Dr. Asok Poudel
Nepal And Its People
1. Location : a. Latitude: 26° 22¢ to 30° 27¢ N
b. Longitude 80° 4¢ to 88° 12¢ E
2. Barrier :
China in the north
India in the South, East, West
3. Size :
1. Area: 147,181 sq. Km.
2. Length: 885 Km. (East to West)
3. Width : Non-uniform, mean width of 193 Km. (North to South)
4. Administrative and Physical Divisions
1. 5 Developments Regions and 75 districts
2. Village Development Committee (VDC) and Municipality is the largest local level administrative unit in each district.
3. No. of VDC = 3095 & Municipality = 36
4. Ecologically divided into three ecological regions; Mountains, Hills and Tarai.
5. Population
1. Estimated population for 1996 is 20,515,938 (18,491,097 in 1991) with an annual growth rate of 2.1 %
2. In 1991, the mountain contains about 7%, hills 46% and tarai 47%
3. Population density 131 persons per sq. Km. (70 to 103 person per sq. Km. in 1971 - 81)
6. Economy
Nepal is one of the poorest countries in the world, with a very weak economic base. The estimated Gross National Product (GNP) per capita is US $ 160 (US $ 120 in 1965 and US $ 180 in 1988). About 70% of the population live in absolute poverty. (1996 World Bank) Nepal is predominantly an agricultural country. The agricultural sector absorbs more than 80% of the total labour force of the country. Per Capita government expenditure on health, education, other social services and agriculture are among the lowest in the world.
The world bank estimates that the minimum cost of providing basic health services is US $ 12 per person per year. Amongst at least 20 countries in the world which cannot hope even to approach this basic minimum. The annual amount for health available per person in Nepal for 1991 was US $ 0.90 (La Fond, 1995).
7. Language and Religion
Nepali is the official language. Classification of language by mother tongue shows that the Nepali speakers were 50.3% of the total population in 1991. Maithili, Bhojpuri, Tharu, Tamang and Newari were about 11.8, 7.5, 5.4, 4.9 and 3.7 % respectively.
Nepal is the only Hindu state in the world. The majority of the population is continually Hindu which is about 86.5%. The second largest religious group, Buddhism, is 7.8%.
Health Statistics and Information
The health status of Nepalese can only be described as extremely poor by any standard, although basic indicators demonstrates that it has improved somewhat over the last ten years or so (table). In general the Nepali population suffers from the common diseases of underdevelopment, the control of which would entail not just health intervention, but also socio-economic improvements. The major health problems include diarrhoeal diseases, tuberculosis, other epidemic diseases of childhood, parasitic diseases including malaria, undernutrition and specific vitamin and mineral deficiencies. The maternal mortality rate is the second highest in South Asia, exceeded by Bhutan.
CHILD HEALTH INDICATORS WITH NATIONAL HEALTH INDICES COMPILATION :
Health Indicator 1980 - 81 1990 - 91 1996 (projected)
________________________________________________________________________________________
Estimated no. of birth 820,638
Estimated no. of live birth 796,018
Crude birth rate per 1000 population 44 42 40.0
Crude death rate per 1000 population 18 16 --
Neonatal Mortality Rate per 1000 live births 56.8 56.8
Estimated no. of neonatal deaths - - 45,214
Infant Mortality Rate per 1000 live births - 143 107/102
Proportional of all deaths that are neonatal deaths 55.7%
Under 5 Mortality Rate per 1000 live births 222 165 (196) --
Maternal Mortality Rate per 1000 live births 15 8.5 5.15
Estimated no. of maternal deaths -- -- 4100
Total Fertility rate per woman 6.3 5.6
Life expectancy at birth 50 54(52.6 females, 54 Males)
Population Growth Rate 2.67 2.1
% of deliveries conducted at home (1991) -- 92.5%
Estimated no. of home deliveries (1996) -- -- 759,090
% of deliveries conducted by a doctor -- -- 5.5%
% of deliveries conducted by a nurse -- -- 1.9%
% of deliveries conducted by a TBA -- -- 24.8%
% of deliveries conducted by a relative / other -- -- 58.2%
Birth wt. (percent less than 2500 gm.) -- -- 26.2
Anthropometry - % malnourished < 2SD median weight / height 6.1 male, 5.1 female
< 2SD median height / age 64% male, 66% female
- Mid-arm circumference < 12.5 cm. 9% male, 9% female
Growth monitoring 2.1% have vaccination card, number with growth monitoring card is lower
Vitamin A Night Blindness : 0.4% under 3 yrs., 1% three yrs.
Received Vit. A : 52% in Vit. A programme received once, one half of these received more than once.
Measles: 9% of children under the age of three yrs.
Diarrhoea and ORT: 14% of 0 - 3 yrs. olds had diarrhoea in last two weeks, 25% had ARI in last two
weeks, 67% continued food, 58% gave more liquid.
Breast Feeding 50% use exclusive BF up to 4 months, Average stop at 18 months, 5% stop under 4 months.
Iodization 13% of salt purchased is non-iodised
32% of salt purchased is 7 - 15 ppm iodised
46% of salt purchased has 30+ ppm
Water 63% walk 15 minutes or less to fetch water; Safe Drinking water : 37 %
29% household water recipient.
Sanitation 20% have latrines; Proper sanitation facilities : 6 %
Adult Literacy 73% mothers say they do not know how to read and write.
52% of males and 21% of females aged 18+ yrs. read and write.
Disability : 3.4 % of the children are physically and mentally retarded.( under recorded)
National Health System and Integrated Health programme of Nepal
The Ministry of Health has announced National Health Policy in September 1991. The policy is based on broad four areas.
1. Primary Health Care Service
2. Private Sector Involvement
3. Community Participation
4. Cost Recovery
The basic thrust of the National Health Policy is to increase access to primary health care services of the majority of the rural population by the expansion of integrated promotive, preventive and curative primary health services to the village level through sub health posts and primary health centres and improving the access to secondary and tertiary care through development of appropriate referral system.
Health Infrastructure and Population Ratio
S. N. Population Ratio Health Institution Projected Number Existing Number Level of Infrastructure No. of Beds
1:4000 Sub Health Post 3199 1299 1/each VDC No
1:29000 Health Post 611 787 1/5 VDC No
1:100,000 Primary Health Centre 205 ? 20 1/ Electoral constituency 3
1:200,000 District Hospital 75 60 1/each district 15 - 25
1:1,300,00 Zonal Hospital 14 9 1/each zone 50 - 150
1:3,600,000 Regional Hospital 5 1 1/each region 150 - 200
Central Hospital 5 Super Specialist 100 - 300
Ayurved Inst.
Ayurved clinic 1 / 165 teaching facility
The primary programmes are FP/MCH, nutrition, immunization, Safe Motherhood, Malaria, kala azar, tuberculosis, and leprosy, AIDS control and prevention. Priority is given to preventive health programmes which directly help reduce infant and child mortality.
Projected Health Manpower Needs to Meet MBHN Strategy (Minimum Basic Health Needs)
S. N. Position Current Number Ratio to population 1990 No. to meet MBHN Strategy
1 Doctor 951 1:19,980 2400
2 Nurse 601 1:31,616 1202
3 Asst.-Nurse (mid Wife) 2379 1:7989 5000
4 Vaidya ( Ayurved) 130 1:146,161 750
5 Health Asst. 1186 1:16,021 2463
HEALTH INFRASTRUCTURE FROM DISTRICT TO VILLAGE (Proposed)
District Health and Curative Service DirectorateÕs office
District Hospital District Public Health Section
Electoral Constituency level
PRIMARY HEALTH CENTER
a. Medical Officer - 1
b. Health Assistant - 1
c. Auxiliary Health Worker - 3
d. Assistant Nurse Midwife - 3
e. Village Health Worker - 1
f. Sweepers - 2
g. Maternity Bed - 1
h. General Bed - 2
District Division Level
HEALTH POST
a. Health Assistant - 1
b. Auxiliary Health Worker -1
c. Auxiliary Nurse Midwife - 2
d. Village Health Worker - 1
Village Development
Committee Level
SUB-HEALTH POST
a. Auxiliary Health Worker - 1
b. Village Health Worker - 1
c. MCH Worker - 1
Ward Level
WARD LEVEL VILLAGE HEALTH WORKER
at present Female Community Health Volunteer
( 40,000 )
============================================
PEDIATRIC MEDICINE WITH VARIOUS MORBIDITY OF CHILDREN IN NEPAL :
In relation to the Pediatric Medicine Infrastructure, there exists one National Children Hospital with 150 beds with specialised services like neonatology, besides other components medical, surgical, dental, nutrition service, diarrhoea treatment unit, emergency etc. Institute of Medicine produce diploma in Child Health (one year course) three candidates in a year since 6 years. Thus the existing subspeciality of Pediatric Specialist is around 1 doctor versus 200,000children. At the village level MCH workers trained for three months provide basic Under Five clinic services including referrals supplemented by integrated programs like vitamin A distribution, ARI Control, CDD. Though there exists good networking on expanded program on immunization with considerably good coverage of majority of vaccine preventable diseases (statistically e.g. as BCG coverage MOH/ EPI quotes 90 % but sentinel surveys shows 67 % only. There remains still doubtful efficacy of the vaccines at most of the villages.
Through Zonal Hospital level upwards ( few district hospitals) certain beds are allocated for pediatric admission and services rendered by at least one pediatrician, with limited basic services for newborn.
As it is evident from most of the surveys that 90 % of births occur without any contact with a trained health practitioner (NPC, 1991).
Special studies have highlighted some of the specific disease problems. Upto 70 % of children below 5 years of age suffer from malnutrition. 50% of females of child bearing age are anemic. Vitamin A deficiency causes about one-third of all cases of blindness.
The perinatal mortality (PMR) which represent still births and early neonatal deaths i.e. death within 7 days (168 hours) of birth has been found to be 40/1000 births according to a study at largest maternity hospital, Kathmandu. The PMR outside Kathmandu is expected to be higher as perinatal services are remote, besides more than 90% deliveries are conducted by untrained persons. The other basic problems are poverty, illiteracy and poor health services coverage.
The current status of maternal and child health is dismal in Nepal. Almost 90 percent population lives in the villages. The annual births in Nepal around 7,00,000. In the view of current incidence of low birth weight babies of 25-30 percent, alomost 1,75,000 - 2,00,000 low birth weight babies need to be provided care every year. About 10% of babies (70,000) are expected to be below 2000 gms requiring intermediate or level II newborn care. Intensive neonatal care is required for about 3 % (21,000) of babies weighing less than 1500 gms at birth. It is estimated that around 5 percent newborn babies are likely to suffer from birth asphyxia, respiratory distress syndrome and hyperbilirubinaemia contributing to a load of around 35,000 each for these common disorders of the newborn.
The major bottlenecks for effective delivery of neonatal care facilities include female illiteracy (87%), ignorance and lack of health awareness, poor infrastructural facilities due to poor transport and communication facilities. Most deliveries are non-institutional and merely 6 percent births are attended by trained personnel. Our 90 percent deliveries take place in rural areas with problems of accessibility and acceptability of available health services. The quality of health professionals is rather poor and referral system is practically non-existent. The specialized neonatal care facilities are by and large unavailable in Nepal. Thus, all these leading to neonatal mortality rate of over 50 per thousand live births.
44 % of childhood deaths are due to diarrhoea and the number of diarrhoeal episodes per child is about 3.4 %.
Diarrhoea is the most common of all child illnesses in Nepal. The National Diarrhoeal Diseases Survey showed that the children who were reported dead nationwide in 1986 deaths, some 16 per thousand deaths were diarrhoea related. Every year some 45,000 children die of diarrhoea alone. The same survey indicated that diarrhoea associated death in Under 5 amounted to 46% of deaths all causes, and for every 400 cases of diarrhoea there is one death. The number of diarrhoeal episodes per child per year has fallen from 6.1 in 1986 to 3.3 in 1990.
Tuberculosis continues to be a major public health problem in Nepal. ÒTuberculosis ControlÓ is defined by the WHO is said to be achieved when the prevalence of natural infection in the age group of 0 - 14 years is of the order of 1 % , which at present is about 40 %. Average annual risk of infection is 2 % , meaning 2 out of every 100 people are infected with tuberculosis every year and 60 % productive age group of 15 - 49 years.
70 - 80 % of the population suffer from helminthic (worm) infestation, of which majority of children succumb repeatedly.
Acute Respiratory Infections (ARI) and diarrhoea account for more than 75 % of deaths in children under 5 years of age. In Nepal ARI alternates with diarrhoea as the major cause of morbidity and mortality among children under five years of age . Each year about 40,000 of these children are estiamated to die from pneumonia. Infants are at highest risk of death from pneumonia as was shown in one of the mountainous district called Jumla where 70 % of all childhood pneumonia deaths occurred within the first year of life, with the majority occurring within the first 6 months.
Malnutrition - ÒStuntingÓ or chronic malnutrition affecting the height of the child - affects two children in three in Nepal (65%). There is little or no gender disparity. Children start off closer to the international norm, then their growth drops off. Because the stunting ÒproductionÓ levels out after 18 months , it is probably not a question of food availability in the household. Infants feeding practices are implicated as low energy density of most diets, liquid diets given with water leading to dilution and frequency of feeds are very low. Despite the breast feeding practice in Nepal being very good. Only 15 % of mothers introduce food before the child is four months of age and only 5 stop breast feeding before 4 months.
Based on weight for height, ÒacceptingÓ that children are smaller than they should be, a further 5 - 6 % are underweight. This probably reflects acute malnutrition. Often vicious cycle of preceeding infectious morbidities are encountered. Those sick children are loaded with numbers of items of medicines forgetting the importance of food, fluid and frequency during the illness. Furthermore traditional rituals aggravate to chronicity and mortality. The available health services excepting few NGO engaged in child survival programs are not well versed and skilled on nutrition intervention.
Amongst most of the vaccine preventable diseases, 9 % of children under the age of three years were reported to have suffered measles. Measles vaccination coverage is low, with one out of three children in the target age group (32 % among 9 - 12 months olds, and 54 % among 12 - 36 month olds). Of the vaccinated children, not all will be protected, because of low vaccine efficacy. Added to the low vaccination coverage and low efficacy, this means a large number of children are likely to be susceptible. Finally, when vaccination levels are low, measles follows an epidemic cycle of five years. Since measles rates are low amongst the under three years olds, this means an epidemic is likely to occur soon, posibly this winter. Again it spreads among the succeptibles, in epidemic there is practically way to stop it. Measles makes a lethal combination with malnutrition. During each epidemic the mortality has reported high amongst under rfive children because of diarrhoea or pneumonia. Furthermore in Nepal, only one died in four (23%) receives ORT when they suffer from diarrhoea.
The goitre prevalence of 44 % is one of the highest in the world. A striking finding in one survey showed 48 % sell iodised salt with less than 15 ppm of iodide and 5 % with 50 ppm. The correlation of goitrous family with low consumption of iodised salt correlates to the existing high level (65%) of stunting in relation to other countries. There are 12.84 % of total iodine deficiency disease handicap representing 3.2 %, Endemic cretinism and 9.63% milder mental, motor or developmental handicap
In Nepal, many parents lay much more stress on the health of the male child for they feel that the daughter, after all is going to be given away by ÒKanyadaanÓ or going away once she gets married. She is after all going to be somebody elseÕs responsibility. The male child is preferred to continue the progeny into our male oriented society, to act as a keeper/ provider of the parents in old age and finally to offer the fire at the time of final rites once death occurs. Nepal ratified the convention on the rights of the child on the end of the 26th National ChildrenÕs Day. Nepal was the 23rd country to do so. Because of this it means that as per Article 2, this sex bias against the girls should no longer efficiently exist.
Saying such as ÒTo be born as a daughter is a defeated fateÓ as well as Òlet it be later, but let it be a sonÓ, one very common in our society. There is considerably high malnutrition rate amongst girl child compared to boys child ( in reality rather than sentinel survey figures) and as such low enrollment in education which is 32% primary, lower secondary and secondary schools 26% and 24 % respectively.
The main reasons for such low enrollment are the existing social values and norms towards the girl child. The low economic status of parents, heavy workload around home such as collecting fuel and looking after small siblings are equally responsible for lowering the enrollment of the girl child.
A very serious social problem faced by our society related to the girl child is the trafficking of our girls. This is a very dangerous social cancer. On top of this, early child marriage is still prevailing about 40% below 14 yrs. of age and 7% at 10 years old.
Nepal being one of the least developed countries of the world and 70 percent of the families are said to be living below the poverty line. Children supplements the household income from an early age. Before they reach the age of ten, many of them contribute to agricultural labor, in addition to looking after the younger children, taking care of animals, dish washing in hotels, restaurants, household worker, labor in industries mostly unorganized and informal sectors where children work remain unprotected. In a carpet industry where the child labor is estimated at almost 50% of the total labor force, where they are exposed to risk and health hazards. Children are paid less than the prescribed minimum and the basic facilities and preventive measures are practically non-existent. In eastern Nepal 25 percent of children in a sample of tea estate workers claimed to be the sole earners in their families. The children also contributed about 12 percent of the total tea production.
Right from early childhood boys are encouraged to develop themselves mentally and physically. If resources are scarce it will go to educate boys instead of girls regardless of who displays greater aptitude and learning potential. Girls are expected to confirm to her typical traditional role e.g. household chores and skills limited to nurture the family. The male and female enrollment differences starts right at early grade of class one and goes on increasing at each successive grade.
Morbidity & Mortality pattern in order of service outlets studied
reveal as follows (of under 15 years children)
Health post
Community) % Hospital
outpatient attendance % Hospital Admission % Causes of mortality
Worms 16 Diarrhoea 3.96 Broncho-pneumonia 8.8 Bronchopneumonia
Diarrhoea 13 Worm infestation 3.87 Gastroentritis 4.1 Septicaemia
Acute Resp. Infection 12 Diseases of skin & sub-cut tissues 3.76 severe pneumonia 6.5 Gastroenteritis
Dysentery 10 Chr. Bronchitis/ Asthma 2.99 All other chest inf. 1.8 Ill defined chest inf.
Skin Diseases 10 Diseases of respiratory system 2.54 Bacciliary infection 1.9 Enteric fever
Enteric Fever 9.0 Acute Resp. Infection 1.97 Enteric fever 3.1 Encephalitis
Accindents / Injuries 9.8 Accidents / injury poisoning 1.45 PUO 2.1 Meningitis
Meningitis 4.2 Enteric Fever 1.09 All other chest infection 1.6 PUO
Malaria 3.0 Dysentery 1.07 Acute abdomen 1.3 Nephrotic syndrome
Otitis Media 2.0 Pulmonary TB 1.03 Meningitis
Others 24 Scabies 0.95 Febrile convulsions
Bronchial asthma
Nephrotic syndrome
Severe anemic epilepsy
Thrombocytopenic purpura
Congenital hear disease
TB Lymphadenitis
RTA
Hysteria
‚bomparison of basic health indicators of country of origin and host country of Bhutanese Refugees Health Program (BRHP), Jhapa.
Indicators Country of Origin
Bhutan (1991) Host country
Nepal (1991) BRHP (1996 mid year)
Population 1,551,000 19,605,000 92,836
Population Growth Rate 2.3% 2.6% 3.7%
Total Fertility Rate 5.5 5.9 5.6
Crude Birth Rate /1000 population
38.3
39.6
24.5
Crude Death Rate per 1000 popn.
16.8
14.8
4.3
GNP (US$) 110 160
Adult Literacy Rate 36.8 (men) 10.0 (women) 34.8
Infant Mortality Rate/ 1000 live births
142.0 (1985)
107 / 102
32.6
Under 5 Mortality Rate/ per 100 live births
196
47.3
Maternal Mortality Rate 7.7 (1985) 8.5 (1985) 15-20 (1991) 1.63
Birth wt. (%) <2500 gms 2.800 gm
Weight/ height age (% acceptable)
62.1
38.2
98.8
Immunization: (% immunized) - 1991
BCG
Measles
DPT
Polio
Tetanus (% pregnant women immunized) WHO/ SEARO
1991
98.0
89.0
95.0
95.0
63 Household Survey
86.0
65.0
69.0
69.0
74.0 Second Evaluation. Report
95
58
74
73
24.0 WHO/ SEARO
1991
97
67
79
78
27.0
96.0
95.3
94.2
94.2
97.0
Pregnant women attended by trained personnel (% of live birth)
Deliveries attended by trained personnel (% of live births)
7.0
16.0
9.4 (1988)
5.6 (1988)
97.0
22.1
CONCLUSION :
Finally, it is evidenced that high incidence of maternal, perinatal and neonatal mortality rate, low birth weight coupled with low literacy of mothers and most deliveries conducted by untrained persons. A feasible system for delivery of newborn should be established. Most deliveries are taking place in the community which forms the foundation of base of the system and it should be strengthened by meeting adequate primary neonatal care facilities by training the health professionals like auxillary nurse midwives and traditional birth attendants and provision of basic equipments such as disposable sterile safe delivery kit, portable syringe balance or tricolored measuring tapes and mucus suction trays with a catheter. In the same way upgrading the facililties at health post / health center for neonatal care and maternal services with training on resuscitation and identification of high risk mothers. Furthermore, the referral system for perinatal care cannot function unless international level maternal and neonatal specialized services are established in the district, zonal, regional and central teaching/ non-teaching hospitals.
The health of the fetus and newborn baby is more dependent on the health of the mother because she is both the seed as well as the soil. An improvement in the mother - child life - cycle should begin with the girl child. The neglect and discrimination she is subjected to are extensive. This bias is rooted in a complex set of social, cultural and historical factors. The degree of bias may vary but it exists at various levels, in rural and urban areas, inside and outside homes, at different stages in the girlÕs life, affecting her nutrition, health, education, social status and economic position.
A focus for enriching the mother child life - cycle is the mother - to - be, by raising the educational status of girl child. The adolescent girl should be enabled to avail of learning opportunities; specially for the development of a self - image. Her burden of child care and domestic work should be reduced by providing supportive services and facilities. The relevance of child survival to limiting family size needs to be widely propagated, within a design that brings together birth spacing and maternal and child health into a single programme. Legal marriage age should be strictly followed to minimize teenage marriage, pregnancy and mortality. Antenatal care should be made into a comprehensive service package with optimum availability of iron and folic acid, vitamin A supplementation, use of iodine fortified salts and high coverage of tetanus vaccination. Majority of births should be attended by trained persons through the level of sub-health post and trained TBAs. Thus a critical reappraisal and restructuring of MCH services are called for. Environmental and personal hygiene, faster expansion of training of traditional birth attendants and health and nutrition education for mothers are imperative.
A commitment to accomplish universal immunization of children and pregnant women should be made practicable and sustaining it thereafter. The constant preponderance of diarrhoeal diseases and deaths due to dehydration should be combated by acting in concert to propagate oral rehydration therapy at the household level, transferring knowledge related to home - made fluids, stepping up indigenous production and distribution of oral rehydration salts and promoting correct use of this therapy. As part of the communication process, knowledge on prevention of diarrhoea, through safe water and personal hygiene, as well as knowledge related to the management of diarrhoea, has to be disseminated through complementary channels in a sustained manner.
Acute respiratory infections are a major threat to infant and child life in Nepal. The ARI Control program needs to be restructured and strengthened through grass - root level networking of community level workers by training them in Standard Case Management Protocol of Ministry of Health.
Malnutrition of infants and young children in the country is a consequence of material poverty, and related to delayed weaning and inadequate foods. Furthermore, infectious morbidity episodes aggravate to vicious cycle to worsen the health of a child in early age. The main response will have to be an educational and demonstration effort to encourage home preparations using locally available foods.
Monitoring child growth from pregnancy through infancy and early childhood needs to be promoted as a universal practice, not in isolation but as part of a composite scheme of literacy and education of mothers, infant stimulation, nutritional support and health care for the mother and child , environmental sanitation and personal hygiene.
Early childhood care and education should be accepted as a priority. The public distribution system for food with the aim of establishing countrywide networks with appropriate pricing systems and equitable attention to urban and rural areas to provide adequate access to food for low - income groups.
Parasitic infection is extensive among children in our country. While treatment is indicated on a far greater scale than at present, preventive measures like protected feet, sanitation and health and nutrition education have to be promoted and safe water has to be ensured.
A firm commitment is required to achieve universal primary education coupled with appropriate changes in the content, process and system are needed particularly to relate learning to the improvement factors like health, nutrition and sanitation which are support systems for primary education, as well as to enhance the capacity for productive work. The school system should be increasingly used for raising awareness on issues of child health and nutrition.
