Dr. Praveen Mishra
Nepal is more than soaring mountains with breathtaking views. We also have dry plains and hilly regions, and dealing with poverty is a challenge for communities in all these regions. Yet in the past 20 years we have slashed our high rates of maternal and infant mortality faster than other countries with comparable income levels or even wealthier than we are. What is our secret?
I can point to some ingredients of our success. One is the amma samuha, the “mother groups” that meet every fortnight to discuss local problems in every Nepalese ward, our administrative neighborhoods of up to 700 people. We asked each group to discuss various maternal health issues among themselves and then recommend one woman in their community to become a Female Community Health Volunteer (FCHV). We also began health information campaigns of posters, broadcasts and – most importantly – street campaigns and video documentaries that are popular, especially in rural areas.
We now have 49,000 FCHVs who cover all 75 districts of Nepal. Nearly half have never been to school, but because they are neighbors, they are respected and listened to. They receive no salary, only a token incentive of 4,000 rupees per year (about $40), a bicycle and a sign for their homes that proclaims they are FCHVs.
Since 1995, these dedicated women have visited every home in every community twice a year to give doses of Vitamin A to breastfeeding women and children up to age five. They also collect data on each household, and they have branched out to provide deworming pills, immunizations, family planning materials, and information on sanitation, nutrition and infant care.
The program now reaches 94 percent of all children six months to five years old, whose mortality rate has dropped from 94 per 10,000 in 1993 to 52. At least 12,000 lives have been saved.
The Vitamin A program was a key effort. In 1993, we began trying to persuade pregnant and breastfeeding women and children in the Sarlahi area of southern Nepal to take supplements of Vitamin A because scientific literature shows it is essential to good eyesight and proper overall body function, especially in children. But it is found in the leafy greens, orange and red vegetables and animal liver that are not common in the Nepalese diet.
We were short of funds, but we knew that supplements were cheap and could be a great investment in maternal and child health. The problem was that people were suspicious of government assurances that these pills were a good idea.
We knew the supplements weren’t a magic bullet either. As in most low-income countries, our health care system also needed many expensive changes – better sanitation facilities, improved road access and water and power supplies, and many more trained medical personnel and emergency care facilities, just to begin – but we were determined to start somewhere. The amma samuha propelled the process and made it happen.
We also focused on increasing overall access to maternal health services. We worked to encourage women to visit health centers for pre- and post-natal checkups and deliveries. We publicized an offer of small cash incentives to cover different transportation costs – 500 rupees in the plains areas, 1,000 in hilly areas and 1,500 in the rugged Himalayan region. Mothers who came in received a set of warm clothing for themselves and one for each child.
Since 2006 we have provided skilled birth attendants at every level of the health system, with referrals to clinics for life-threatening pregnancy complications like pre-eclampsia and other emergencies. As a dental surgeon by training, I myself proposed the use of the oral antiseptic chlorhexidine for use on cut umbilical cords, and this proved so successful in reducing newborn mortality that Nepal is now manufacturing it for sale worldwide.
These were small but critical changes that created a nationwide holistic safe motherhood program, and our maternal mortality rate fell significantly, from 850 per thousand live births in 1992 to 170 in 2011.
We still have a long way to go, but Nepal is now among ten low- and middle-income countries on the “fast track” to meet the Millennium Development Goals related to reductions in child and maternal mortality by 2015.
Our experience and the key strategies we used are spotlighted in the new World Health Organization report Nepal: Success Factors for Women’s and Children’s Health: community ownership of the programs, women’s involvement, collaboration across social and economic sectors, respect for local cultures, accurate data collection, long-range and innovative thinking, and rights-based accountability, among other things.
Our interim constitution names health care as an explicit human right, for example, and recent Supreme Court rulings have therefore expanded community engagement and promoted better service delivery. Working together with several external development partners and local non-governmental organizations, the Ministry of Health and Population is striving to make our health care programs universal, affordable, accessible and socially acceptable. Our reward has been the saving of countless human lives.
We realize we have a long way to go in reducing inequities that exist between communities, but our record shows we are on the right track. We call upon all Nepalis – and our external partners –to continue to join hands in our journey and be part of the success story.
This blog is part of a series linked to the Success Factors for Women’s and Children’s Health studies presented at this year’s Partners’ Forum. PMNCH, WHO, World Bank and the Alliance for Health Policy and Systems Research, worked closely with Ministries of Health, academic institutions and other partners on a three-year multidisciplinary, multi-country initiative that aimed to understand what factors enabled some low- and middle- income countries to achieve rapid reductions in maternal and child mortality.