adult literacy rate
                      1991 Census         1995 NMIS           2000 BCHIMES
       Female         17                  23                  35
       Male           49                  57                  66
       Total          33                  40                  51



Goal 8:           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 percent5. 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;


5
    Helander, E. “Prejudice and Dignity, an introduction to CBR”, UNDP 1999, p. 21.


`                                                                                             12
          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

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

                                                                               Percentage of
       Background             Total          Persons                        Disabled Persons in
      Characteristics       Population         with         Prevalence      Different Categories
                                            Disabilities       (%)                 (100%)
    Age Group
     0-4                         10,772               97             0.90                      28.7
     5-9                         10,908              103             0.94                      30.5
     10-14                        9,644              117             1.21                      40.8

    Sex
     Male                         16861              199             1.18                      58.9
     Female                       16151              139             0.86                      41.1

    Location
     Urban                         2712               25             0.92                       7.4
     Rural                        30300              313             1.03                      92.6

    Ecological Belt
     Terai                       13377               140             1.05                     41.4
     Hills                       10554               108             1.02                     31.9
     Mountains                    9081                90             0.99                     26.6
    Total                        33,012              338             1.01                    100.0




Goal 9:        Special attention to the health and nutrition of the female child and to pregnant and
               lactating women




`                                                                                                13
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
HIV prevalence                       Proportion of population aged 15-49                                 who are HIV positive-
                                     disaggregated by gender and age




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

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                     Mortality Rates by Sex (1986-96)
studies, however, have found          200
more malnutrition in girls.                   Boys Girls
                                          deaths per 1,000 live births




Please refer to Goal 3 for a
general     discussion      on                                              142.8 135.5
                                      150
malnutrition rates.
                                                                               101.9
Under 5 mortality rate                                                   100           83.7
(male/female)
                                                                                                        56.5
                                                                                                 45.5
In the Nepal Family Health               50
Survey (1996), mortality rates
were calculated for a 10-year
                                          0
period to assess disparities.
                                                   IMR       Child Mortality    U5MR
The infant, child and under-
five mortality rates by sex are shown in the graph. We see that the 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



`                                                                                                                             14
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).6 And 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 (3 months) with
anaemia.7

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.


6
 Joint Nutrition Support Project.
7
  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.




`                                                                                         15
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
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


`                                                                                            16
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
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               Proportion of women aged 15-49 who are using (or whose partner is using) a
prevalence                  contraceptive method (either modern or traditional)

Fertility rate         for Number of live births to women aged 15-19 per 1,000 women aged 15-19
women 15 to 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.




`                                                                                                        17
                                         Figure 1 Women’s (15-49) Awareness of Modern
                                             Contraceptive Methods, Nepal 1976-1996
                      100
                                                                             Any modern method
                          90
                                                                    Female sterilization             Injectable
                          80                                                                                         Condom
                          70                                                               Pill
                                                                                                                  Implant
                    Pe 60
                    rce 50
                    nt
                        40                          Male sterilization                                             IUD

                          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                   All spacing methods                                        29
                                          Male sterilization
                     25                                                              24            9.6
                                          Female sterilization
                                                                                    4.4
                     20
    Percent Using




                                                                                                   6.0
                     15                                              15             7.5
                                                                    2.0
Availability and Accessibility
                     10                                             6.2
                                                     8
                                                    2.2                                           13.4
                                                                                    12.1
                      5        3                    3.2
                                     3                              6.8
                                   1.9
                                   1.0             2.6
                      0            0.1

                               1976               1981            1986            1991            1996



`                                                                                                                             18
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              1976             1981          1991

    Availabilitya                                 6               33             74
    Accessibilityb
    Up to one hour                               24               29             25
     1-2 hours                                   10               13             25
     3-4 hours                                   15               38             32
     1 day or more                               51               21             18


a
    Refers to having knowledge of the availability of a service outlet.
b
    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.




`                                                                                              19
Table 2.     Percentage distribution of currently married women, 15-49 years, using
contraceptive methods by most recent source of the method, Nepal, 1996




                               Sterilization


                                               Sterilization




                                                                            Inject ables




                                                                                                                Nor-plant
                                                                                                 Condom
                               Female
                                                                                                                                              Total
    Source




                                               Male




                                                                                                                                  IUD
                                                               Pill
    Public
    District hospital,
    district clinic, primary      48.2            31.7                8.3           18.8                  6.5         56.7          52.3       34.5
     health center

    Mobile clinic/camp            38.7            49.8                0.0                  3.9            0.0               4.7         0.0    29.1



    Health post, Sub-                 0.4             0.1        49.4               63.2             34.1             26.2              8.6    17.0
    health post, family
    planning clinic,female
    community health
    volunteer and other
    public sources

    Private
    Pharmacy/shop                     0.0             0.0        27.0                      2.1       45.4                   0.0         0.0     5.3

    Hospital, clinic,                 9.1         10.6           10.1               11.4                  5.6         12.4          29.2        9.8
    community health
    volunteer

    Other
    Friend/relatives and              3.7             7.8             5.2                  0.6            8.2               0.0     10.0        4.5
    source not specified

    Total                      100.0           100.0           100.0        100.0                100.0          100.0             100.0       100.0



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.




`                                                                                                                                               20
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        1976          1981        1986        1991          1996       Difference
    Group                                                                     (1976-1996)

    15-29      3.7           3.7         3.2         2.9           2.7        -1.0
    30-49      4.3           4.3         3.7         3.5           3.2        -1.1

    15-49      4.0           4.0         3.5         3.2           2.9        1.1




`                                                                                                   21
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


                    7                                                                 40




                                                                                           Percentage using contraception
                                                    TFR                               35
                    6
                                                                                      30
                    5
                                                                                      25
    TFR per woman




                    4
                                                                                      20
                    3
                                                    Contraceptive prevalence          15
                    2
                                                       (modern methods)               10
                    1                                                                 5
                    0                                                                 0
                         1976      1981      1986      1991       1996         2001



Knowledge and practice of family planning in Nepal have increased considerably during the 20-
year 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-for-
contraceptives" 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


`                                                                                                                           22
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          Proportion of women aged 15-49 attended at least once during pregnancy by
                        skilled health personnel
Childbirth Care         Proportion of births attended by skilled health personnel
Obstetric care          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




`                                                                                                         23
another. There has been a 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.




`                                                                                                      24
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        Nepal Family Health
                                                                                BCHIMES (2000)
                             and Health Survey         Survey (1996)
                                     (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
    % of births at a
                                     6%                        8%                       11%
    health facility
    % attended by doctor,
    nurse or midwife
    (skilled health
                                     6%                        9%                       12%
    personnel)
    % attended by
    trained health                   6%                        10%                      13%
    personnel
                            Doctor, trained          Doctor, nurse/ANM, Same   as     1996
                            midwife, nurse.          VHW, MCH worker, survey definition
                                                     other          health
    Trained personnel                                professional,
    involved in
                                                     including      health
    providing delivery
    services                                         assistants, auxiliary
                                                     health        worker,
                                                     senior      auxiliary
                                                     health worker.

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



`                                                                                                      25
Information System also does not collect this information from hospitals and health
centers.

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 one-third 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             Gap between
    Region         Total        Comprehensive     Comprehensive             Required &
                Population*      EOC Facilities    EOC Facilities            Available
 Eastern            5,316,150         11**              10                      1
    Western           4,509,076           9                   6                  3
    Mid-Western       2,909,753           6**                 2                  4
    All Regions      12,734,979          26                  18                  8


Basic EOC Services in the Three Regions Surveyed
                  Estimated                                                Gap between
                                 Required Basic       Available Basic
    Region           Total                                                  Required &
                                  EOC Facilities      EOC Facilities
                 Population*                                                 Available
 Eastern             5,316,150         43                    2                  41
    Western           4,509,076          36                  1                  35
    Mid-Western       2,909,753          23                  2                  21
    All Regions      12,734,979          102                 5                  97

* 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


`                                                                                           26
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
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 hospital-
based 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                Proportion of women aged 15-49 with haemoglobin levels below 12g/100ml for
anaemia                        non-pregnant women, and below 11g/100 ml for pregnant women




`                                                                                                           27
Current status

Iron Deficiency Anaemia is the most common nutritional problem in Nepal with profound
economic and social consequences.
According to the Nepal Micronutrient       Figure 1: Prevalence of anaemia in women
Status Survey (NMSS), in 1998 the                          (NMSS 1998)

overall prevalence of anaemia (< 12
g/100ml) in women of reproductive age      100

was 67.7 percent.        Among pregnant     80




                                                      % anaemia
women, the rate (< 11g/100ml) was 74.6      60

percent, with severe anaemia (<             40
                                            20
7g/100ml) in 5.7 percent of the pregnant
                                             0
women. As seen in Figure 1, anaemia




                                                                                                                       l
                                                                  20




                                                                                          40
                                                                          9



                                                                                 9




                                                                                                     nt



                                                                                                                nt


                                                                                                                     Al
                                                                        -2



                                                                               -3
rates decrease slightly with age.




                                                                                                   na



                                                                                                              na
                                                                  <




                                                                                         >
                                                                       20



                                                                              30




                                                                                                 eg



                                                                                                            eg
                                                                                               Pr



                                                                                                          pr
                                                                                                        n-
                                                                                                      No
                                                                                     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                  Proportion of household consuming adequately iodized
                                          salt
Low urinary iodine                        Proportion of population (school age children general
                                          population) with urinary iodine levels below 10
                                          micrograms/100ml urine



`                                                                                                                          28
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
handling, trading and storage practices         Figure 1: Iodine content in household salt
of large crystal salt cause considerable                    by ecological zone
loss of iodine.
                                                      100

The Terai has the lowest usage of          80
adequately iodised salt, probably
                                           60
due to the cross-border trade in
non-iodised    salt  from      India.      40

Because of the high use of                 20
packaged refined salt in urban
areas, adequately iodised salt is           0
                                                 Terai       Hills         Mou n tain s    Nation al
more common in the urban areas
                                                       0 ppm       < 15 ppm         > 15 ppm
(87.5%) than in the rural areas
                                                                                          Source: BCHIMES 2000
(58.9%).   Iodine   retention      in
packaged salt is much better than in the large crystal salt commonly used in the rural
areas.

Urinary Iodine
                                                                    Figure 2: Median Urinary Iodine Excretion
According to the findings of the 1998                                  Women and School-aged Children
                                                             (NMSS 1998)
Nepal Micronutrient Status Survey
(NMSS), Iodine Deficiency Disorders         300

(IDD) is no longer a problem of public
health significance in Nepal (Figure 2).
                                                       Med ia UIE (u g /l)




                                            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
cut-off point designated by WHO to            0
                                                  Terai        Hills     M ountains     National
indicate adequate iodine status (100
g/l). In spite of this overall good
                                                     W om en           School C hildren

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.




`                                                                                                               29
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            No iodine     < 15 ppm     > 15 ppm
    NFHS 1996                  6.8%                       93.2%
    NMSS 1998                 17.2%        27.7%          55.2%
    BCHIMES 2000               9.3%        28.1%          62.6%

  * The NFHS only reports on whether the
salt is iodised or not. There is no                                          Figure 3: Prevalence of UIE < 100 μg/l
information on the amount of iodine.                                                      1985 - 1998
                                                                             100
                                                                              90
                                                  UIE < 100 ug/l (percent)




                                                                              80
Urinary Iodine                                                                70
                                                                                   HMG/UNICEF
                                                                              60      1985
                                                                              50                              NMSS
The first national IDD survey, conducted             40
                                                                                                              1998


in 1965-1967, showed a high goitre                   30

prevalence, ranging from 60 to 90                    20
                                                     10
percent, and also a high cretinism rate. A            0
second IDD survey, jointly conducted by               1985       1990        1995                                    2000

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.

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.8 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.




8
  WHO/UNICEF/ICCIDD 'Indicators for assessing Iodine Deficiency Disorders and their
control through salt iodization'




`                                                                                                                           30
Goal 15:         Virtual elimination of vitamin A deficiency and its consequences, including
                 blindness


Children receiving             Proportion of children aged 6-59 months who received a high
vitamin A supplements          dose vitamin A supplement in the last 6 months

Mothers receiving              Proportion of mothers who received a high-dose vitamin A
vitamin A supplements          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
                                                       Figure1: Vitamin A Capsule Coverage,
                                                                       2000
Vitamin A Supplementation
                                                   100
The Nepal National Vitamin A Programme
(NVAP) has been very successful. Aimed              80
at supplementing high dose vitamin A
                                                    60
twice a year for children aged 6-59
months, NVAP was initiated in 8 Terai               40

districts in 1993. By October 2000, the             20
programme had, after a gradual
expansion, been established in 69 of the                  0
                                                                   Na tio na l                     R ura l   Urba n           G irls        Boys
75 districts in the country. It is anticipated
that the whole country will be covered
                                                                                                                                  Source: BCHIMES 2000
during 2001.

BCHIMES 2000 is the latest nation-wide
survey examining vitamin A capsule                         Figure 2: Age-specific prevalence of
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
                                                    Percentage




very high at 89.5 percent (Figure 1). No                         1.5


coverage differential was observed                                1

between girls (89.8%) and boys (89.3%).                          0.5

As in previous studies, the survey found                          0

the coverage to be lowest in children                                  1     2         3       4         5    6       7   8   9        10    11

aged 6-11 months (75.2%). This finding                                                              Child age in years
could be biased by the problem of




`                                                                                                                                                  31
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

In     1998,    the       prevalence     of                                         Map 1: Sub-clinical VAD in
nightblindness     among        pre-school
                                                                                       children, 6-59 months
children (12-59 months) was 0.27
                                                                                    (serum Retinol < 0.70 mol/l, NMSS 1998)
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                                        40 %

remains a public health problem in older                           30 - 39 %
                                                                   20 - 29 %
children. Figure 2 illustrates how clinical                          < 20 %
vitamin A deficiency rates increase with
child age.

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
Terai (40.0%) and the Mountains            2,400,000                                                 100
                                                                                                     90
(35.5%) than in the Hills (23.4%).         2,000,000
                                                                                                     80
The 6-11 months age group had the          1,600,000
                                                                                                     70
                                                                                                     60
highest rates (41.2%), indicating that
                                           1,200,000                                                 50
the amount of vitamin A received                                                                     40
                                             800,000
through         breastmilk         and                                                               30
                                                                                                     20
complementary feeding is insufficient.       400,000
                                                                                                     10
                                                                   0                                                       0
Trends                                                                  1993/94 1994/95 1995/96 1996/97 1997/98 1998/99


                                                                                                                     Source: NTAG
Supplementation

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
consistently high coverage, with the        Figure 4: Trends in the VAD Situation
interventions reaching about 90               5
percent of the targeted children. The
                                              4
mini-surveys also show that coverage
                                                  P re va le nce




remains high in districts where the           3

programme has been implemented                2

for a long time, indicating that there is     1

                                                                   0
                                                                   1985              1990             1995                2000

`                                                                                    XN (Nation al)   X1B (Terai)                32
no long-term fatigue. The high coverage found by the mini-surveys has been confirmed by
two national coverage surveys (NMSS 1998 & BCHIMES 2000).

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
                                                     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           0.6%
                                                                      0 .5 7 %                 0 .5 5 %
known, however, from both national
and sub-national data, that vitamin A
deficiency was a serious public health          0.4%
                                                  Percen tag e




problem in the 1980s. It is also clear                                            0 .2 9 %
                                                          0 .2 3 %
that there has been a significant               0.2%
decrease in nightblindness. Two
surveys conducted in 1995 and 1996,
Nepal Family Health Survey and Nepal            0.0%
                                                           N ig htblindne ss         B ito t's spo ts
Multiple     Indicator    Surveillance,
                                                          Receive VAC             Not receive VAC
reported nightblindness in children 24-
35 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                   Proportion of infant under 4 months (120 days) who are
breastfeeding rate          exclusively breastfed




`                                                                                                   33
Timely complementary      Proportion of infants aged 6-9 months (180-299 days) who
feeding rate              are receiving breastmilk and complementary food


Continued                 Proportion of children aged 12-15 months and 20-23
breastfeeding rate        months who are breastfeeding

 Number of baby-          Number of hospitals and maternity facilities designed as
friendly facilities       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                                                          Rate (%)
                      Exclusive breastfeeding rate                                                               81.8
                      Timely complementary feeding rate                                                          70.8
                      Continued breastfeeding rate – 12-15 m                                                     96.6
                      Continued breastfeeding rate – 20-23 m                                                     87.7


The relatively lower rates in
                                                     Figure 1: Breastfeeding Status by Child Age
“exclusive      breastfeeding”    and
“timely complementary feeding”                                       100

rates indicate a wide range in the                                    90                                                           No breastfeeding
timing of the introduction of                                         80


complementary foods. This is                                          70                       Breastfeeding with
                                                                      60                       complementary food
                                                     % of children




clearly seen in Figure 1, which
                                                                      50
shows that complementary foods                                        40                       Breastfeeding with
are generally introduced too early –                                  30
                                                                                               water only
and in some cases too late. It can                                    20
also be seen that water is                                            10
                                                                               Exclusive
                                                                               breastfeeding
introduced too early. It is also clear                                 0
                                                                           1   3   5   7   9    11   13   15   17   19   21   23   25   27   29    31   33   35
from      the    figure    that    the                                                                     Age in months
breastfeeding duration is very long,                                                                                                              Source: NFHS 1996

with some 46 percent of 3-year-olds
still being breastfeed.

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



`                                                                                                                                                                 34
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.

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




`                                                                                           35
improvements during the 1990’s. Actual increases in food production have largely
been offset by a rapid population growth.



Goal 19:      Global eradication of poliomyelitis by the year 2000


Polio cases                   Annual number of cases of polio

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
                                                   Fig. 1: Confirmed Polio cases
rounds, with each round covering
                                           12
more than 92 percent of the total                                 11
                                           10
target population, validated by post               9                    9
                                            8              8
coverage surveys. By sex, there was no
                                            6
difference between boys and girls in
                                            4
the polio vaccination coverage in the       2                                  2
NIDs. In order to enhance the                                                      1
                                            0
epidemiological impact, the NID dates
were synchronized with neighboring              1995 1996 1997 1998 1999 2000
countries, particularly India. OPV3
coverage in 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.




`                                                                                      36
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




`                                                                                    37
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
                                                   Fig 2: NT cases in Nepal (Source: HMIS annual reports)
women of childbearing age (WCBA) as
being in the vicinity of 10 percent for the   800
                                                         727
past 5 years. This low coverage is due to
                                              600                     557
inconsistency in the denominator which
                                              400
takes in all women of childbearing age,                                           306
whereas the programme focuses on              200                                             197
                                                                                                           50
pregnant women only. NFHS 1996 found            0
that in about one third (33%) of the                1995         1996          1997        1998         1999

births, mothers received two or more
doses of TT vaccine during pregnancy.
Similarly, the 1998 EPI coverage survey indicated that 65 percent 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                 Annual number of under-five deaths due to measles
measles
Measles cases                          Annual number of cases of measles in children under five


`                                                                                                         38
                                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.

The annual reports of the MOH show
that the measles incidence rate went up                  Fig.3: Mealses coverage and no. of cases annual
                                                                  (source: HMIS annual reports)
from      around     40    cases/100,000
population in 1996 to more than 50
                                                             90                                             15000
cases/100,000 population in 1997, but
                                                                                                            10000
gradually decreased to 30 cases/100,000                      80
                                                                                                            5000
in 1999. Measles coverage in the routine                     70                                             0
                                                                    1996      1997        1998       1999
immunisation       programme         has
                                                      coverage       87        88          89         81
remained at over 81 percent, validated                              7812     12677        5771       6874
                                                      No of cases
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                         Fig.4: comparison of measles and DPT3 coverage
System (HMIS) and various surveys,              100
also indicate that the measles coverage                                              82
                                                80
rate is higher than DPT3 or OPV3.                           57
                                                                                                65
                                                60                  54
This signifies that measles is a public                                                                     Measles
health problem, and people are more             40                                                          DPT3
conscious about it than other vaccines.         20

                                                 0
Of the four immunisation goals, Nepal            DHS 1996      BCHIMES 2000
has lagged behind in the measles goal.
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          Proportion of one-year-old children immunized against
coverage                  diphtheria, pertusis and tetanus (DPT)



`                                                                                                                     39
Measles immunization        Proportion of one –year-old children immunized against
coverage                    measles
Polio immunizations         Proportion of one-year-old children immunized against
coverage                    poliomyelitis
TB immunization             Proportion of one-year-old children immunized against
coverage                    tuberculosis
Neonatal tetanus           Proportion of one-year-old children protected against neonatal
protection                 tetanus through immunization of their mother
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              120
overall coverage seems to have             100
stabilized at 76 per cent.                  80
                                              60
The HMIS does not provide gender            40
disaggregated data. BCHIMES                 20
2000 indicates no gender disparity            0
in BCG, DPT1 or OPV1. However,                  1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
the dropout rate for girls is slightly
higher than that of boys for both                       BCG        DPT3        OPV3       Measles
DPT3 and OPV3, indicating that
fewer girls 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           100    86 87
                                                                        78          83 81
children against it.                       80                67 64          70
                                             60                                            Boys
                                             40                                      Girls
The      1998    coverage     survey         20
conducted jointly by CHD, WHO                 0
and UNICEF showed that the                      BCG      DPT3     OPV3    Measles
programme has 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.



`                                                                                             40
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.

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       Annual number of under-five deaths due to diarrhoea
from 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        Proportion of children aged 0-59 months who had diarrhoea in
of diarrhoea           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.


`                                                                                           41
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).




Recent surveys on diarrhoea prevalence
           Survey                     NMSS 1998                   BCHIMES 2000
 % of children with
 diarrhoea during the 2
 weeks prior to the survey,             25.4%                         16.2%*
 according to mothers’
 report
 Age of children                 6 months – 5 years                 0 – 5 years
 Data collection months           December – May                   March – May
* 16.8% for children aged 6 months to 5 years.

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 Mid-


`                                                                                      42
Western 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
    NFHS 1991       Aug 1991 – Feb 1992       0 - 5 years                     16%
                                                                              15%
    NMIS 1 1995    January – March 1995       0 - 3 years

                     August-November
    NMIS 4 1996                               0 - 3 years
                           1996                                               16%




Surveys conducted during the peak season (April/May/June/July)
                                                         Diarrhoea in 2 weeks prior to
                                       Peak season                  survey
     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                                              19.3%
                   March – May          April/May                 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.




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.”



`                                                                                                    43
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, 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                    NFHS 1996              BCHIMES 2000
  Use of ORS           26.5%                        25.9%                   26.0%




`                                                                                           44
                     Mothers with           Mothers were asked       Mothers were asked
                     children under 5       to list all the          to list all the liquids
                     having diarrhoea in    treatments, including    given during
                     the two weeks prior    recommended home         diarrohea episodes
                     to the survey, were    fluid, pill,             for all children under
    Remarks
                     asked whether ORS      intravenous drugs,       5.
                     (Jeevan Jal) was       given during
                     given to the child.    diarrohea episodes
                                            for all children under
                                            3.


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.


                                                                              Continued
                         Increased
                                        Same amount                            feeding
       Survey              fluids                         No fluids given
                                        of liquid given                     (same amount
                       (more liquids)
                                                                            or more food)
      NFHS 1996
    January – June         35%               N/A               N/A               N/A
       0-3 years
     NMIS 3 1996
      February -
                           24%               12%               47%               17%
         April
       0-5 years
     NMIS 4 1996
     August – Nov           N/A              N/A               N/A               24%
       0-3 years
    BCHIMES 2000
     March - May           20%               41%               10%               43%
       0-5 years



`                                                                                         45
Goal 24:       Reduction by one third in the deaths due to Acute Respiratory Infections in
       children under five years


Under-five deaths from         Annual number of under-five deaths due to acute respiratory
acute respiratory              infections
infection (ARI)
Care seeking for acute         Proportion of children aged 0-59 months who had ARI in the last
respiratory infections         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 disease 9.

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              Cough or difficult breathing during past 2 weeks           30%
 (Jan – Mar)                       (0-3 years)
 1998            NMSS              ARI 14-day prevalence – 0-5 years (cough with or           48.8%
 (Dec – May)                       without difficult breathing)
                                   Maternal observation – 0-5 years (cough or                 30.2%
                                   difficult breathing) at time of survey
                                   Clinical observation – 0-5 years (cough or difficult       19.3%
                                   breathing) at time of survey
    2000              BCHIMES      Cough and cold during past 2 weeks (0-5 years)             29%
    (Mar – May)


Another survey, NMSS10, 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.


9
     IMCI (Integrated Management of Childhood Illness) training materials, WHO.
10
      Nepal Micronutrient Status Survey, 1998.


`                                                                                                     46
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                    17%
 (Aug-Oct 91)            children 0-5 years
 (Nov-Feb 92)
 1996           NFHS Cough and Fast Breathing in 2 weeks prior to survey in                    34%
 (Jan – Jun 96)          children 0-36 months

For the classification of pneumonia, WHO uses the definition „cough or difficulty in breathing
with fast breathing‟11. 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

 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.



11
     IMCI (Integrated Management of Childhood Illness) training materials, WHO.


`                                                                                                    47
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). Community-based 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
  100
                                                               health facility staff and 9,311
            % of Expected Pneumonia Cases Treated by CHW       community       health     workers,
   80       % of Expected Pneumonia Cases Treated by HF        including 8,124 FCHVs, have been
                                                  57
                                                               trained in the standard case
   60                                                          management       of     pneumonia.
                                                               FCHVs have provided orientation
   40               22                                         to over 115,000 mothers in the
                                                               rural   areas     on     pneumonia
   20
                                                               symptoms, appropriate home care,
    0
                                                               and on when and where to seek
                                                               help. Over 2,000 traditional healers
        Non-Intervention Districts      Intervention Districts as well as 301 district-level and
                                                               7,524 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.
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.




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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.




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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 broad-
based 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


`                                                                                           50
fluids during episodes of diarrhoea, and more than 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



`                                                                                               51
their children to a health care provider. Over 70 percent of those who get treated for ARI are
children of literate mothers.

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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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                  Pop and % of                     Births        (%)
               Populations            children                         registered
                                      under 1 year

1991           18,491,097             565,413 (3.06%)                  84,818        15.00
1992           18,937,160             578,147                          68,814        11.90
1993           19,393,984             593,455                          147,285       24.81
1994           19,861,827             607,771                          188,897       31.08
1995           20,340,957             622,433                          116,387       18.69
1996           20,831,644             635,365                          176,040       27.70
1997           21,331,362             652,739                245,361         37.58
1998           21,843,068             668,397                          102,657       15.35
1999           22,367,048             684,431                          311,590       45.52
2000           22,903,598             700,850                          293,664       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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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 1996-
2000. 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




`                                                                                             54
as well as victims of violence, rape, suppression and atrocity, and, therefore, compelled to
abandon their families and live on the streets.

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
utensils or shopping for the              Children's Work vs Schooling (5-14 yrs)
household, cleaning the house,
                                                                 41%
minor household repairs, or            Currently
                                                                   45%
caring for the elderly, the sick,      working
                                                               37%
or young children.
                                                               20%
The population in the 5-14 age        Usually working            24%
                                                             16%
group is estimated at 4.86
million for this survey.                                                               71%
                                      Going to school                               62%
                                                                                          80%

                                                        0%   20%       40%      60%     80%     100%

                                                               Boys     Girls   Total
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Proportion of working children: Over 40 percent of all children 5-14 years, or 1.987
million children, were found to 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                        Rural
 Age group
                Total      Male Female Total            Male      Female   Total    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                       Rural
 Age group
                Total      Male    Female Total          Male     Female    Total    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                    Rural
  Age group
                 Total     Male Female Total         Male Female Total       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%




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      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% 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                 Rural
  Age group
                  Total     Male Female Total            Male Female Total     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                                                    (2.0%)
   - House Keeping and Restaurants                     13,000         (0.7%)
   - Shop Sales persons                                26,000         (1.3%)
   Agriculture                                                       (84.3%)
   - Animal Producers                                  53,000         (2.7%)
   - Subsistence Agriculture                        1,617,000        (81.6%)
   Craft and Related Trades                            22,000         (1.1%)
   Plant and Machine Operators                          4,000         (0.2%)
   Elementary Occupation                                             (9.84%)
   - Agricultural laborers                             39,000         (2.0%)
   - Water Fetching                                    78,000         (3.9%)
   - Firewood collection                               78,000         (3.9%)

Industries (kind of goods produced or services supplied)
   Agriculture, Hunting and Forestry               1,725,000         (87%)
   Manufacturing                                      26,000         (1.3%)
   Construction                                       10,000         (0.5%)
   Wholesale and retail trade                         29,000         (1.5%)
   Hotel /Restaurants                                 16,000         (0.8%)
   Private holds with employed persons               165,000         (8.3%)
   All other categories                               10,000         (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


`                                                                                           57
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.

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 children12 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                          Population   Blood slide    Positive
belt and the forest fringes of the foothills and the                     at risk     examined      detection
inner Terais. Ministry of Health estimates that 16                  1995 12,298,141      338,189      9,718
                                                                    1996 15,225,411      204,355      9,020
12
     The Kamaiya System in Nepal, Shiva Sharma a.o., SAAT ILO New Delhi, 1998 page 46.
                                                                    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
                                                                                                          58
percent of the 22 million people of Nepal are at malaria risk. The morbidity rate for the
malaria-risk 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.

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



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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
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



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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

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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