E973 Volume 2 June 8, 2004 Vulnerable Community Development Plan for Nepal Health Sector Programme Implementation Plan (2004-2009) submitted to: The World Bank, Nepal June 2004 FWE COPY Abbreviations AAW Assistant Auxiliary Worker AHW Assistant Health Worker AIDS Acquired Immuno Deficiency Syndrome AMK Aamaa Milan Kendra ARH Adolescent Reproductive Health ARI Acute Respiratory Infection BBC Beyond Beijing Conference BCC Behaviour Change Communication CBS Centre Bureau of Statistics CB-IMCI Community Based - Integrated Management of Disease CDD Control of Diarrhoeal Disease CEDAW Convention on the Elimination of All forms of Discrimination Against Women CERD International Convention on Elimination of All Forms of Racial Discrimination CHD Child Health Division CRC Convention on the Rights of the Child CPR Contraceptive Prevalence Rate CWIN Child Workers in Nepal DACAW Decentralised Action for Children and Women DALY Disability Adjusted Life Years DDC District Development Committee DWSS Department of Water Supply and Sewerage DEIP Dalit Empowerment and Improvement Plan DFID Department for International Development DoHS Department of Health Services EDP External Development Partners EHCS Essential Health Care Services FHD Family Health Division EMOC/EOC Emergency Obstetric Care EPI Expanded Programme on Immunisation FAO Asian Food Organisation FCHV Female Community Health Volunteer FP Family Planning FWLD Forum for Women, Law and Development FWR Far Western Region FY Fiscal Year GDP Gross Domestic Product GEFONT General Federation of Nepalese Trade Union HDI Human Development Index HEFU Health Economics and Finance Unit HIV Human immunodeficiency Virus HMGN His Majesty's Govenmuent of Nepal HRDC Hospital and Rehabilitation for Disabled Children HSPSP Health Sector Program Support Project HSRS Health Sector Reform Strategy HSSP/GTZ Health Sector Support Project/GTZ HURDIS Human Resource Development Information System ICIMOD International Centre for Integrated Mountain Development ICPD International Conference on Population and Development IDA International Development Agency IEC Information, Education and Communication ILO International Labour Organisation IPPF International Planned Parenthood Federation jj VCDP Health June 2004 10/06/2004 IMR Infant Mortality Rate INGO International Non Governmental Organisation INSEC Informal Sector Support Centre KAP Knowledge, Attitude and Practice LSGA Local Self Governance Act MCH Maternal and Child Health MCHW Maternal and Child Health Worker MDG Millennium Development Goal MGEP Mainstreaming Gender Empowerment Programme ML Migrant Labour MLW Migrant Labour Wives MMR Maternal Mortality Rate MOES Ministry for Education and Sports MoH Ministry of Health MTEF Medium Term Expenditure Framework MWCSW Ministry of Women, Child and Social Welfare MWR Mid Western Region NAHD National Adolescent Health and Development Strategy NCASC National Centre for AIDS and STD Control NDHS Nepal Demographic and Health Survey NFDIN National Foundation for the Development of Indigenous Nationalities NFE Non Formal Education NFHP Nepal Family Health Project NHDR Nepal Human Development Report NHSP-IP Nepal Health Sector Programme - Implementation Plan NPC National Planning Commission NRHS National Reproductive Health Strategy NSMP Nepal Safer Motherhood Project OD Operational Directive PHCC Primary Health Care Centre PLA Participatory Learning Action PRSP Poverty Reduction Strategy Paper PWD People With Disabilities RH Reproductive Health SAARC South Asian Association for Regional Cooperation SCF UK Save the Children Fund (UK) SLTHP Second Long Term Health Plan STD Sexually Transmitted Disease STI Sexually Transmitted Infection SWAP Sector-wide approach TB Tuberculosis TBA Traditional Birth Attendant TFR Total Fertility Rate TT Tetanus Toxoid U5MIR Under Five Mortality Rate UNICEF United Nations Child and Education Fund USAID United States Agency for International Development VCDP Vulnerable Community Development Plan VDC Village Development Committee VDP Village Development Plan VHW Village Health Worker WFP World Food Programme WHO World Health Organisation WRLH Women's Right to Life and Health iii VCDP Health June 2004 10/06/2004 Table of Contents ABBREVIATIONS 11 TABLE OF CONTENTS IV LIST OF ANNEXES V 1. Introduction and Executive Summary of Recommendations 1 1.1 Executive summary of recommendations 2 1.1.] National level 2 1.1.2 District level 2 1.1.3 Community level 2 1.2 Social inclusion 3 1.3 Consultation, Participation and Disclosure 3 1.4 Social safeguards 4 2. Legal and Policy Framework 5 2.1 Background 5 2.1.1 Janajati Communities 5 2.1.2 Dalit communities 6 2.1.3 Policies on Women's Development and Gender mainstreaming 6 2.1.4 People Living with Disabilities 6 2.2 International Policies 6 2.3 National Policies 7 2.3.1 The Tenth Five Year Plan 7 2.3.2 Medium Term Expenditure Framework 2002 8 2.3.3 The Local Self Governance Act (LSGA), 1999 8 2.3.4 First Long Term Health Plan 8 2.3.5 National Health Policy 9 2.3.6 Second Long Term Health Plan 9 2.3.7 Health Sector Strategy - An Agenda for Reform, 2002 9 3. Parameters of Social Exclusion and health in Nepal: factors impacting exclusion of women, Dalit and Janajatis 11 3.1 Barriers to Social Inclusion 11 3.2 Exploring the social barriers to health for vulnerable groups 13 3.2.1 Gender-based exclusion 14 3.3 Operational linkages between social structure, cultural norms and health service delivery 15 3.4 Caste and ethnicity based social exclusion 16 3.4.1 Nepal's indigenous peoples 16 4. Programme Components 17 4.1 Essential Health Care Services (EHCS) 17 4.1.1 Family Planning 17 4.1.2 Safer Motherhood 19 4.1.3 Child Health 21 4.1.4 Communicable disease control 23 4.1.5 Strengthened Outpatient Services 24 4.2 Decentralisation 24 4.3 Public Private Partnerships 26 5. Institutionalframework and capacity building 27 5.1 Institutional capacity of the State 27 5.1.1 Ministry of Health (MoH) 27 5.1.2 Department of Health Services (DoHS) 27 5.1.3 National Health Education, Information, Communication (Acting) 30 iv VCDP Health June 2004 10/06/2004 5.1.4 National Centrefor AIDS and STD Control (NCA SC) 30 5.1.5 National Health Training Centre (NHTC) 31 5.1.6 Operational Challenges for MOHfor implementation of VCDP 33 5.1.7 Ministry of Women, Children and Social Welfare (MWCSW) 34 5.1.8 Ministry of Local Development (MLD) 34 5.1.9 National Commissions 34 5.1.10 Local bodies 34 5.2 Civil society 35 5.2.1 Women 's development organisations 35 5.2.2 Janajati institutions 35 5.2.3 Dalit organisations 35 5.2.4 Children's organisations 35 5.2.5 Special interest groups 35 5.3 International agencies 36 5.4 Multilateral and bilateral agencies 36 6. Monitoring and evaluation 36 6.1 Monitoring and evaluation 36 6.2 Implementation 37 7. Recommendations 38 7.1 Core recommendations for actions at the community level 43 7.1.1 Establish block grants to Sub Health Post Management and Operation Committee (SHPMC) for support from CBOs particularly women 's and adolescent community groups for implementation of NHSP-IP 43 7.1.2 BCC in bilingual languages 45 7.1.3 HMIS disaggregated data 46 8. Monitoring framework and indicators for VCDP implementation 50 9. Bibliography 54 List of Annexes Annex-1: Persons met Annex-2: Hazardous employment and health Annex-3: Geographic Distribution of Ethnic Groups Annex-4: Cumulative impact on Social Exclusion from health services in Far Western Region Annex-5: Cumulative impact on Social Exclusion from health services in Siraha district Annex-5a: MDG Goals and Social Inclusion in Health Annex-6: Budget Formulation and Annual Planning Processes of Local Bodies Annex-7: Partnership Defined Quality Program: A Partnership Approach to Quality Improvement in Health Services Annex-8: Social Protection for Vulnerable Communities Annex-9: Formation of Local Health Management Committee Annex-i 0: Public Private Partnership Annex-I 1: Major Health Related Projects Financed by Donors in Nepal v VCDP Health June 2004 10/06/2004 1. INTRODUCTION AND EXECUTIVE SUMMARY OF RECOMMENDATIONS This Vulnerable Community Development Plan (VCDP) addresses social exclusion in health services in Nepal and the effects and implications for vulnerable people for the Nepal Health Sector Program- Implementation Plan (NHSP-IP). The NHSP-IP is the five year operational guideline for the Health Sector Reform Strategy - An Agenda for Change'. His Majesty's Government of Nepal (HMGN) is committed to bringing about tangible changes in the health- sector development process. The health sector's vision is: "A health system in which there is equitable access to coordinated quality health care services in rural and urban areas, characterized by: self-reliance, full community participation, decentralization, gender sensitivity, effective and efficient management, and private and NGO sector participation in the provision and financing of health services resulting in improved health status of the population ".2 The key outputs3, of the NHSP-IP focus on achieving this vision by providing an equitable, high quality health care system for all citizens regardless of their gender, caste, ethnicity, economic status and location through: a. Prioritised Essential Health Care Services, b. Decentralised Management of Health Facilities c. Public -Private partnerships The foundation of the NHSP-IP was set in the objectives of the Second Long Term Health Plan 1997-2017: "Improve the health status of population particularly those, whose health needs often are not met: the most vulnerable groups, women and children, the rural population, the poor, the underprivileged and the marginalised population". In Nepal's diverse yet hierarchical society, previous experience suggests that citizens' access to public facilities and resources is highly dependent on social identity (caste, ethnicity and gender), economic status (landowner, sharecropper or business person) and physical location (urban, rural or remote rural). A significant proportion of the total population of Nepal are women, Dalits and indigenous people (recent estimates from the 2001 census suggest 16 % Dalits and 36.4 % indigenous population). Due to an absence of reliable data and an institutional reluctance on the part of earlier governments to implement reforms that fundamentally address structural inequality, a number of groups have been excluded from mainstream health policies. The excluded groups are predominantly women and girls, indigenous peoples and occupational castes. Because they inhabit all regions and districts of Nepal covered by this broad national health project, a Vulnerable Communities Development Plan is an essential prerequisite for achieving the stated objective of social inclusion in basic health services as set out in the NHSP- IP Document. 'This Health Sector Strategy is the outcome of considerable work that has been carried out by His Majesty's Govemment of Nepal (HMGN), the NGO and private sectors and External Development Partners (EDPs) over the past three years. This process started with a joint review of the sector in autumn 1999 and has continued through a series of workshops and consultations led by the Health Sector Reform Committee (HSRC) chaired by the Health Minister and a core group. The strategy draws on several key HMGN health sector documents: The 1991 National health policy; the second Long Term Health Plan 1997- 2017; the strategic analysis to support that plan (May 2000); the Medium Term Strategic Plan to operationalise that plan approved in 2001; the draft medium term expenditure framework (MTEF) for the first three years of that plan and the policy documents for specific programme areas developed by the Department of Health Services, including the 10th plan concept paper or Health Approach paper - a Poverty Reduction Strategy Paper (PRSP) of the Government of Nepal. 2 Second Long Term Health Plan, 1997 Final Draft Nepal Health Sector Programme - Implementation Plan (NHSP-IP) 2004 - 09 His Majesty's Government Ministry of Health, 19 April 2004 1 VCDP Health June 2004 10/06/2004 1.1 Executive summary of recommendations 1.1.1 National level 1. National Advocacy workshop on Conflict and Health with focus on specific constraints for girls and women, Dalits and Janajatis in conflict areas 2. Sensitising IEC, Behaviour Change Communication Programmes to include women, Janajati and Dalit health and socio-cultural factors 3. Review health related training given by other line ministries such as Education and Labour. 4. Documentation of forms of abuse women health employees and health seekers face and introduce a Directive against sexual harassment 5. Building the knowledge base on traditional healers and practices 6. Production of instruction manual/social safe guard for NGOs/MOH/DDC/ VDC employees working in Janajati and Dalit locations. 7. Human Resource Development of staff at levels on gender and RH and rights to be coordinated with the MoH institutional and management capacity development programme support affirmative action. 8. National Meet of FCHVs from all regions representing different castes and ethnicity to review the FCHV programme in order to identify constraints ; conduct orientation on RH and gender issues and enhance programme efficiency promote sensitivity to gender, Janajati and Dalits related issues 1.1.2 District level 1. Strengthening Regional Social Inclusion issues related to accessibility, utilization, and impact of health care provision related to marginalized communities in Far West an Mid Western regions 2. Health Insurance Schemes for Vulnerable Communities 3. Instruction/training programme for I/NGOs, VDC and DDC staff working in districts in Far- and Mid-Western regions to enhance Janajati/Dalit sensitive HSS programme implementation. 4. Intersectoral linkages mainstreaming social inclusion issues in health 5. Establish networks for emergency travel, supply of medicines, and immediate medical care to patients with donors and I/NGOs and private sector 6. Establish conflict support funds which people without resources can access to for health care 7. Psycho-social support for conflict victims by creating " safe space" for health service delivery 1.1.3 Community level 1. Development of training programme for community women as assistant health workers in close relation to the BCC and EHCS tasks of FCHVs. 2. Evaluation role of local bodies as implementer of government policies since 1999 towards disadvantaged groups, including IP and Dalits and women 3. Social assessment of the community drug scheme 4. Establish block grants scheme for SHPMC to form agreements with selected local community group 5. Establish community based Adolescent Reproductive Health Counseling Center for peer support. 2 VCDP Health June 2004 10/06/2004 1.2 Social inclusion is defined in the World Bank Social Analysis Sourcebook as 'the removal of institutional barriers and the enhancement of incentives to increase the access of diverse individuals and groups to development opportunities' (as cited in Bennett 2003. 4). The Ministry of Health has no definition of the disadvantaged or socially excluded. The Ministry for Education and Sports (MOES) presents the following definition of the disadvantaged/marginalised: "inclusive education is to 'incorporate learning needs of socially marginalized groups, children with disabilities, indigenous children and children living in difficult circumstances with special needs". MoES further defines 'disadvantaged children' as children with disability, girls, Dalit (23 disadvantaged groups) and other marginalized groups4. The VCDP assesses NHSP-IP compliance with accepted safeguard policies, primarily The World Bank's Operational Directive (OD) 4.20 on Indigenous Peoples. This directive requires that vulnerable people benefit from development projects and that potential adverse effect on these vulnerable communities resulting from Bank-assisted activities are at best completely avoided or at least mitigated. It includes the following components, as per recommendations for a thorough Vulnerable Community Development Plan: a presentation of the legal framework for Indigenous People, baseline data, analysis and critique of the proposal under discussion, strategy for local participation, technical identification of development or mitigation activities, institutional capacity, implementation schedule, monitoring and evaluation, cost estimates and a financing plan. Although the directive on Involuntary Resettlement (8) Operational Directive 4.12, is not applicable for the present loan, a separate section details how any sales or donations of land involved in the programme should be dealt with to ensure that poor or vulnerable households do not suffer any loss of livelihood due to such sale or donation.Both these World Bank Directives are in line with Government Policies. The spectrum of health issues confronting vulnerable people in Nepal is vast and complex. Within a holistic framework of health, this development plan for vulnerable people focuses on priority health issues that marginalised groups of people such as women, dalits and Janajatis are most vulnerable to. These include: Child Health and communicable diseases, Adolescent Reproductive Health, Safe motherhood and Sexual and Reproductive Health of women, HIV/AIDS and STD infectious diseases, and the impact of conflict. For the present plan, and for the successful implementation of the NHSP- IP, understanding the effects and implications of the Maoist insurgency on Nepal's health system is essential. According to a USAID report5 and the experiences of HSSP/GTZ6, harassment and threats by both Maoists and security forces have exacerbated the chronic lack of qualified health staff in remote communities, thus decreasing service delivery in many areas. Health workers have requested reallocation, but there are no hard figures to indicate whether this is more than usual. The mobility of health workers has decreased, due to reluctance to travel. Outreach clinics are defunct in affected areas. In some districts the security forces have stringently restricted the provision of medicines to rural areas, reducing the availability of appropriate treatment. (Source: NSMP. Impact of Conflict on Accessibility of EOC Health Services, By Monique Beun and Basu Dev Neupane, June 2003 1 76/96/DFD). 1.3 Consultation, Participation and Disclosure This plan draws on qualitative and quantitative data from primary and secondary sources which have been carried out for an intensive social assessment of the health sector. A series of meetings and interviews were conducted with a wide range of professionals and scholars In the Nepalese context this includes women, former "low caste" or Dalits and Indigenous Peoples or Janajati. The latter two groups especially fir the World bank description in its Operational Directives. i.e. "ethnic minorities. linguistic minorities. children from indigenous groups as per 2002 Act, working children, street children, conflict & calamity affected children, children from remote regions, poor children, children from parents in prisons, those rescued from trafficking and children from migrant parents." (EFA core document) 5 Martinez, Esperanza C., Hari Koirala, Primary Health Care Services in Nepal, October 2002 6 Unpublished field visit reports, Health Sector Support Project (HSSP) 3 VCDP Health June 2004 10/06/2004 working in the field of health, language development, gender, conflict, anthropology and social exclusion issues as part of the consultation. Members of community organisations representing socially excluded groups, indigenous people and linguistic minorities were interviewed. (Refer Annex I for list of people met). This document draws extensively on the Vulnerable Communities Development Plan prepared for the Education for Al17 for the Ministry of Education and Sports in February 2004. On January 8, 2004, separate meetings were held with key national stakeholders from the activist communities representing women, Janajatis and Dalits followed by high-level consultation with line ministries and I/NGOs along with representatives. Given that the root causes for gender and social exclusion of vulnerable groups in particular, Janajatis, Dalits, and women as a cross- cutting concern for most sectors, these consultations provided valuable insight for the social assessment for this VCDP. Specifically for the health sector a Stakeholder Consultation was organised to promote further public participation, and discuss, inter-alia, the project objectives and activities, focusing particularly on the findings and draft recommendations of the VCDP. The workshop was successful with the active participation of key stakeholders, about 60 participants, including HMG/N officials, NGOs, academic institutions and Community Based Associations working in the health sector. The recommendations of the VCDP were well endorsed. The feedback and recommendations from the consultation were incorporated into VCDP. 1.4 Social safeguards Indigenous people social safeguards cover two issues: (i) Indigenous people; (ii) Involuntary settlement. The current document is devoted to ensuring that the recipients of OD 4.20 on IPs are fully met by the NEFA lending operation. Safeguard related risks and measures proposed: Based on findings of the Social Assessment Team's review, the program will not entail any involuntary resettlement or land acquisition. The project does not envisage any land purchase. Land for the construction of public health centres in Nepal is not purchased; rather wealthier members of the community donate it or health centres are built on public land that is not owned by any individual. Therefore this program does not trigger the OP/BP 4.12 on Involuntary Resettlement. However, OD 4.20 on Indigenous Peoples does apply. After conducting a separate and detailed study, the Government prepared this Vulnerable Communities Development Plan (VCDP). The VCDP lays out a number of steps that the MoH will take to comply with OD 4.20 on Indigenous People by ensuring that the program not only will not have negative impacts on IP and other vulnerable groups, but that it also provides the necessary measures to insure that they get equal access to project benefits. (See recommendationsfor details). Rules of taking possession of land: DDC will not resort to any involuntary land acquisition. All donations and purchases will be voluntary. Mechanisms will be developed not only to ensure that any land donations are fully voluntary, but also that such donations do not involve physical displacement or any significant adverse impacts upon incomes of the donor household. All voluntary land transactions will meet the following criteria: (i) The land in question will be free of squatters, encroachers or other claims of encumbrances; (ii) Land will be chosen by the community after ensuring that it will not be disturbing any other land related resources available in that particular piece of land; (iii) Verification of the voluntary nature of land donations in each case; (iv) Land transfers will be completed through registration, with land title vested in the SMC; (v) Provision will be made in DDC procedures for redressal of any grievances related to the land acquisition. 7Vulnerable Community Development Plan by Kiran Bhatia for the World Bank, June 2004 4 VCDP Health June 2004 10/06/2004 Procedure: Lands will not be accepted from such land owners whose holding will be less than the minimum economical viable stipulated size. This size of land might vary from one locality to another. In this case, an agreement of minimum stipulation size will be determined by the SAs in the local context. Land to be used may also not be registered with government (Ailani) and the possibility that such land may have been occupied by landless (Sukumbasi) is high. If Ailani land is occupied, it will not be accepted for the project. All land transactions will be subject to registration (as per market transactions) under the ownership of SMCs of community health centres that are involved in the project and will be done only after ensuring that water will indeed be available in that particular piece of land. Essentially, Social Analysis will arrange for field verification of all cases of land purchases in such a way as to ensure that land has not been taken under any psychological, social, and economic domination and that the above obligations and criteria have been fulfilled. Where such land donation involves vulnerable household, the DDC may wish to seek assistance from local organisations for field verification. The DDC Portfolio Chairman should visit the field and consult with the community for final verification. Information obtained from the community can be used to verify that the correct procedures for the land acquisition have been carried out by the local organisations and the community. 2. LEGAL AND POLICY FRAMEWORK 2.1 Background There has been considerable commitment by HMGN in investing in the health of its people and extending better health services to the Nepalese populace. Nepal became a party to the 1978 global declaration on "Health for All by 2000" and since then significant policy and programme developments have been implemented to meet the challenge of improving the health status of the people despite poverty, wide socio-economic disparities and a difficult geographical terrain and health indicators that at present are among the worse in the world. A brief overview of the legal and policy framework of Nepal's commitment to International obligations and national policies relating to women, Dalits and ethnic and linguistic minorities is presented below. 2.1.1 Janajati Communities The Nepalese Constitution and HMG/N's policies indicate the government's increasing emphasis on the development of Nepal's Janajati groups. The 1990 Constitution defines Nepal as a 'multiethnic, multilingual, democratic, independent, sovereign, Hindu and Constitutional Monarchical Kingdom', officially recognising Nepal's ethnic diversity. The Constitution also makes 'promot[ing] the interests of economically and socially backwards groups' a key directive principle of the state. Furthermore, a proviso to Article 11, Rights to Equality, states that 'special provisions may be made by law for the protection and advancement of the interests of ... those who belong to a class which is socially, economically or educationally backward.' This proviso accords recognition to positive discrimination for disadvantaged groups8. Article 6 of Part 1 of the constitution, relating to the 'Language of the Nation', states: (1) The Nepali language in the Devanagari script is the language of the nation. The Nepali language shall be the official language. (2) All the languages spoken as the mother language in the various parts of Nepal are the national languages of Nepal. Article 18 of Part 3 (in the section on Fundamental Rights) states that: (1) Each community residing within the Kingdom of Nepal shall have the right to preserve and promote its language, ' NEFEN: Janajati Empowerment Project, Project Document Submitted to Enabling State Programme 3 February 2004 5 VCDP Health June 2004 10/06/2004 script and culture. (2) Each community shall have the right to operate schools up to the primary level in its own mother tongue for imparting education to its children. The Government formed the National Committee for Formulating Cultural Policy and Programs in 1992 to conceive and realise concrete plans to help preserve and promote Nepalese culture. In order to implement the provision of the 10th Plan, the Nepali Parliament issued an Act in 2002 to establish the National Foundation for the Development of Indigenous Nationalities (NFDIN) which had a broad mandate to ensure the social, economic and cultural development and upliftment of indigenous peoples, as well as their mainstreaming and equal participation in national development. While these policies do highlight the rights for indigenous people, the real concern is the implementation modalities and political climate that enables socially excluded people to access these rights. 2.1.2 Dalit communities Dalit communities have not witnessed much change since the fall of the Rana regime during which they were the most religiously, culturally, socially and economically oppressed population of Nepal. An exception was the introduction of the New Legal Code (Naya Mulki Ain) in 1963. According to this Code, nobody could claim inferiority or superiority on the basis of race, caste and creed; everybody was equal before the law. Two recent measures, the Local Self-Governance Act, 1999 and the establishment of the National Dalit Commission, aim to increase Dalit participation in governance with improved protection of rights. Despite this, and the signing of other national and international acts and conventions (in particular CERD), caste ideology has continued to exert a strong influence on Nepalese society and Dalits, particularly Dalit women and girls, continue to have the lowest social, economic and political indicators. Life expectancy of Dalits is 50 years when the national average is 59. 2.1.3 Policies on Women's Development and Gender mainstreaming Nepal continues to present poor improvement in the HDI for girls and women in most sectors in spite of significant efforts at all levels to confront gender-based inequality and discrimination. This is indicative of the deep-rooted socio-cultural norms and practices of a patriarchal society that both government and civil society continue to struggle with. Nepal has been signatory to numerous International Conventions (Beijing Platform for Action, CEDAW and CRC) and is providing increasing policy reform and resources for women's development and gender mainstreaming. Recent policy reform includes Laws guaranteeing women's right to property, rights against sexual offences, the formation of the National Women's Commission. Laws relating to abortion, which was liberalised two years ago to ensure the availability of safe and accessible abortion, have been passed. The Tenth Plan, building on the efforts of the Ninth Plan, has a specific focus on social inclusion that has created a strong and positive policy environment for the empowerment of women and girls. 2.1.4 People Living with Disabilities Disabled Persons (Protection and Welfare) Act is the only comprehensive legal arrangement made for the welfare of persons with disabilities. It spells out specific rights of PWDs such as: Right to health - Free medical check ups in all governmental health service institutions; Right to equality in all matters and right to live with dignity; Right to Education; Priority in government and semi-government jobs and free legal aid. 2.2 International Policies Over the past few decades the international development agenda has witnessed rapid progress in policy reform on health. There has been a shift from traditional centre driven targeted delivery of health services to an attempt at introducing a more rights based holistic approach to meeting the health needs of all. Among the main components of the rights-based approach are: gender equity and equality; sexual and reproductive rights and client-centred health care. The rights-based approach 6 VCDP Health June 2004 10/06/2004 to sexual and reproductive health emerging from the International Conference on Population and Development (ICPD) in 1994 reflects a new global policy consensus on the relationships between population policy and sexual and reproductive health and rights: if women are empowered and people's needs for sexual and reproductive health are met, population stabilization will be achieved by virtue of choice and opportunity, not coercion and control. The rights-based approach was reaffirmed and extended at the Fourth World Conference on Women in Beijing in 1995, and again at the Beijing +5 and ICPD+5 review in 1999. The World Social Forum and the Millennium Development Goals reaffirm the global commitment to priority for addressing rights of marginalised men and women. (Refer Annex 2for details) 2.3 National Policies Historically Ayurvedic medicines, and different forms of faith healing, were the principal means of treatment amongst Nepal's traditional communities. Numerous alternative beliefs, knowledge and practices of health and non-formal medical traditions have been in practice. Despite these traditional systems and the subsequent establishment of a government public hospital in Kathmandu, access to public health facilities for the common people was extremely restricted. The new Constitution of 1990 established Nepal as a much more inclusive state by explicitly describing it as "multi-ethnic, multi-lingual and democratic country". A number of key reforms have been introduced to strengthen the focus on equity and decentralisation, most significantly the Local Self-Governance Act, 19999. 2.3.1 The Tenth Five Year Plan The Tenth Five Year Plan (2002-2007), Nepal's Poverty Reduction Strategy, is the first national plan to have social inclusion as one of its four pillars. It has recognized gender-based disparities in income and human development as important elements of the poverty profile in Nepal. The Plan also gave priority consideration to major social variables, such as gender, ethnicity, and caste related differentials, which exacerbate the intensity and depth of poverty for the affected groups. The PRSP has identified: (1) the sociological factors that constrain women's access to household income and resources in male-headed families and that the absence of this access is a crucial factor for women to receive health services. (2) the many indigenous ethnic (Janajatis) and caste (Dalits) groups that have been historically disadvantaged. (3) the health sector as a critical area of human development, improving living standards in rural areas for mainstreaming marginalised groups and communities. (4) that service delivery remains weak due to lack of trained staff, drugs and medicines and inadequate or misallocation of resources. (4) that women development has been regarded as cross cutting theme across the four pillars (P-155) PRSP's health sector objective is to extend Essential Health Care Services (EHCS) to all, especially to rural, remote, and poor populations. In order to mainstream the marginalised groups and regions, the plan has emphasized access to health facility within one hour's walk to all, and to prioritise special programs in the Mid and Far Western regions as it presents specific challenges to women and vulnerable communities. The plan sets explicit objectives of reducing existing gaps between these groups and the rest of the population through monitoring mechanisms of targeted programs to ensure equal attention to the deprived communities through the Ministry of Local Development, together with Nepal Dalit Commission and National Academy for the Upliftment of the Indigenous People. However specific strategies for behaviour change of health personnel towards the poor women and socially excluded groups for service delivery and representation of the women and marginalised groups in the management committees of Health posts are not clearly stated increasing the risk of limited social inclusion. 9 LSGA Governance Act 1999: The LSGA, 1999 stipulates that representatives from 'socially and economically backward tribes and ethnic communities, downtrodden and indigenous groups' shall be nominated to each village, municipality and district council. This clearly includes the Dalits. Clause 43 (3) of the act requires VDCs to prioritise projects that provide 'direct benefits' to the so-called 'backward classes' (Dalits) 7 VCDP Health June 2004 10/06/2004 2.3.2 Medium Term Expenditure Framework 2002 HMG/N's Medium Term Expenditure Framework 2002 has categorised public health activities with Essential Health Care Services as a first priority. HMGN is implementing an annual Immediate Action Plan for priority reform and has initiated an incremental transfer of sub- health posts to local management committees and contracting out of district hospitals. In all the policies, decentralisation is presented as a core strategy with health to be managed locally with increased community participation. 2.3.3 The Local Self Governance Act (LSGA), 1999 The LSGA has emphasized priority areas of local bodies to "enhance the living standards, income and employment of, and render direct benefits to, the village people and contribute to poverty alleviation". This Act has sanctioned authority to village committees to operate and manage health centres, health posts and sub health posts, primary health care services including family planning and maternity and child care services. It has made the provision of representation of women, economically backward tribes, ethnic communities and indigenous people at village and ward level development committees The Act has directed the bodies to allocate funds earned from their sources in the health sector on a priority basis'°. Social analysis: the LSGA in its provisions does not address issues of inequity and vulnerability as a result of gender, caste or ethnicity. Directions to recognize and address specific barriers faced by such vulnerable groups, are absent. The absence of such specific directives has resulted in very few women being elected to executive positions of local institutions" with only marginal representation of women in elected institutions except for the reserved grass roots positions. There were no women mayors, vice mayors or DDC chairpersons (Bhusal, 1998 and Shrestha, 1998). Both VDCs and municipalities do not have gender-disaggregated data of their staff, beneficiaries, user groups, development project and services to women. (Gender Budget Audit; Meena Acharya) The Gender Budget Audit carried out recently, has found that the VDCs and DDCs budget formulation process has negligible involvement of women, Dalits and Janajatis. (Refer Annex-6for details on VDCs and DDC budgetformulation process). Among women, 71% (compared to 57 percent of men) have little or no involvement in planning village health programmes and 67 per cent of women (compared to 59% of men) are only marginally involved in implementation. A sharper gender differential is found among the Dalits: 75 per cent either do not participate or participate very little in the planning of village health services, compared to 58 per cent of the advantaged groups (largely Brahmin and Chettri men.) This difference parallels that of implementation where non-participation is 74 per cent for Dalits compared to 56 per cent for the advantaged groups. (Neilson) 2.3.4 First Long Term Health Plan The government prepared The First Long Term Health Plan (1976-92) to address the major health requirements of the population. Though a comprehensive strategic document, this Plan was never operationalised. Primarily a centre driven plan, it was not developed through a participatory approach and was not shared and disseminated with the concerned partners and failed to bring the desired results. "' A Manual Prepared for Transfer and Operation of Local Health Institutions 2060 (2004) His Majesty's Govemment, Ministry Of Health, Department of Health Services Only 289 women were elected as ward chairpersons in a total of 35217 wards, where election was completed. Among nearly eight thousand chairpersons and vice chairpersons only 26 were women. Only one woman had managed to be elected to the position of vice chairperson of DDC. Altogether, only three women had fought for the DDC chairperson and vice chairperson positions. Among 26 women who had fought for DDC membership, only eight got elected. This was less than nine percent of 924 members in the 75 DDCs to which election had been completed in 1997. (Meena Acharya: Gender Budget Audit ofMinistry ofLocal Development: MWCSW/ MGEP/UNDP. 2003) 8 VCDP Health June 2004 10/06/2004 m~~ ~ ~~~~~~ 1 2.3.5 National Health Policy The National Health Policy (1991) provided the key guiding instrument for the policy framework for health sector development in Nepal. Its objectives include: (i) extension of basic primary health care services up to the village level; (ii) provide opportunity to rural people to enable them to obtain the benefit of modem medical facilities; (iii) Priority targets for women and children (MMR, IMR and TFR). It focuses on local resource mobilization to reach people with special needs. It has directed for the adoption of micro planning process in health planning to target all groups with special efforts to reach the underprivileged However, the policy lacks recognition of the rights of women dalit, and ethnic groups and no mechanisms to ensure representation of these groups in the planning process. It also lacks any commitment to the need to develop a data base and monitoring systems of disaggregated data by gender, caste and ethnicity. 2.3.6 Second Long Term Health Plan Building on the National Health Policy and to further guide health sector development the Second Long Term Health Plan (SLTHP)-1997 - 2017) was developed. The SLTHP has considered health as a human rights issue12 and emphasized improvement in the health status of the population particularly those, whose health needs often are not met: the most vulnerable groups, women and children, the rural population, the poor, the underprivileged and the marginalised population. However, strategies and clear mechanisms of service provision for the economically and socially deprived populations including people living with disabilities and women are again not clearly stated. 2.3.7 Health Sector Strategy - An Agenda for Reform, 2002 The Health Sector Reform Strategy draws on key HMGN health sector documents including the 1991 National Health Policy; the Second Long Term Health Plan 1997-2017; the Strategic Analysis to support that plan (May 2000); the draft Medium Term Expenditure Framework (MTEF), and the policy documents for specific programme areas developed by the Department of Health Services as well as the 10th plan concept paper or Health Approach paper - a Poverty Reduction Strategy Paper (PRSP) of the Government of Nepal. There is considerable commitment by HMGN and its EDPs to poverty reduction and achieving the millennium development goals (MDGs). The key issues identified for reform are: Ensuring access of the poor and vulnerable to EHCS; Ensuring that public health services are run in a most efficient manner; Ensuring services out side the EHCS with the provision of safety nets; Monitoring and tracking sector performance. Strengths for Social Inclusion: Major equity issues are related to gender, age, caste, ethnicity, income and area of residence. Transportation cost causes significant restriction to the poor accessing health care in remote areas and the largest equity discrepancies relate to area of residence. The document focuses in particular on how the health sector would make its contribution to poverty reduction and to improving health outcomes for the poor and those living in remote areas. Health expenditure is very low in Nepal in spite of some real increases over recent years. The strategy has emphasized the importance to ensure that pubic finance would be directed to the EHCS and the poor and vulnerable. This would only be achieved if alternative financing schemes for these services are developed along side resource allocation policies for pubic finance that target the EHCS and the poor and vulnerable. There are serious concerns about access to services by the poor. Access to both public and private inpatient facilities varies considerably by income group with the wealthier having higher utilization of both public and private facilities. Need of monitoring data from benefit incidence studies as to which socio economic groups are accessing health care at all levels is. 12 SLTHP, Health Policy Context, pp-10 9 VCDP Health June 2004 10/06/2004 Challenges for Social Exclusion * The strategy is silent about the ongoing political conflict and its implications on the health sector - the requirements of children, widows, female headed households particularly from dalit and Janajati households have been excluded due to conflict. * There had been many policy commitments in the past but were not translated in to practice due to lack of realistic implementation plan. In the present strategy too these gaps are evident and may inhibit full implementation. * Though the strategy has emphasized for the implementation of decentralisation in the sector, the required process has not been defined. * During the process of developing the strategy there was no involvement of stakeholders at the district and level below. Review of NHSP - IP The Nepal Health Sector Programme -Implementation Plan's (2003-07) key focus is to "ensure access by the poor and vulnerable to EHCS": increase the coverage and raise the quality of EHCS, with special emphasis on improved access for poor and vulnerable groups (pp-7). Selected outputs are directly related to social inclusion strategies (pp-16) and one key indicator states: "by the end of 5 years (in 2006/7) XX% of the poor and vulnerable groups are utilizing the prioritized EHCS" (pp-23). Systems for priority access to poor and vulnerable groups have been outlined in the project document in major areas: to develop criteria to identify the poor, expansion of EHCS, subsidized drugs and services, safety net, rehabilitation (of the conflict affected), and participation (pp-23). For the implementation of NHSP-IP a, "Statement of Intent" to guide the partnership for health sector development in Nepal, has been signed by major External Development Partner (EDP) representatives in health and the Ministry of Health. The framework suggests that all support will be consistent with HSRS. Strengths for social inclusion NHSP -IP has clearly outlined social inclusion strategies. Systems for priority access to poor and vulnerable groups have been detailed. * It emphasises the need to ensure that the poorest people, receive the greatest share of public subsidies for essential services (i.e. services which produce the greatest reduction in health burden) * NHSP has outlined five Sector Management Outputs to ensure effective implementation. * The emphasis of the reform strategy is on outputs and health outcomes. The HSRS is reqarded as a move towards strateajic pIanning and a sector-wide approach (SWAP). * NHSP-IP has been developed after wide consultations with key stakeholders at different levels and is based on various studies including one on social assessment13. Challenges for social inclusion * Lack of conceptual clarity on social inclusion: A review from the perspective of gender and social inclusion reveals that conceptual clarity on gender and mainstreaming is still lacking, and a substantive rights based approach is absent. * Clear recognition of the specific needs and concerns of Dalits and Janajatis is absent in NHSP-IP. While it states that criteria to identify the poor will be finalised and incorporated in the decentralised reform actions, it has not defined who the vulnerable are and lacks a clear definition of vulnerability with relevance to by gender, caste or age. * The indicators in the NHSP-IP are not disaggregated by gender, caste and ethnicity and thus specific initiatives necessary for social inclusion of women, Dalits and Janajatis may not occur. 13 Social Assessment in consideration of gender and marginalised population including in conflict areas (February 2003) 10 VCDP Health June 2004 10/06/2004 * While the NHSP has recognised the health needs for rehabilitation due to the ongoing conflict it has not provided the necessary resources or strategic plan to manage the impact of conflict on non-functioning of health facilities, the rising needs for curative services, psycho-social consequences and infrastructure. The special health concerns of conflict affected children, widows, female-headed households and resource poor families of Janajati and Dalits in remote locations have not been recognised. The NHSP-IP explicitly reflects a poverty focus, coherent with the HSS, both in policy statement and strategy. However, both the HSS and NHSP-IP make no reference to the current conflict in the country. While arguably this may be justified for a "long term" strategy, it would be highly relevant to include reference to the conflict and the negative consequences on implementation of services and reforms over the next 3 years. The NHSP-IP generally does not address other types of inequity and vulnerability in depth. such as by gender, caste, or age. The few explicit references to services for vulnerable groups are found in the Output 1 statement ("Clear systems in place to ensure that the poor and vulnerable have priority for access"), in the HIV programme emphasis, and in the Disaster Management activities. However, lacking a detailed Annual Work Plan and Budget, it is difficult to judge how these statements are to be made real. (Joint Review of the Nepal Health Sector Programme - Implementation Plan, 15-26 March 2004) Social analysis of other health policies HMG/N has developed various national policies and strategies for different health components. Those relevant to the prioritised areas of this VCDP are child and adolescent health, national reproductive health strategy (NRHS), 1998 and national HIV/AIDS strategy (2002-2006). (Refer Annex 3for details). 3. PARAMETERS OF SOCIAL EXCLUSION AND HEALTH IN NEPAL: FACTORS IMPACTING EXCLUSION OF WOMEN, DALIT AND JANAJATIS This section includes specific primary and secondary data on the types of barriers that different social groups of Nepal face, the socio-cultural framework including structures, which govern rural economic life, and the key factors of social exclusion, which impact the health of the people of Nepal. 3.1 Barriers to Social Inclusion Barriers to social inclusion in all facets of life in Nepal include gender-based social stratification, which in turn must be placed in the prevailing ethnic, and caste based hierarchies that structure econornic and social relationships in Nepal. This defines how the lives of girls and boys, men and women will be shaped according to the caste and ethnic groups they are born in, their religion and the location of their community and the rules and norms that these social structures define. These social structures govern all spheres of an individual's daily life. The health status of the people in Nepal remains low on account of four main barriers: economic, social, physical/mental, and geographical. 3.1.1 Economic barriers: Nepal is predominantly an agricultural country, drawing about 40 percent of its Gross Domestic Product from this sector with approximately 85 percent of its population still earning their living from farming. The annual per capita income of Nepal is now USD $240 and around 42 percent of the population are estimated to be living in poverty. The majority of the population is rural-based, where poverty is at its worst, particularly in the mid- western and far-western regions of the country which are beset by the double problem of continuing food shortages and the ongoing impact of the State-Maoist conflict. Poverty presents many disincentives for families to invest in health seeking care, especially for girls and women who are historically less valued and hold a lower social status than men and boys in almost all communities. The user charge, levied to provide additional income for the hospitals, generally discourage children, elderly and the low-income groups from seeking care because of the 11 VCDP Health June 2004 10/06/2004 unavailability of money during sickness. (Public Expenditure Review of the Health Sector in Nepal, HEFU, MoH, 2003, page 18). There are certain systematic associations between social identity and economic status. Ninety percent of Nepal's Dalits live below poverty line with an average per capita income of only $ 39.60. 3.1.2 Geographic barriers: Nepal is one of the poor est and most mountainous countries in the world with great diversity in terrain that presents a range of challenges for access and infrastructure. Significant geographical variations mirror the existing income poverty differentials. The HDI for urban areas (0.616) far outstrips that for rural areas (0.446), because of better access to services, resources and opportunities. Similarly, there are significant differences among ecological zones. The HDI for mountains (0.378) is well below that for the hills (0.51). The broad scattering of communities in the mountains limits access to services and resources and severely disadvantages people who live there. Human development in the hills is higher than in the Terai (and the national average). The central and eastern regions of the country have the highest proportion of indigenous peoples, but the data overwhelmingly indicate that Janajatis primarily occupy the hilly and mountainous regions of Nepal, and that these districts are often remote and accessible only by foot. All available data in Nepal suggest that poverty is deeper and more severe in rural areas especially in the mid and far Western regions. Hill districts with a high concentration Hill Dalits are Surkhet, Kailali and Kaski; Terai districts with a high concentration of Dalits are Siraha and Saptari. Gender-based development indicators are low in almost all these same districts. Poverty is more extensive in the hills and the mountains as compared to both urban areas, as well as the (rural) terai. Over 90% of the poor live in rural areas. Poverty in both the Terai and the Central Hills is close to the national average, but is much higher (56%) in the Mountain region. The poverty rate is the highest in the more remote rural areas-the Mid-Western and Far-Western hills and mountain regions where it is as high as 72%. The highest proportion of people with disability without access to education was found in the mountains (77%) as compared to the hills (58%)14. Relative to people in other parts of the country, residents of rural and remote areas in Nepal have lower life expectancy and suffer more from chronic and acute illness. As a result, the impoverished populations of the underserved areas depend heavily on public sector facilities, which are most deficient in those very areas. These regional disparities are among the worst in the world. (Report No. 19613 Nepal Operational Issues and Prioritization of Resources in the Health Sector June 8, 2000 Health, Nutrition and Population Unit, South Asia Region) Drinking water containing high amounts of arsenic has adverse affects on human health, including increased risks for cancer, diabetes and heart disease. (http://www.south-asia.com/USA/ hub_arsenic.html) In Nepal no medical case of arsenicosis has been reported15 so far. But arsenic contamination has been detected in 11 Terai districts of Nepal. 3.1.3 Mental and Physical Barriers for children with special needs: Children with disabilities are the most visible group of those targeted in the MoES definition of disadvantaged people and there is a specific focus on special needs education. WHO estimates that 10 percent of the total population of Nepal suffers from disability with the number being higher in women and comparatively worse in the case of women above 25 years of age 35% were under 19 years of age (UNICEF 2003, Lansdown). More than 50 percent of disabilities are seen in children below five (A Situation Analysis on Disabilityv in Nepal, 2001). In rural Nepal, many girls suffer disability due to lack of timely access to vaccine for polio and other related diseases. A study of eight surveyed districts in 1995 indicated that 12.4 percent of the population was mentally retarded with many cases being acquired retardation caused by neglect of disease, especially high fever, severe diarrhea, typhoid, pneumonia, measles, polio, encephalitis and paralysis (A Situation Analysis of Disability in Nepal, 2001. Chitrakar, 2004) 14 Source: Disabled Children in Nepal Progress in implementing the Convention on the Rights of ihe Child, Gerison Lansdown, 2003 5 Reports on the Household survey on the health impact of arsenic contaminated ground water I nNawalparasi, 2001, Drinking water quality programme NRCS/JRCS/ENPHO 12 VCDP Health June 2004 10/06/2004 Studies done on disabilities so far have traditionally used a gender-blind approach. (Dhungana, 2003). Absence of barrier-free development is a fundamental need of disabled people and they need access to these services (Hema 1966; Ototake, 2000; Maqbool, 2003). 3.1.4 Barriers caused by Maoist conflict: In the most severely affected areas, Maoists have reduced health service availability since health staff have often left their postings due to harassment. The security forces have restricted delivery of medicines. The conflict has had a major impact on transport during the night, when curfews are imposed and mobility is severely restricted. The number of male household members has been significantly reduced, leaving the decisions concerning health expenses to the female household members. Since the Maoist conflict started more than 35 thousands pregnant women have died and post partum haemorrhage is the main cause of maternal death. (The Space Times daily newspaper dated 01 April 04). Particularly at night, it has become more difficult to ask advice from relatives, neighbours, and nearby TBA and FCVH who would otherwise be consulted before taking major steps involving financial expense. Uneducated, poorer, low-caste people in particular, are not aware that they can get permission for night travel (Source: NSMP: Impact of Conflict on Accessibility of EOC Health Services, By Monique Beun and Basu Dev Neupane, June 2003 176/96/DFD). A new emerging concern is the growing number of physically handicapped children who will require special health care. Those separated from parents and families in the midst of conflict are amongst the most vulnerable. It has been estimated that 2000 children have lost at least one parent and over 4000 have been displaced from their villages in the conflict-affected areas and forced to migrate. Impact of conflict on women, Dalits and Janajatis: The insurgency has had several consequences on vulnerable and disadvantaged groups. The safety, livelihood and status of women and girls have been especially negatively impacted, with a sharp rise in male migration. Dalits too have become victims as both the warring parties and the general public treat them with suspicion. Forces have committed violent acts, including gang rape, torture and murder against women who were believed to support Maoists or who were hiding information concerning their husbands or sons- there are 24 documented cases of pregnancies caused by rape. Psycho social impact: Ongoing research16 has revealed that out of 37 respondents (of whom 25 were women and 16% Janajatis), 31 (84%) have admitted to behavioural disturbances such as sleeplessness, anxiety disorders, and feelings of guilt and sadness. Three quarters of the population was in substantial emotional distress (74%). Given the far-reaching impact of the conflict it is unrealistic to speak of a "National" Health plan where whole districts are without more than a few functioning health facilities. His Majesty's Government of Nepal's most immediate task must be to seek a speedy and complete resolution to the present conflict. Without this, NHSP-IP may be implemented in Kathmandu but will remain a distant dream in most of rural Nepal. 3.1.5 Social Barriers: Social barriers include gender-based social stratification, which in turn must be placed in the prevailing ethnic and caste-based hierarchies that structure economic and social relationships in Nepal. The lives and opportunities of girls and boys and men and women are shaped according to the caste and ethnic groups into which they are born, their religion and the location of their community and the rules and norms that these social structures define. These social structures govern all spheres of an individual's daily life. 3.2 Exploring the social barriers to health for vulnerable groups The primary focus in this analysis is to understand the various barriers for exclusion of people from improved health status. Past research has concluded that social exclusion occurs due to inequality in: 1 UNU/swisspeace: Case Study on Gender perspectives in Small Arms and Light Weapons, HURDEC, INSEC, IHRICON, 2004 13 VCDP Health June 2004 10/06/2004 Fig. 1. Social barriers to inclusion Social barriers to inclusion Social Category- | 5ttuso C Gender Caste Ethnicity Language Religion Age pola Moeyns aharin Anrydan Nepali Hindu Adult Parbatiya Woel Dalit and Non- Child, .Subordinate Occupational Janajati Other du Adole /Madhsi_ Gender relations: How the given socio- cultural structures in a particular community define the formal and informal rules for men and women, boys and girls for equal opportunity in decision- making, access, control over resources and participation and the resultant impact on their social status. Caste: How the social stratification by caste hierarchies prescribes the degree of exclusion and inclusion of specific caste groups and the discriminatory norms and practices that results between higher and lower castes. Ethnicity: How the norms and socially defined practices of dominant ethnic groups define the degree and form of discriminatory practices towards disadvantaged Janajatis Language: How communities speaking the dominant language have more possibility for inclusion and the resultant inequality between Nepali speaking people and other minority mother tongue languages. 3.2.1 Gender-based exclusion Though women are the backbone of Nepal's agrarian economy, their access to productive resources, education, informnation, training, and other opportunities is extremely limited. Their social status and privileges are comparatively much lower than of men. Nepal's development indicators starkly dernonstrate this. While average life expectancy for women has finally surpassed that of men in urban areas, women in rural areas still die younger than men in contrast to the nonnal pattem observed worldwide. A study17 on 53 women in Kathimandu prison convicted of "infanticide" has revealed that 42% were from ethnic groups (including Newars), 23% were Dalits and 20% Chettri. Evidence also shows a glaring health disparity based on caste and ethnicity. Even in better off households, a woman's share in household assets and income including basic food security is less than that of a man's. Given the social stratification in Nepal, women and girls are often the first victims of resource poor households. Although the structure of gender relations varies significantly among different social groups, generally it is men who traditionally inherit family land, and who, for the most part control the allocation of household income and assets. In addition customs and social practices create greater vulnerability for women and girls than for men and boys. Women's limited decision-making and bargaining power affects their ability to seek health care for themselves and their daughters/children and mostly have to consult the head of the household and /or whoever controlled the cash/family finances before seeking care. In a study covering about 650 women of different caste/ethnic groups (Newar; Magar, Gurung, Rai and Tamang; Yadav, and Ahir; Damai, Sarki and Kami; Bralman and Chhetri) in 5 districts, 51.2 percent consulted their husbands and 44.5 percent consulted their mother in law or sister in law for seeking health care. Women who earned money through self-employment or PCRW credit " Forum for Women in Law and Development: Abortion in Nepal 14 VCDP Health June 2004 10/06/2004 sometimes used their earnings to pay for health care, but most women would only seek care on their own accord if services were free. (World Bank: Understanding Access, Demand and Uitlisation of Health Services in Nepal and their Constraints, June 2001) Neglect: The same study states that in all districts women were recognized to be ill by family members only when they were bedridden or unable to perform their daily tasks. Family members and women themselves place a very low value on women's lives, thus women's health is often ignored. Fear of domestic violence contributed to women's reluctance to voice their need for healthcare services. Janajati women: Women's position relative to men varies by caste and ethnic group. Ironically women from the dominant "high caste" groups are among the most severely restricted in terms of access to assets, opportunity and voice. The status of women and girls among the ethnic groups speaking Tibeto-Burman languages and among the lower caste Hindus is much higher than among the dominant high-caste Indo-Aryan groups (Bennett 2003). Janajati women are relatively better off in terms of gender equality within their own communities as compared to upper caste Hindu women. Janajati women are in the paradoxical role of being at once oppressed by state and national forces yet relatively better off in terns of gender equality within their own communities as compared to caste Hindu women. However, education and literacy are particularly low among Janajati women, while literacy in Nepali - a language which is a mother-tongue for very few - is lower still. Dalit women: Dalit women constitute 50.6 percent of the total population of Nepal, as per the 1991 census. It is estimated that more than 98 percent of the Dalit women live in the rural areas. Dalit women's literacy is much lower to that of Dalit men. The literacy rate is more than 3 times higher among Hill Dalit women (14.7%) than among Terai Dalit women (4.0%). Dalit women face triple discrimination in their daily lives -as a woman, as a Dalit, and as a Dalit woman. Dalit women have to face more discrimination than men in places like water taps, markets, training centres, wage payment and food distribution for agricultural work. The majority of trafficked girls and women are from the Dalit and Janajati community. Women with special needs: Women and girls with disabilities in Nepalese society experience additional discrimination because of their disabilities as they are exposed to greater risk of physical and sexual abuse, denial of reproductive rights and reduced opportunity to enter marriage and family life. Apart from birth affected disabilities, women and girls in Nepal also become disabled due to discriminatory social and economic practices and issues of gender based violence. Service delivery programs largely ignore these social dimensions of disability. 3.3 Operational linkages between social structure, cultural norms and health service delivery Gender, caste and ethnicity -along with geographic location and distance from the seat of power in Kathmandu - remain highly correlated with poverty and vulnerability in Nepal'8. Available data demonstrates how the presence of several barriers (e.g. poverty, residence in a remote area (especially in the Mid and Far Westem Hills), being a girl, being from a Dalit or Janajati group and being disabled) can lead to multiple exclusions and compounded disadvantage. Yet membership in some sorts of excluded groups can actually help to reduce other forms of exclusion. For example, Janajati children face a linguistic barrier and often suffer from low enrolment and high drop out rates because of their unfamiliarity with Nepali as the medium of instruction. Yet districts with a high Janajati population are found to have a lower gender gap in literacy. Conversely, although children from districts with a high proportion of Hindu Caste populations (both high and low) who grow up speaking Nepali do not suffer linguistic disadvantage, girls from these districts face the highest gender-based barriers. Those districts where the Hindu caste population is dominant (clustered in the mid and Far Western regions) also have the highest gap between male and female. (Refer to Annexes 11, 12 and 13 for geographic distributions of ethnic groups and representations of barrier linkages in the Far West Region and Siraha district) 18 World Bank, 2004, Concept Note on Nepal Gender and Social Exclusion Assessment 15 VCDP Health June 2004 10/06/2004 3.4 Caste and ethnicity based social exclusion The Dalits, as historically disadvantaged groups, lag behind in their income and asset levels, in their education and other human development indicators - and in the extent to which they are represented in the power structure. There are 205 types of caste-based discrimination currently practiced against the Dalits that have been documented in a recent national survey. The national average Dalit literacy rate for 6 years and above is only 23 percent (12 percent for Dalit women and 33 percent Dalit men) and only 30 percent of Dalit children go to school.'9 The Dalit children outnumber other groups in the worst form of child labour prevalent in Nepali society. U5MR (Under 5 Children Mortality Rate) was 171.2 compared to 79 of the national average (per 1000 live births) in 1996 (NEsAc, 1998). IMR (Infant mortality rate) was 116.5 (compared to 52.5 for Brahmin) per 1000 live births in 1996 (NESAC, 1998). Immunisation coverage on Dalit children is 43 per cent, which is less by 20 per cent than the national average. Regarding the young age mortality, the child mortality was reported 15 out of 33 from the Dalits (TEAM Consult. 1999: Table A4.2a: 256). 3.4.1 Nepal's indigenous peoples Various definitions20on indigenous people exist (Cohen 1999. Gurung 2001). On basis of the National Academy for the Upliftment of Indigenous People/ Nationalities Act, 2058 (2001) the law has identified 59 indigenous peoples, which may be changed after periodic review. Of the estimated 300 million indigenous peoples of the world, 8.27 million live in Nepal. Currently, there are 59 cultural groups identified as indigenous nationalities or Adibasi Janajatis by the government. The indigenous peoples possess distinct identities, cultures, languages, religions, histories, institutional structures (Human Rights Yearbook, 2004), health care practices, medication practices, utilization of specific shaman healers, worshiping, health seeking behaviours with spiritual relationship to their land and with their unique customary laws, knowledge system, values and world views, the indigenous peoples from different societies apart from those with rigid hierarchy of the Hindu caste system in Nepal. The discrimination and exclusion, which is often structural and systematic, based on their ethnicity, language or religion, has barred the indigenous peoples from exercising their individual and collective rights for non-discrimination, and to effective participation and cultural identity. The failure to observe civil and political as well as economic, social and cultural rights is a major concern for promoting an equitable, inclusive and peaceful society in Nepal (Human Rights Yearbook, 2004). Of the estimated 300 million indigenous peoples of the world, 8.27 million live in Nepal. Currently, there are 59 cultural groups identified as indigenous nationalities or Adibasi Janajatis by the govermnent. Discrimination and marginalization of indigenous peoples represent a major threat to the rich diversity and democracy in contemporary Nepal. Janajatis are disadvantaged due to. Nepali, the 'language of the nation' is the only 'official language', which is reportedly spoken as a mother tongue by 48.61 percent of the total population (CBS 2001) There are also large populations in the Terai who are not Janajati but who speak Maithili, Hindi or other distinct languages as their mother tongue. If health service providers are not conversant with the languages, access for Janajati people becomes constrained. Family poverty - especially among disadvantaged Janajati groups -leads children to seek work and exposes them to health risks. Representatives of indigenous population groups consider language as one the most severe access barriers experienced by indigenous people in accessing basic health care, - even bigger than barriers connected to economic and resource limitations. The language barrier is therefore perceived as leading to significant under-utilization of public health services. '9 Situational Analysis of Dalits in Nepal, 2002 20 Definition on indigenous peoples relies on the three variables: I) language, 2) self-perception, and 3) geographical concentration. These variables are used in different combinations and are given different priorities depending on the country under investigation. The definition has been applied in World Bank investigation on poverty among indigenous peoples of Latin America. (Cohen 1999) 16 VCDP Health June 2004 10/06/2004 Chepang: Chepangs, also known as 'Prajas' have depended on forests and forest products for food for generations. With decreasing natural resources, they are caught in a vicious cycle of insufficient food, increasing poverty, chronic starvation leading to various types of illnesses. * Distance: Living high up on mountains, slopes, Chepangs are far from health service centres and other facilities. In Chit wan, they have to walk for seven hours before they can reach a sub-health post or a school. The strain sometimes results in their contracting other illnesses, leading to more complications of arranging emergency funds. Disillusioned with the available services (no medicines, no health workers) most Chepangs today are unwilling to make the effort. * Language issues: Most health workers are not Chepangs making language a huge barrier. In Chit wan, out of 20 teachers, only two (kept locally by the Chepangs themselves) were Chepangs. * Discrimination: The humiliating language and the discriminatory behaviour of the health workers are additional barriers, forcing them to prefer their traditional methods. Women find it more difficult to access health centres because of gender specific constraints. This state of starvation and ill health bears direct impact on children's education. Only when children are able to cope with staying hungry and walking long distance, which usually only be adolescents, can manage do they start aKtending schools. (Source: SNV: Can Orange Trees Blossom On A Barren Land, 1997; Interviews with SNV staff) 4. PROGRAMME COMPONENTS Selected initiatives of the Government and other agencies supporting the programme components of NHSP-IP are reviewed from a social inclusion and gender perspective in this section. The progranime components are linked to those included in the PAD and categorised accordingly. 4.1 Essential Health Care Services (EHCS)21 4.1.1 Family Planning HMG/N's long term goal in famnily planning is to reduce fertility and under -five mortality. Programme strategies are (i) increasing demand for services through Behaviour Change Communication (BCC); (ii) increasing access to integrated family planning and reproductive health services; (iii) improving care quality with counselling, infection prevention and management of side effects and complications; and (iv) increasing access to condoms through multiple channels. DOHS's Family Health Division (FHD) implements the program. Challenges for social inclusion Contraceptive Prevalence Rate22: Nepal continues to experience high levels of population growth (2.27 per annum). Numbers of women of reproductive age is projected to increase upto 71 percent (Nepal Health Profile on Women, Health and Development 2001, Planning and Foreign Aid Division, DoHS/MoH) indicate the need for massive FP services in the future. 2 The Program will support the expansion and/or strengthening of eleven priority cost-effective services by: (i) developing and implementing technical standards to improve service quality;(ii) providing in-service training to upgrade the technical skills of about field workers; (iii) ensuring drug availabilitv in health facilities by improved drug procurement and distribution; (iv) using behaviour change communication (BCC) to inform the public about services; to promote healthy behaviours; and to promote a client focused, gender-sensitive attitude among providers; (v) improving outreach activities especially in the Mid and Far-Westem Regions; (vii) contracting NGOs for service deliverv in eight municipalities; and (viii) conducting Service Deliverv Surveys (SDS) to obtain client and provider experience of and perceptions about the quality and adequacy of health services(PAD, World Bank April 2004) 22 CPR expresses the percentage of married women of reproductive age (MWRA) using any contraceptive device at any time 17 VCDP Health June 2004 10/06/2004 More men than women are well-informed about family planning methods due to men's access to information and mobility being higher than women's across geographic, age, caste and ethnicity diversity. However, contraceptive prevalence rate (CPR), which is a direct indicator of people's conscious efforts to control fertility, is 38%23 in Nepal with forty-nine districts having CPRs below the national average24. Women have poor access to sexual and reproductive rights National studies indicate that despite 92% men agreeing that contraception is not a woman's responsibility alone; almost 70% men believe that male sterilization is the same as being castrated (NDHS 2001). The most widely used form of sterilization is female sterilization, which is 15% among currently married women while male sterilization is only 6%. Data reveals that only about 24% of men are among new FP acceptors. In fact Voluntary surgical contraception of men has increased in the MWR and FWDR, but has actually decreased nationally over the past three years as per the latest DoHS annual report. New acceptors of different spacing methods have decreased except for condom use. Wide differences exist between districts in the range and quality of FP services provided (e.g. IUCDs and Norplant are available in 60 and 55 districts only). Womens unmet need: There is a high unmet need25 with two in every three Nepalese women demanding FP services but only three/fifths are receiving it. Approximately 35% of teenagers 26 have an unmet need for FP services , and the wanted fertility rate amongst adolescents is 2.5. These factors lead to unwanted pregnancies, sometimes leading to abortions, which until recently was illegal. Social exclusion impact on Total Fertility Rate: (1) A strong linkage between education and fertility has been clearly established. While women had a TFR of 4.8, women with some secondary education had a TFR of 2.3 (NDHS 2001). The total fertility rate27 estimated at 4.1 per woman is quite high. There are vast geographical disparities with urban TFR (at 2.1/woman) and rural (at 4.4/woman) and the TFR is the highest in the mountain- 4.8 births/woman. (2) The under-5-year mortality rates for children of uneducated mothers in Nepal is 121 per 1000 births, 64 per cent higher than for children of mothers who have some primary education and nearly double that of children of mothers who have some secondary education (DIIS 2002). Compared with children of mothers with SLC and above children of uneducated mothers have 8 times higher risk of dying. Reducing one key social risk exposure - such as lack of education - might decrease the vulnerability of women to the effects of other health risks (WHO 1998, Ostlin et al 2001). (Refer Annex 5, Figure 3for correlation between mother 's education and U5MR.) Research has indicated that contrary to other population groups in Nepal, Dalit women have not experienced any progress in indicators such as use of family planning devices, girls attending schools and increases in life expectancy in recent years (Koirala 2002). Social norms: In Nepalese society women are often viewed as a biological means of human reproduction. Various socio-cultural, socio-economic, religious cultural and political factors have been influencing the women's health and relevant attitudes, traditions and behaviours (Rajbhandari et al., 1998). These factors are deeply rooted in our social structure, where women have subordinate status resulting in low self-esteem. There is lack of knowledge among wide population groups, particularly rural women, about women's health concerns. Indigenous knowledge, technology, experience and plant resource of medicinal values have been gradually disappearing and at the same time resorting to health facilities is very low in rural areas. Muslim women for example, face religious constraints in the use of FP services. Mobility constraints 23 NDHS 2001: The respondents in the NDHS survey were: Brahman/Chhettri/Newar: 31 %; Janajati: 24%; Occupational castes: 21%, Muslim: 4.6; Rajbhanshi/Yadav/Ahir:10%; Others: 10% 24 Differences between districts: Maximum: Kathmandu: 77.42%, Kalikot: 7.87% 25 Unmet Need: Women who want to wait before another child but are not using any contraceptive are considered to have an unmet need. 26 Adolescent and Youth Reproductive Health in Nepal: Status, Issues, Policies, and Programs, Policy Project, 2003 27 TFR expresses the number of children a woman will bear by the end of her reproductive life under prevailing fertility conditions. (Annual Report 2002-03) 18 VCDP Health June 2004 10/06/2004 also hamper their access.28 Social realities in Nepal would constrain access to FP services for unmarried women, especially girls. Discussion within couples about contraceptive use is still uncommon due to women's poor bargaining power. One in two married women has stated that their husbands alone have the final say in the wife's health care (NDHS 2001). 16% of women, who have no say in household decisions, are using a modern method of contraception compared to 42% women who actively participate in household decisions. Use also varies with attitudes towards wife beating. 36 percent of women who believe that a man is not justified in wife beating are using modern FP methods compared to 26 percent of women who believe otherwise. Thus women's status is strongly linked to access to family planning services (NDHS 2001). Research by Engender health29 has indicated that while men take majority of the decisions, they are not informed decisions because men are unaware of FP/RH issues. Due to unavailability of disaggregated data, the specific issues of Dalits and Janajatis could not be identified. [Responses of government and other agencies (Please refer to annex ... for examples)] Gender, Caste and Ethnic issues: Various I/NGOs and projects are supporting the Family Planning programme of HMG/N. But apart from SCF US, specific strategies or guidelines to reach the socially excluded have not been adopted. While gender concerns have been addressed to a certain extent, needs and interests of Dalits and Janajatis have not been consciously recognized. Female Community Health Volunteers (FCHVs) have become key delivery agents and many activities are focused on increasing their skills. Most FCHVs are from families, which have a more secure economic background than others in their community. Due to the work without pay, some examples of FCHVs facing domestic violence from husbands and mothers-in-law were found where the women were beaten for attending meetings30. The overall caste ethnicity disaggregation of the 47000 FCHVs is unavailable but it is generally recognized that most FCHVs are of Brahman/Chettri caste and very few are Dalits or Janajatis31. Lower caste representation can be found only in areas with a high concentration of lower caste people. Poor people were found to have more trust in FCHVs, and those who were further from health facilities consulted them more often. People with education did not consult FCHVs as they had better access to health services 4.1.2 Safer Motherhood The FHD's National Safe Motherhood Plan (2002-2017) plans, over 15 years, the establishment of basic and comprehensive emergency obstetric care (B/CEOC) in all 75 districts, skilled attendance at all births and increased access to emergency fund and transport services. NHSP-IP will establish CEOC in 10 hospitals, place midwives at the village level and improve basic obstetric care with competency based training to outreach female providers. Prioritised Health Service Achievers and Social Exclusion Gender based inequality results in several additional constraints for women and girls that cause maternal death and several illnesses. Women 15-44 years old experience a 26 percent higher loss of DALYs than men in the same age group. Much of this excess loss is related to problems related to pregnancy. * Heavy workload: No rest during pregnancy and after childbirth. * Deprivation: Inadequate food during pregnancy and after delivery; deprived of love and care during pregnancy and during the adolescent period; deprive of education, health 28 Interviews with key informants 29 Interview with project staff 3 Matemal and Neonatal Health and HMG/N: A Study of the Concept of Volunteerism: Focus on Community Based Health Volunteers in Selected Areas of Nepal, February 2003. 3' Interviews with key stakeholders 19 VCDP Health June 2004 10/06/2004 care, expression of feelings; lack of financial security; deprived of information due to language. * Cultural Practices: food restrictions during pregnancy, lactation or post partum (certain food restrictions during menstruation 48%, lactation 23% and post partum 43% is an example)32; Chhaupadi (field observation)33; hazardous practices such as - practice of making the women vomit forcefully in retention of placenta. * Dropping out from school, child labour, gender discrimination, violence and abuses including girl trafficking and prostitution. Significant effects on women's reproductive health amongst women workers were identified, including over bleeding, miscarriage, loss of reproductive capacity, high infant mortality, under weight child, and disabled baby. The agriculture sector showed the highest effect followed by the tea sector, mainly from over bleeding and miscarriage. 27.2 women workers have suffered from over bleeding, 13.3 from loss of reproductive capacity, 20.3 from miscarriage, 13.4 from under weight children, 13.3. from high infant mortality and 10.8 from disabled children. (Gefont/KAD Study Report on Women Worker issues, Searchfor Alternatives, 2003) Heath seeking behavior is deeply influenced by caste and ethnicity with some traditional practices providing treatment based on natural remedies and indigenous knowledge (see chart below). The findings of a study in Baglung revealed that the Mangol and Dalit population as a proportion of the total population in Baglung (29% and 25% respectively) are relatively higher in comparison to the national proportion. However, their representation of the population using caesarean section is disproportionately small (only 10% & 13% respectively). Conversely the percentage of caesarean sections by the Brahmin, Chhetri and Newar is disproportionately high. (NSMP/DFID: Assessing the quality of Comprehensive Essential Obstetric care using an audit of the 100 Caesarean sections in Baglung District - Pandit Upendra*; Clapham Susan). Refer to Annex 4 for table Women's Major Health Problems in Rural Nepal and Effective Health Remedies Challenges for social inclusion Nepal has one of the highest maternal mortality rate in the world (539 per 100,000 women) and neonatal mortality rate of 39/1000 live births. Around 50% infant mortality is due to deaths during neonatal and perinatal periods. Delivery conducted by trained health personnel is 13% only. Antenatal and post natal care is very limited (NHsp-Jp). Nepalese women of reproductive age comprise 23% of the population. Women 15-44 years old experience a 26 percent higher loss of DALYs34 than men in the same age group. Much of this excess loss is directly related to pregnancy complications. 70% women are anaemic. 90% deliveries take place at home, most deaths occurring at the community (79%) and 21% at the health institution levels. Only 28% women receive care from doctor, nurse or midwife or ANM; 11% from health assistant, AHW; 3% from MCHV; 6% from VHW (NDHS 2001). Abortion complication is a major problem and 20-27% of maternal deaths in the hospital are due to complication of abortion (Maternity' Hospital, 1993). The Maternal Mortality and Morbidity study in 1998 showed that in the community 5% of the deaths are due to abortion. 46% maternal deaths are due to bleeding (NFHP). Disparities based on geographic access and education have been documented e.g. 23 percent of rural adolescents have begun childbearing as compared to 13 percent in urban areas for the same age group (Nepal Demographic and Health Survey 20001). The number of pregnancies among women who had attended school compared with those who had never attended school was 2.1 vs. 4.4 in Achham district and 2.5 vs. 3.7 for Doti. (GTZ/UNFPA: Reproductive Morbidity - A Neglected Issue?) 32 Reproductive Morbidity a neglected issue? report of a clinic-based study in Far Westem Nepal, GTZ/IlNFPA, 2002, pp-23 33 Chhaupadi is the system in Far Westem region that menstruating women have to stay in a separate small room outside the house or at the cowshed. 3 DALY is a summary measure of population health, developed as a means of combining morbidity and mortality in a single index. World Bank, World Development Report 1993 20 VCDP Health June 2004 10/06/2004 Social norms and practices have a profound effect women's health. Young mothers are forced to follow food restrictions during critical periods, such as pregnancy, menstruation and lactation. Practices like Chhaupadi goth (cowsheds where women are kept in isolation during childbirth and menstruation) in the Mid and Far Westem Regions expose women to high risks of infection, mental trauma and even increase sexual vulnerability (there have been many cases of rape reported)35. While largely undocumented, discriminatory behavior within communities and by health service providers has been stated by women and men from different vulnerable groups and increase the constraints faced by Dalits and Janajatis. Significant gender specific effects on women's reproductive health were identified in a study on women's work and occupational hazards. Women workers suffered from over-bleeding, miscarriage, loss of reproductive capacity, high infant mortality, under weight and giving birth to children with disability. The agriculture sector showed the highest effect followed by the tea sector, mainly from over bleeding and miscarriage. Carpet and hotel show the highest % of infant mortality; agriculture, tea and construction show the highest % of disabled children. In the garbage sector, 66.7% women suffered from over -bleeding. A review of Tharu and Magar obstetric practices36 revealed that there was only fragmented documentation about birthing practices, decision-making, and sources of information, health care-seeking beliefs and behaviour, and other related aspects of social organisation in many ethnic groups in the different parts of Nepal. But considerable ethnic differences exist37, enough to highlight the importance of understanding localised knowledge to the increasing access component of the project. [Responsefrom Government and other agencies (Please refer to Annex 8for examples)] 4.1.3 Child Health The DOHS's Child Health Division (CHD) implements child survival programs with priority focus on ARI, Immunisation and Nutrition. The programme faces an enormous challenge of reaching preventive and curative services to women and children. CDD, ARI, Immunization, Nutrition are being integrated with the community based integrated management of child illnesses (CB-IMCI). The ARI Control Programme covers 75 districts, with 10 having the community-based IMCI. Prioritised Health Service Achievers and Social Exclusion Gender inequality affects girls throughout the life cycle. Female children are more likely to be stunted (52% for girls, 49% for boys) or severely stunted than male children (24 for girls, 19 for boys) due to neglect and less access to food, care and timely treatment. (NDHS, 2001). Children in rural areas are more likely to be stunted i.e. 52% than those in urban areas: 37%, children in mountain areas are more likely to be stunted (61%) (NDHS, 2001) 43.7 percent of adolescent girls are currently married of which 23 percent of female adolescents in rural Nepal have begun childbearing as compared to 13 percent in urban areas for the same age group and percentage of adolescent mothers and pregnant mothers is highest in Terai as compared to hill and mountains. (Adolescent and Youth Reproductive Health in Nepal: Status, Issues. Policies, and Programs, Policy Prqject, 2003)Refer Annex 4 for tablefor Situation of Adolescents in Nepal.) I Interviews with key informants and NGO field staff 36 NSMP: Obstetric Health Perspectives Of Magar And Tharu Communities: A Social Research Report To Inform The Nepal Safer Motherhood Project's IEC Strategy, Mary Manadhar, 1999 A Needs Assessment conducted by Nepal Safe Motherhood Project 37 The role of the traditional healer (lamajhankri among Magars, and guruwas among Tharu) is central. Apart from the traditional healers, the most common additional sources of help and information are the private medical shop, and the untrained traditional birth attendant, rather than trained govemmental health service providers. Decision-making is characterized by many different types of delay at all stages of the process, from the woman's first recognition of something abnormal to a decision to her take to the hospital. Men generally showed little awareness of women's obstetric and menstrual problems, but some, especially the younger men, did express an interest in leaming about it. For their part, women were largely skeptical of any benefit of increasing knowledge of these issues among men. Some traditional systems that can operate to organise and provide help in emergencies were found. (NSMP: Obstetric Health Perspectives Of Magar And Tharu Communities: A Social Research Report To Inform The Nepal Safer Motherhood Project s IEC Strategy, Mary Manadhar, 1999) 21 VCDP Health June 2004 10/06/2004 Challenges for social inclusion The highest risk groups are children under five, particularly girls, who account for 52.5 percent of all female deaths. One in every 11 children born dies before reaching age five (NDHS 2001). Although children under 5 years old represent only 16 percent of the population, they account for over 50 percent of the total DALYs lost from all causes and 80 percent of the under-five deaths are due to causes in Group I. The statistics regarding children's health bear evidence to the double impact of poverty and exclusion. One in two Nepalese children under five years is stunted; 10% wasted; 48% underweight and 27% women fall below cut-off for body mass index. One-third children with diarrhoea are not given any treatment at all and one in four children is taken to health facilities for treatment of ARI symptoms (NDHS 2001). Evidence suggests that only 60% of children aged 12-23 months are fully vaccinated (2002)38. Cases of respiratory infection and diarrhoeal diseases are found to confront people from all age groups. Only in four children is taken to the health facility for treatment of ARI symptoms (NDHS 2001). More than 50% of children suffer chronic malnutrition and stunting, forever crippling their potential for growth, development and productivity.39. The proportion of malnourished children is 14% in Nepal, with the highest in the FWR at 16.4%. Prevalence of anaemia among the preschool children was higher (78%) and the highest was among the infant age 6-11 months (90%) (DHS Annual Report 2001-2002). One in four Nepali women suffers from malnutrition. Girl children under five face violent assaults more than twice as many than boy children. A very significant proportion of the children who run away from home are actually escaping violence and brutality at home (Gerison, 2003). Of 200,000 women trafficked: 20% girls below 18 years; Age group most vulnerable for trafficking40 is 11-18 for girls and 6-12 for boys. A higher number of girl children, mostly ex-Kamaiya Tharu girls, work as domestic servants. 43 percent of women convicted for infanticide41 were adolescents. The limited data that is available about Dalit children reveals that U5MR was 171.2 compared to 79 of the national average (per 1000 live births) in 1996 (NESAC, 1998) and IMR was 116.5 (compared to 52.5 for Brahmin) per 1000 live births in 1996 (NESAC, 1998). The immunization coverage on Dalit children is a mere 43 per cent, which is less by approximately 20 per cent than the national average. In a study on Dalits in Siraha, 20 cases of disabilities were found out of the sample population of Dalits in Siraha whom 16 were male and 4 were female. The 'Chamars' seemed to have the highest instances of disability followed by Danuwars and Teli/Sudi and Musahars. Over the period of five years, there were 52 deaths cases of whom 15 were reported to be children. The highest number of cases of children's death was found to be among Musahar caste groups. The Muslims, Musahars and Chamars comprised the largest proportion of those who did not take vaccines due to lack of immunisation. the instances if not taking TT among the untouchable castes group. Dalit children outnumber all other groups in the worst form of child labour prevalent in Nepal (Situational Analysis of Dalits). The caste/ethnicity of child labourers in the carpet sector is highest of Tamangs with 34 percent boys and 24 percent girls. Though these children (of 14-16 age groups) work for an average of 15 hours a day, their earnings are controlled by relatives. And this is more so for girls (36.1 %) than for boys (22.2%) (Child Labourers ILO) According to field information, there are several components of the EPI programme that are currently dysfunctional throughout the country. Some of the difficulties can be attributed to the conflict in a direct or indirect way, but some others are due to dire and chronic lack of 3 The reported coverage of different antigens at the national level was 94% for BCG, 80.3% for oral polio vaccine (OPV3), 80.3% for diphtheria, pertussis and tetanus (DPT3) and 75.6% for measles during the last year (Annual Report) 39 Nepal Micronutrient Survey, 1998. 4' (UNNIFEM/IIDS: Status and dimensions of trafficking within Nepalese context, 2004) 41 Forum for Women, Law and Development (FWLD); Laws of Nepal have classified many abortion cases as "infanticide" and this "crime" carries heavy criminal penalties 22 VCDP Health June 2004 10/06/2004 maintenance of equipment or to local decisions based on personal interest. Dissolution of the locally elected bodies resulted in reduced funds and inadequate coordination as VDC funds, leaders and members were the key for the coordination of volunteers as well as for the provision of information to the community and of food and shelter for the EPI teams in hilly and mountainous districts. (Martinez and Koirala) [Responsefrom Government and other agencies (Please refer ta annex ... for examples)] 4.1.4 Communicable disease control Tuberculosis and Leprosy has impacted poor households, more and within these, girls and women are worse off. Prevention and Control of HIV/AIDS/STI: Strategies include: (i) preventing STIs and HIV among the high-risk groups; (ii) ensuring safe blood supply; (iii) preventing infections among the young; (iv) ensuring care and support for persons infected and affected by HIV/AIDS; (v) improved monitoring and evaluation; and (v) establishing an effective management system. Challenges for social inclusion There are 60,000 people suffering from HIV/AIDS in Nepal of whom 26% are women. 2400 AIDS related deaths have been recorded. Amongst the high-risk group, 40% are migrant labour42, and 18% are clients of sex-workers. Knowledge of preventive measures was found lowest amongst Dalits and Tharu migrants and their wives. Ethnicity, education and marital status were found to be significantly associated with sexual behaviour43 and vulnerability to HIV AIDS. Girl child workers suffer sexual harassment which puts them at an increased risk of HIV infection (CWJN 2000). Women and girls vulnerability is four times greater than that of men and boys. 64 men, 143 women were HIV affected in the age group 14-19 years, in 2000 (NCASC). 17.3% prevalence of HIV among female sex workers in the Kathmandu Valley 62% of female sex workers range between 20-29 years in age.44; Males make the decision to use condoms HIV/AlDS prevalence consistently exceeds 5% in one or more sub-groups (Source: NHSP - IP, 2003). Nepal's epidemic is beginning to show signs that it may be on the verge of becoming generalized in some communities, especially among those in the Far-Western45 and Western regions of Nepal where heavy migration to India occurs. Stigmatization and discrimination of those infected with HIV have become commonplace - and acceptable. PLWHA have limited access to care and support services, treatment, and opportunities to create sustainable livelihood and to participate in decision-making regarding the HIV response. STI and Gender dimensions: Women are still stigmatised with regard to STI treatment and care. Almost all health workers, FCHVs and peer educators stated that many of the men, mostly those from elite and educated groups, are unwilling to support their wives in the treatment of STIs. It was observed that partner treatment for the ML group was particularly difficult, since the men live in India for more than six months in a year (SC, STI Prevalence Study: 2001) and are thus also hard-to-reach for project interventions.. The vulnerability of MLWs has been fuelled by economic and social subordination and limited access to information and education. In a study covering 141 migrant labour, 37.6% were found to be Dalits. Enhanced Supportfor HIV Prevention in Nepal Programme Phase II (Oct 1999 - Sept. 2002) Final Survey Report, Submitted to: Save the Children US By Deve opment Resource Centre (DRC) October 2002. Thefield work was in Kailali. Bardiva, Kanchanpur, Banke, Dang 43 With higher levels of education there was an increase in high-risk sexual behaviour such as MSM, oral and anal sex. Respondents who were educated to grades 1-5 were the most risk indulgent group followed by respondents who had education of more than grade 10. Unmarried respondents were more likely to indulge in high-risk sexual behaviour. In particular MSM and oral sex is significantly higher among unmarried respondents. The men having sex with men (MSM) behaviour was higher among the Newars, Tharus, Gurung and Magars and least among Dalits. Enhanced Support for HIV Prevention in Nepal Programme Phase 11 (Oct 1999 - Sept. 2002) Final Survey Report; Submitted to: Save the Children US By Deve opment Resource Centre (DRC) October 2002 44 Enhanced Support for HIV Prevention in Nepal Programme Phase II (Oct 1999 - Sept. 2002) Final Survey Report, Submitted to: Save the Children US By Deve opment Resource Centre (DRC) October 2002 45 Among migrants in the Far-West, a recent JICA study in Doti district found 10% of men who had migrated to Mumbai were HIV positive. 23 VCDP Health June 2004 10/06/2004 It is harder for them to afford the cost of STI treatment, which is, on average, Rs5OO to Rs800, and some have had to borrow money for the purpose. In addition women are looked down upon if they are known to suffer from such diseases as STI. Because of the social stigma and fear of the apprehension of their husbands, MLWs do not like to keep a stock of condoms in their house. A few of the MLWs noted that it creates mistrust between husband and wife, and breaches the relationship, if the husband finds his wife is keeping condoms when he returns home. It is the males who make the decision to use condom during sexual intercourse. The males thought that talking about condom and sexual health is not necessary because they were having sex with their wives. [Responsefrom Government and other agencies: (Please refer to annex ... for examples)] 4.1.5 Strengthened Outpatient Services Strategies are (i) expanding the Community Drug Programme (CDP); allowing public facilities to charge for drugs to have these in stock; (iii) switching to a "pull" system of drug ordering and local purchasing under central price negotiation; and (iv) improving staff motivation by decentralizing some personnel functions. MOH will promote rational drug use; implement standard treatment schedules and essential drug lists through training, monitoring and supervision; and ensure essential infrastructure, repair and maintenance. The existing situation: Hospital use data indicates that women access hospital services far less than men. Even for women above 70 the use of public hospitals is far less than that of a man (Male: 8; Women: 5). 4.2 Decentralisation46 His Majesty's Government has introduced one of the world's most progressive legislation for decentralization in the world devolving primary responsibility for local development to elected local authorities. The Local Self-Governance Act (LSGA) has given authority to the local bodies (VDC, Municipality and DDC) to operate and manage health centres, health posts and sub health posts, primary health care services, perform public health related works including toilet construction, protection of water sources, family planning and maternity and child care services. The LSGA has emphasized priority areas of the local bodies to "enhance the living standards, income and employment of, and render direct benefits to, the village people and contribute to poverty alleviation ". It has directed the bodies to allocate funds earned from their sources in the health sector on a priority basis. (A Manual Preparedfor Transfer and Operation of Local Health Institutions 2060 (2004) His Majesty's Government, Ministry Of Health, Department of Health Services). Government policy with regard to health is consistent with the decentralised and participatory process of decision making and inplementation, and hence in keeping with the LSGA. However, in implementation, there is lack of clarity as to the functions and responsibilities of government health agencies and local bodies. The problem is compounded by gaps in the provisions of the LSGA and the way health services are currently administered by the public sector agencies.47 While the LSGA mandates local government bodies to manage and supervise S/HP and their functioning, local committees and VDC and bodies like HMC should control resources and management of S/HP. Another discrepancy is the allocation of responsibilities without any provision for the required resources. These differences in rules and regulations between LSGA, 46 Greater local authority and responsibility over service provision (IDA, GTZ, DflD, SDC): The Program will support capacity building for the decentralized management of health services. By the conclusion of the five year Program, responsibility and authority over health posts and sub-health posts throughout the country will be handed over to Local Bodies (i.e., local government structures). The program will articulate roles and functions of the Local Bodies in the health sector and provide training in leadership, setting local priorities in health, personnel management, performance appraisal, planning, budgeting, financial accounting and controls. MOH officials at all levels will receive orientation and guidance regarding their roles in supporting Local Bodies (Project Appraisal Document, World Bank,April 2004) 4 The World Bank Study on Local Organisations: Roles and Relationships, Review of the Health Sector, National Labour Academy, Nepal 24 VCDP Health June 2004 10/06/2004 10th Plan and MoH guidelines and the role of local bodies (VDCs and DDCs) are a major concern for enhanced community ownership of S/HPs. The 'Health Sector Reform Strategy: An Agenda for Change' authorizes local bodies to be "responsible and capable of managing health facilities in a participative, accountable and transparent way with effective support from the MoH and its sector partners" (MoH 2002). The HSRS recognizes that management of health facilities requires transfer not only of budgets but also of responsibilities for planning and implementation of health service development within the districts and has implications for a new relationship between the Ministry, DDCs and VDCs. Indicators of progress have also been identified. Current progress in implementation of decentralization has been the following: (Joint Review of the Nepal Health Sector Programme - Implementation Plan, 15-26 March 2004) Hospital Autonomy: Hospital Development Boards have been formed for all government hospitals above the district level. This has recently been extended to 12 district hospitals. In addition to grants from MOH, Hospital Development Boards have to generate there own resources to recover some portion of the recurrent cost through user charges. According to Public Expenditure Review of the Health Sector (2003) financial cost recovery rate varies considerably, but on average the zonal hospitals recover around a third of the total costs. In addition to resource general function, Hospital Development Boards have the responsibility to: . oversee the day-to-day running of the hospital, * undertake assessment and subsidy for those unable to pay, * ensure smooth functioning of the hospital, and * hire staff. Sub-health post handover: Since 2002 the MOH has handed over responsibility for the management of 922 sub health posts to communities. According to the Guidelines developed by the Ministry of Health for orientation of Health Committees, handover has two broad objectives, i.e.: * To ensure quick, timely and effective health services in the local level by ensuring transparency and good governance, and * To mobilize the available local resources to its possible extent. Currently Village Development Committees receive central government grant of which 25% are earmarked for social services including health. In addition, VDCs can generate additional resources to cover the services. No extra central government funds accompany the new arrangements under SHP handover. While the committees have the responsibilities to oversee and monitor the functioning of health staff, they have no responsibility for their hiring and firing, which remains under the MOH. The chair of the SHP health committee is the VDC chairman when in post. In the current climate the chairman is the VDC secretary. The guidelines state that the committee must have four women as members and two candidates have to represent the dalit/Janajati community (with one being a woman). The SHP Management Guidelines outline the functions of the SHPMC but no role or responsibility to address gender and social inclusion concerns are stated. The functions are stated in a neutral manner, based on the assumption that services will reach all the members of the community. Experience has indicated that unless directives are established, access of Dalits and Janajatis remains limited (Refer Annex 9 for a detailed review of the Local Institution Health Operation and Management Committee). A report of Sub-Health Post Decentralisation Process Review pointed out that the MOH's responsibilities should not end with the mere handover of local health facilities to local communities and giving orientation to its committee members, but continue to provide support, guidelines, build their capacity and monitor their performance. But feedback from informants has been that the handing over is as yet not effective as the required financial and human resources have not been transferred. Decentralisation and EDPs: Decentralisation presents a major challenge to the process of aid coordination, hannonisation, and sector wide programming, partly because of the absence of 25 VCDP Health June 2004 10/06/2004 detail , but also because many EDPs have a strong presence at district level. However neither the draft harmonisation paper, nor the NHSP-IP addresses how EDPs are to engage with government at the different levels. On the one hand there is the need to for EDPs to engage at central level to promote decentralisation plus all the other reforms, and to engage in sector dialogue. On the other hand there is the reality of a strong EDP presence at district level engaged with capacity building for planning and other interventions which necessitates discussions between local authorities and EDPs about their current and future support. It is not clear at this stage how this issue can be addressed, but considerable thought needs to be given to it to ensure that EDPs do not just relocate their highly project focussed debate from the centre to the districts. This will then need to be reflected in a revised Code of Conduct or Memorandum of Understanding between MoH and EDPs. The social issues which affect decentralization include: . High level of poverty and its impact on health needs; . low per capita funding for health care; . relatively limited role of the private health care sector; . problematic allocation of resources in the health sector in the existing epidemiological and demographic profile; . poor technical efficiency of the government health sector; inequality of the system particularly in the urban/rural and rich/poor relationship; . ethnic composition of the country and the regional and federal aspirations of some political groupings; . domination by local elites . existence of an important network of self-help groups 4.3 Public Private Partnerships48 Private sector contributes to about 76% of the total health expenditure (NHSP-IP). This sector and NGOs already make an important contribution to health provision in Nepal. Various agreements and operating modalities exist between MoH and NGOs and private providers, and in many cases these are vital for supporting EHCS programmes and directly providing curative care that cannot be covered by public expenditure. HMG/N has rightly identified the potential for developing this contribution further. The HSS states that the 'public sector will develop a major new role in working with the private / NGO sector', and identifies four areas where this will operate: 1) sustainable financing 2) providing an integrated approach to delivery EHCS; 3) quality assurance by government; and 4) pharmaceuticals, other consumables and new technology. The joint review of the NHSP -IP has carried out an in- depth review of the Public Private Partnership. Detailed recommendations for addressing the future challenges to improve Public Private Partnership are presented in Annex-10. Social Protection Measures for Health Nepal's middle-income group and the mainly urban, formal economy workforce have been the beneficiaries of existing social security provisions (e.g. provident fund, maternity leave, medical care). At present, the formal social security systems (provident fund and citizen's investment fund) cover mainly civil servants, army, police, and teachers. In total, about 400,000 government officials are covered. The Government is the single largest employer in the country. 48 The MOH will appoint a focal point for PPP. The Program will support the development of guidelines, contract standards and regulatory frameworks, and provide training. New service provider agreements/contracts will be defined with NGOs and the private sector. Large district/zonal hospitals will be made autonomous, and NGOs/private sector will be contracted to manage others (Project Appraisal Document, World Bank, April 2004) 26 VCDP Health June 2004 10/06/2004 Any private enterprise with more than 10 employees can join the provident fund on a voluntary basis. All enterprises can join the retirement plan under the citizen's investment fund. However, there is no mandatory social insurance provision for the private sector. The Labor Act and regulations provide some special rights for women workers, who are legally entitled to equal pay for similar jobs, maternity leave, breast feeding time and creche facilities. But women have to be on a permanent pay roll, which is often not the case. There is no recognition that the poor, caste and ethnic disadvantaged require specific provisions. Government, employers' organizations, trade unions, community groups and women's cooperatives as well as families, caste based and occupation based groups and communities are implementing different social protection schemes. Apart from the formal sector social security provisions, there are various informal, partly traditional, community-based insurance arrangements (micro-insurance). (For details on impact on vulnerable communities, see Annex 8 on social protection). 5. INSTITUTIONAL FRAMEWORK AND CAPACITY BUILDING One of the tasks of a successful Vulnerable Community Development Plan is to identify the institution or institutions who should and can take responsibility for implementing the suggestions contained in this report. In many developing countries, government institutions assigned the responsibility of supporting disadvantaged groups are weak and thus unable to provide the level of engagement, which vulnerable people deserve. Assessing the track record and capabilities of these institutions is fundamental to assessing what they can deliver both in terms of the availability of funds for investments and field operations, the adequacy of experienced and trained professional staff, the ability of vulnerable peoples' own organisations, local administration authorities and NGOs interacting with government institutions and stakeholders groups, and the ability of the executing agency or agencies to mobilise other units to successfully implement the NHSP-IP vision and the recommendations contained within this Vulnerable Community Development Plan. 5.1 Institutional capacity of the State The following institutions should be involved in the successful implementation of the NHSP-IP vision and the recommendations contained within this Vulnerable Community Development Plan. Their specific tasks will involve the development of a working system and skilled and motivated staff to support social inclusion in primary health centres throughout the nation. More than rles, a shift in attitudes and behaviour are called for to bring social transfornation in health centres. 5.1.1 Ministry of Health (MoH) With the lead responsibility from the government to manage and oversee the national health service program, the Ministry of Health (MoH) is best positioned to take the leading role in the successful implementation of NHSP-IP and the recommendations of this VCDP. With numerous departments and sections, a large human resource and skilled employees as well as ongoing donor support, the Ministry has the potential to galvanise interest and support across a wide range of institutions in government. In order to effectively implement the Vulnerable Community Development Plan, it will be necessary to establish: (1) policy directives for increased social diversity in staff; (2) capacity building for improved attitude behaviour and skills towards woman, Janajati and dalits; (3) more effective partnerships with NGOs for improved responsiveness to vulnerable communities and their social exclusion from health services 5.1.2 Department of Health Services (DoHS) The department has the primary responsibility for delivery of all the national health service programs. It comprises of five divisions, three centres and two sections and has full 27 VCDP Health June 2004 10/06/2004 administrative and financial authority to coordinate wide range of technical functions for health service development programs. It is directly responsible for all program planning, implementation and monitoring and is therefore the most critical agent of change and implementation. A unit in charge of the successful implementation of the VCDP must be established in the DoHS which can liaise with the ministry and District Health Offices. DoHS is largely limited in concept and scope to is not a conducive framework for holistic health. Institutional exclusion brings many negative consequences. Such traditional divisions within institutions result in less resources, leverage, status and value than mainstream technical units. More so, such segregation reduces accountability of others towards these specified clients. It is the classic dilemma of finding the right balance between special structures for special groups of clients and mainstreaming. Human Resource Development: Ministry of Health Staff Profile: A review of the staff profile reveals that a total of 30186 posts (administration: 9236 and technical 20,950) has been sanctioned for the MoH. Of a sample of 21,805 staff, 28% are women and 72% men (HuRDIS). There are a significant number of women in the health sector but most of them are occupying peripheral and assistant level technical positions with very few in managerial, programming and policy level decision making positions. A gender assessment review49 had identified that in the Ministry of Health, 85% were men and 15% women. Of the 11 women, none were gazetted class I, II, III officers and only one was of special class. Most were peons or equivalent and non-gazetted. Similarly the DoHS staff had 81% men and 19% women. Of the 55 women, 35 were non-gazetted/peon equivalent. The Regional Directorates have 76% men staff. Figure 4 in Annex 5 for gender representation in health services. The disaggregation reveals that a majority of the women staff are posted as nurses while the male presence is highest in Paramedics/Profession Allied to Medicine and in admin/support staff. Caste and ethnic disaggregation of health ministry staff has not been done and was unavailable with HurDIS. Fig. 2. Gender Disaggregation of Health Staff Proportion of Female Health Staff Proportion of Male Health Staff Admin + Ayurvedic Public Admin+ Public Support (Tradibonal Health Support Paramedics Health S1 Medicine) 21% Staff / Profession 5% 11% 0% 34% Allied to g Doctor Medicine IndVgnous (Traditonal 7% Health Medicine) Profession Paramedic Doctor 0% s/Professio 4%lndigenous Nursing n Allied to Health Medicine Nursing Profession . 39% NuOr°s/ln90% 2% Human Resource Issues: NHSP-IP recognizes that the implementation of the Health Sector Reform Strategy requires re-definition of roles, responsibilities and powers of the MoH, the Department of Health Services and the Regional Directors and a re-modelling of roles through out the health system. The public sector bed to population ratio is I bed to 5,435 populations. This becomes worse by the reported under-staffing and hence under utilisation of district beds. 49 MWCSW/MGEP/UNDP: Gender Assessment of the Health Sector, 2002 28 VCDP Health June 2004 10/06/2004 Staff vacancies and absenteeism are widespread - only 60% of sanctioned posts are filled. The total number of staff in proportion to the population is extremely low. A Strategic Plan for Human Resources for Health has been prepared by MoH covering the period 2003-2017. This introduces new policies and operational mechanisms to improve the ability of the Ministry to manage systematically the deployment, utilisation, development and careers of its staff50. The overall distribution of staff in terms of the mix of skills shows a deficiency in the middle technical grades. There is currently a large number of unskilled staff support (35% of the total work force). These unskilled staff along with other low level staff makes up 70% of the workforce. (Strategic Plan for Human Resources for Health) The MoH has started recently upgrading MCH workers by providing ANM scholarship in 500 VDCs and plans to place ANMs in all VDCs. The fact that MCHWs are being upgraded to ANMs leading to a decrease in support staff from 70% to 45% and an increase in the mid-level from 18% to 38% is a positive shift. The issue here is of representation of Dalits and Janajatis as it can be assumed that MCHWs5' are mainly from the dominant castes. The shift from 12% to 17% in the high-level staff also raises the issues of gender and social inclusion as representation of women is minimal at the higher levels. The strategic plan identifies the need to produce more graduate nurses. While a caste/ethnicity profile of the nurse students was unavailable52, a micro-survey of four Medical Colleges in Kathmandu reveals that out of a total of 758 students for MBBS, only five were Dalits (see Annex 4 table 7for details). The Institute of Medicine has started its own undergraduate programme to prepare medical graduates who will have the skill, knowledge and attitude to work in Nepal's varying environments. Stronger emphasis has been placed on community medicine. It is estimated that 47,949 medical staff will be recruited between 2003 and 201753. Of these the highest number is that of ANMs, followed by certificate/staff nurses. This can be used as an opportunity for recruiting representatives from the dalit and Janajati groups, increasing the diversity of the staff profile. The staffing proposals for health posts and sub-health posts reveal that a nurse and an ANM will be added to HP. In sub-health posts, one MCHW will be upgraded to ANM, an additional MCHW will be added along-with one support staff, taking the total number of service providers at the sub-health post to 6. This again can provide the space for inclusion of Dalits and Janajatis so that issues of caste and language are addressed. This Strategic Plan for Human Resources has not identified any policy or strategies for increase of women in decision making positions, when data indicates that there are very few in the gazetted class in higher positions. There appears to be no recognition of the need to adopt alternative strategies to recruit and retain staff from dalit and Janajati caste/ethnic groups. The projected staff requirements do not include measures for caste and ethnic disadvantaged group's inclusion or address gender issues. Retention of core health staff - especially women - at the level of health facilities due to lack of motivation is a major concern. Most of the time, health workers are absent in the health posts and sub-health posts, limiting the availability of critical safe motherhood and reproductive health related services. Only peons and clerks are available to provide services, which further constrains of women as they are reluctant to consult male health workers especially when a gynecological examination is required. (World Bank: Understanding Access, Demand and Utilisation of Health Services in Nepal and their Constraints, June 2001) 50 Policy Paper on Health Sector Development of His Majesty's Government of Nepal, Nepal Development Forum- 2004, Pre Consultation Meeting, Presented by Ministry of Health, HMG/Nepal, February 2004. SI Since disaggregated data is unavailable, this is based on informant opinions. 52 The Lalitpur Nursing Campus was unable to provide the details of the students profile due to intemal regulations. '3 MoH: Strategic Plan for Human Resources for Health 2003-2017 29 VCDP Health June 2004 10/06/2004 5.1.2.1 District Health Office (DHO): DHO is responsible for planning the delivery and management of all national programs on education at the district level. Potential goals include: the handing over of public health service centres to the community and the coordination and cooperation with traditional health centres. All DHOs are overstretched and are constantly challenged with far too may targets to complete. Social accountability will be close to impossible for DHOs without technical support from civil society groups. DoHS needs to do two actions to enable this. First, provide directives on the 'how to' for setting up agreements with NGOs/local groups. Second, facilitate workshops with NGO/local partners to discuss modalities and create a culture for effective partnership. 5.1.2.2 Sub Health Post Management Committees (SHPMCs): With the meaningful involvement of parents of women, Dalits and Janajatis of vulnerable groups, Sub Health Post Management Committees (SHPMCs) and local conmmunities should be given responsibility in actual practice of managing the health centres and the health service it provides at the local level. The Rules and Regulations for SHPMCs do not provide sufficient practical guidelines for enhancing SHPMCs to address social inclusion. Without capacity building on these social factors, SHPMCs will face difficulty in making the strategic shift as the lead body for addressing social inclusion in primary health centres. FCHVs and TBAs: The 47,873 Female Health Volunteers54 (FCHVs) and 12,682 Traditional Birth Attendants55 (TBAs), being unpaid volunteers are not part of the Health Ministry staff. At the bottom of the service provider hierarchy and closest to the community, it is on them that many health programs rely for service delivery. FCHVs are increasingly the entry point for many lINGO supported initiatives and have been acknowledged as the prime contributors for the success of programmes such as Vitamin A distribution. There is an ongoing debate about the use of women as volunteers since it reinforces the belief that women are secondary earners and have the "time" to volunteer. While one recent study56 indicates that FCHVs claim they are happy doing "dharma", their need to eam and the lack of remuneration has often been cited as a major de-motivating factor (see box belowfor details). There is an ongoing discussion about the voluntary status of the FCHVs with one argument stating that it is better to be an unpaid volunteer than to be the poorly paid lowest member of the staff67. The Ministry made the policy decision early in the programme not to make them part of the staff due to lack of funds for sustained remuneration of such large numbers. 5.1.3 National Health Education, Information, Communication (Acting) The NHEICC plans, implements and reviews the Health Education Programme, the Family Health Programme, the Control of Diarrhoeal Diseases/ Acute Respiratory Infection Programme, and the Health Literature and Library Information System. The main activities carried out by this centre are: (a) Production and distribution of printed materials; (b) Presentation of regular weekly and periodic audio-visual programmes; (c) Dissemination of health messages through mass media, mobile video shows and cinema slide shows; (d) Facilitation of seminars/workshops. The centre coordinates with other GOs and I/NGOs to support district and central level IEC programmnes. It would have a lead role in developing materials in all languages of the nation for Janajati population to be less excluded. 5.1.4 National Centrefor AIDS and STD Control (NCASC) This centre could critical role in coordinating the establishment of community based adolescent and youth centres for reproductive health and sexual rights and peer support. This centre could also coordinate with development of life skill based package for training of peer educators. 5 Refer above and the annex for more details 5 The TBA programme has been phased out from this year. 5 Maternal and Neonatal Health and HMG/N: A Study of the Concept of Volunteerism: Focus on Community Based Health Volunteers in Selected Areas of Nepal, February 2003 5 Interviews with key informants 30 VCDP Health June 2004 10/06/2004 5.1.5 National Health Training Centre (NHTC) HRD has been a core part of health services delivery programme and the revision of MoH services structure in 1993 brought the institutional leadership in HR training. NHTC manages a training network of regional and district training centres and in addition works closely with I/NGO , private sector and donors to provide technical training to health officials at different levels. Numerous types of trainings are organised by NHTC in 2002/03 a total of 7,741 health staff were trained achieving 94% of the target at the central level. At the district level as well over 80,000 FCHVs received training. The cumulative target over the 9h Five year Plan, average target of 75,000 health workers was achieved. A quick review of the central level training programme in 2002/03 indicates a very strong focus on bio medical information and practically no inclusion on the social dimensions of health. To address social exclusion it would be essential for service providers at all levels to have conceptual clarity on gender and social inclusion and the socio-cultural dimensions of health. The NHTC and the district training institutions would need first capacity building themselves before they can facilitate effective partnerships with NGOs for introducing training for field service providers on gender -social inclusion and health. Budget Review of Health Sector Finances: The planned allocations for MoH over the next two years of the Medium Term Expenditure Framework (MTEF), through 2005/06, are expected to increase to 5.5 percent by 2005/06. This suggests a strong governmental commitment to health, as there has been a sharp increase in security and defence budgets, leaving the govemment with little funds. (Refer to Annex 6 for details on Health Expenditure Budget) The previous trend has been of the regular budget of HMG being fully spent, but the government and donor development budget remaining heavily under utilized, with the utilization rate of donor fund decreasing from 61% to 27% over the period from 1999 to 2002 (HEFU, pg 8). This is mainly due to the low absorptive capacity of the government and the different budget release rules of the EDPs. The proportion of government recurrent funding has increased. Much of the increase (77%) has been used to finance wages which have increased from 48 to 55%. Trends suggest a decreasing share of funding going to rural areas. They benefit from only 50% of the spending. MOH expenditure on secondary and tertiary care facilities increased from 14.6 percent of the health budget in 1991/92 to 37.5 percent in 1997/98 while the share of spending on primary care decreased from 76.8 percent to 57.25 percent over the same period. In addition, the portion or resources spent on hospital construction over the last five years has increased three times from 3% to 11% (Maskay et al 2002, NHEA 2002). These tendencies indicate an urban vis-ai-vis rural resource allocation bias58. Since the most disadvantaged populations live in the rural areas this urban/rural allocation bias indicates a de facto policy which contradicts the stated political commitment to primary care since initiation of the National Health Policy of 1991. (Social Assessment of the Nepal Health Sector Reform Submitted to World Bank, Nepal Office (draft 130503) Nielsen et al) Despite the fact that Nepal spends 5 percent of its GDP on health, most of Nepal's expenditures come from private out-of-pocket contributions, which in 2000 accounted for approximately 70 percent of total health expenditures. This, as the NHSP-IP recognizes, constrains the poor and disadvantaged from accessing health services as they are less capable of private out-of-pocket contributions. 58 This needs to be evaluated more in detail since there has been an increase in expenditures to district and below health services (as a proxy for Essential Health Care Program) which can be seen as a compensation for the indicated recent tendency of urban bias. But dominance in power structure on the basis caste hierarchy is one potential explanation for the discrepancy between enunciated policy and actual performance. All but 8.8% of the individuals occupying the top political, bureaucratic and executive positions in Nepal in 1999 are recruited from high caste Hindu groups (92.2%) (Gurung 2002). People with IP and Dalit identity held respectively 8.4% and 0.3% of total top positions with potential influence on policy enunciation. Political marginalisation of IPs and Dalits is based on social discrimination and is therefore considered a main reason why these groups are deprived of economic, educational and overall social well-being (Gurung 2002) 31 VCDP Health June 2004 10/06/2004 Approximately 14 percent of total health expenditures in Nepal are channelled through the Ministry of Health and an additional three percent is spent by other ministries (e.g., MoF, MLD, and MoE), autonomous bodies (e.g., universities) and local bodies (DDC, VDC and municipalities). Direct expenditures by external development partners (EDP) account for another 13 percent of health expenditures. (NHSP-IP) Donor contributions are roughly the same size as HMG contributions to public health expenditures. Direct EDP assistance is 90% as technical and financial assistance goes directly to MoH and funds are self-executed by donors (for details see Annex-li). This indicates less money available in the government treasury. A gender assessment of government programs and budgetary allocation in health sector revealed the following: * Budgetary allocations (for the health sector) that are was allocated to programs exclusively targeted to girls and women - such as allocations made to Maternity Hospital, Mid-wife (Sudeni) Program, Women Health Volunteer Programme and Mother and Child Programme in Ramechap and Dolkha Districts was, during the period 1998/99-2000/2001, only about 1.5 to 1.7 percent of the total budget of the Ministry of Health * Programmes that did not exclusively target women but contained such components that benefit women more than other programs60, had about 16 to 18 percent of the total budget of the Ministry of Health in 1998/99-1999/2000. However, this share decreased to only 8 percent in the budget for 2000/2001 due to a large gap between the allocation and actual expenditure under Population and Family Health programs. * The rest of the allocations in the health sector amount to roughly about 80 to 90 percent of the total health budget allocated (on average during 1998/99- 2000/2001) to programs that did not target either male or female in particular. (New Era 2001:39). UNIFEM/UNDP: Gender Budget Audit, Meena Acharya, Gender Issues in Health Sector Budgeting This assessment study also reports that budget inadequacy is not a major issue at the central level but that management deficiency is the problem. The health budget was found to be highly insufficient at the village and the district levels. Another review of the health budget from a gender perspective covering the period from 1995/96 to 2001-0261 found that exclusively women programmes had 1.5 percent of the budget of 2001-02. Primarily women programmes had 2.0% and programmes benefiting both women and men had 96.4% (Source; MGEP, Gender Assessment of Health Sector, pg 41). Women's share of the total health budget is estimated at 50 percent but maternal health problems form a very large proportion (11 %) of the total disease burden which indicates a severe gender bias in potential needs. Gender difference in susceptibility, exposure and social consequences of ill health argues for an increased share in the health budget to be allocated for women health (Neilson et al) Dalit and Janajati concems are not reflected in the budget. Interviews indicated that next years's budget will reflect such concerns especially for trafficking and nutrition62 NHSP -IP has presented Resource Envelope estimates for the health sector as well as for EHCS under different scenarios. This is an estimate of the overall resource envelope that will be available to the health sector over the Tenth Plan period. The projections have been made fewer than three alternative scenarios based on the assumptions regarding the GDP and revenue growth rate, proportion of foreign assistance and internal borrowing in GDP, government 5 Meena Acharya,: Gender Budget Audit, Gender Issues in Health Sector Budgeting UINIFEM/UNDP 6 such as allocations made to Family Planning and Matemal Child Welfare Programs, Population and Family Health, Nutrition Acquired Immuno Deficiency Syndrome (AIDS) and Sexually Transmitted Diseases (STDs) control programs 61 MWCSW/MGEP/UNDP: Gender Assessment in the Health Sector, January 2002 62 Mr. Tanka Mani Sharma, Hefu/MOH 32 VCDP Health June 2004 10/06/2004 expenditure allocation to health and to basic health care packages. Three alternative scenarios were set out - a base case (felt to be the most realistic one), a high case (the most optimistic scenario) and a low case (a more pessimistic worst) scenario. The key assumptions involved in making the projections are provided. The base case assumptions are the prevailing situation (2000/01) as indicated by major macro economic indicators. For the base case, it is assumed that the present situation will continue in future as well. (The three alternative scenarios presented are given in Table 3 in Annex 6.) According to the budget estimate for 2001/2002, an amount of Rs. 224 (US $3) roughly will be spent on average on a person in the public sector. This is an extremely low amount of expenditure. According to an estimate, a developing country should spend around US $ 10-12 for ensuring the primary health care package alone (New Era, 2001:3 7). In Nepal health expenditures external to government is not reported (as much as 85%) and therefore significant donor contributions are not reflected in the government's budget system (Maskay 2002). Nevertheless, HMGN is gradually incorporating more and more direct funding in the health budget. This lack of transparency constitutes a major barrier when planning and analyzing impact. A major gap in the allocations and the discussions about the budget is the complete absence of resources necessary for addressing the issues of gender and social inclusion. As has been repeatedly identified, there is a persistent inequity in the use of services by girls and women and for non-maternity care. Boys benefit significantly more from public hospital care than girls; if maternal care is excluded, the overall balance service provision favours men and boys within almost every age group (Public Expenditure of the Health Sector in Nepal 2003, HEFU/MoH). Issues concerning Dalits and Janajajtis have not been recognized at all. To increase access of these groups to health services, various innovative strategies will be necessary. Funding for such issues needs to be planned for. Another gap has been the complete ignorance of the effects of conflict on health services and the emerging need to address issues like psycho-social issues, curative services: and orthopaedics. 5.1.6 Operational Challengesfor MOHfor implementation of VCDP Although the health policy of the government emphasises three key aspects, namely, decentralisation of planning at the lowest level, decentralisation of health service management, and integration of vertical programs for effective service delivery, the existing system has not been able to make progress on all three counts. Nepal's institutional capacity for strategic planning, policy development, resource mobilization, and coordination of external donors and national stakeholders is extremely limited. Skills in planning, management, health economics, and financial analysis are lacking. Responsibilities within MoH and DoHS are poorly delineated. The Ministry of Finance lacks an effective mechanism for monitoring and coordinating domestic and external resources that flow into the health sector. Programs are inadequately integrated, resulting in duplication of effort and inefficient implementation. Planning, budgeting, operations and monitoring functions remain overly centralized. Both quality and quantity of outreach services are diminished by lack of drugs, supplies, and qualified health care providers and the problem of staff absenteeism, especially in remote areas. (Nepal Operation Issues and Prioritization of Resources in the Health Sector, World Bank, June 2000). Whilst health policy, health provision and health finance are all Kathmandu centered there are still weaknesses in terms of communication and engagement. Leadership of the health sector programme by HMGN is a critical requirement; that leaderships needs to be confidant, robust and open to the involvement of all stakeholders. Health workers have been confined to district headquarters. Confidence in the service and its accessibility needs to be maintained. Political dissonance of whatever kind undennines the institutional integrity of services whoever happens to be the provider. 33 VCDP Health June 2004 10/06/2004 Financial constraints: The main constraint seen in the institutional options available to HMGN in the health sector is finance. Maximizing efficiency, accessing new resources, focusing public funds on a limited range of cost-effective interventions and acknowledge the continued requirement for personal expenditure on health will all be part of the financial strategy; tempered with pragmatism. Based on relatively optimistic assumptions regarding the growth of both Government and EDP resources, the 10t Plan envisages per capita public expenditure on health increasing from $2.58 to reach just $3.50 by 2006-7. The main institutional constraints on staff performance are low pay scale, very seldom recognition of good work, weak supervision and management and lack of sharing of reform vision at all levels. (Institutional Assessment of Nepal Health Sector, World Bank, Verulam Associates for Core Group of Health Sector Reform Committee, 2002- Page 5) MOH and related government institutions who are assigned responsibility for the health of vulnerable sub-population groups, like indigenous people, are found to have weak capabilities for dealing with these matters. In order to enhance the institutional capacity for appropriately addressing issues related to indigenous people, support of the following activities are relevant: (i) Assessing the track record, capabilities, and needs of those institutions is a fundamental requirement. Other institutional issues that need to be addressed through Bank assistance are the (ii) availability of funds for investments and field operations; (iii) adequacy of experienced professional staff; (iv) ability of indigenous peoples' own organizations, local administration authorities, and local NGOs to interact with specialized government institutions; (v) ability of MOH to mobilize other agencies involved in the plan's implementation; and (vi) adequacy of field presence. (World Bank social safeguards and the Social Assessment of HSS) 5.1.7 Ministry of Women, Children and Social Welfare (MWCSW9 MWCSW is an important national voice for most of the socially excluded groups and can provide valuable policy reform for inclusion in the national agenda. It has been appointed the gender focal point for all government programs but the Ministry has poor resources and visibility in spite of extensive technical support from several donor agencies. Coordination with Ministry is critical for MOH for implementation of the VCDP as gender is a crosscutting concern for all socially excluded groups. 5.1.8 Ministry of Local Development (MLD) The MLD has lead accountability for the management of local bodies and decentralization. The linkages with the education sector are essential given the recently approved 7h Amendment of the Education Act. The MLD has in the past been pivotal in supporting primary health centres through District funds and its role needs to be strengthened for this. Harmonisation of the current discrepancies in legal frameworks is an urgent immediate task. 5.1.9 National Commissions Commissions such as the National Women's Commission, National Dalit Commission, National Committee for the Development of Nationalities and the National Federation of the Disabled have been working intensively, becoming a strong national voice for their constituencies. Councils and other bodies representing the interests of women, Dalits, and Janajatis and children have also been established. All these would be key partnership for addressing several of the VDCP recommendations. However they are largely young organisations and would require capacity building, resources and improved accountability measures for improved functioning. 5.1.10 Local bodies VDCs, DDCs and associations like Association of District Development Committees, Nepal (ADDC/N) advocate the cause of decentralization. Directives for social inclusion and community monitoring need to be developed and coordination mechanisms need to be established. 34 VCDP Health June 2004 10/06/2004 Common to all such government agencies would be sustained dialogue and reflection on issues of social inclusion, affecting women, Dalits, Janajatis and other disadvantaged groups to enable an attitudinal shift towards inclusion. 5.2 Civil society The past two decades have witnessed steady progress in civil society responsiveness to the development of the socially excluded. National bodies, district networks, community groups have mushroomed to respond with commitment and perseverance to getting their daughters into schools and their women literate. With easy access to donor aid and huge demand for advocacy, training, research and technical support, a growing number of NGO's have taken up community health issues as their priority development program. 5.2.1 Women's development organisations: Nepal at present has a vast network of community-based groups that have demonstrated a rich range and wide coverage of work by women groups in several critical development sectors. At national, district and community level, there are several thousand women's groups and many federations who could be valuable partners in advocating social inclusion of girls and disadvantaged children and women. Many of these groups have demonstrated how to work successfully with communities on issues of gender and caste discrimination, equal representation in local bodies, more equitable resource allocation and children's and women's well being. 5.2.2 Janajati institutions: The Nepal Federation of Nationalities (NEFEN) is as an umbrella organisation and advocacy forum for Nepal's vulnerable peoples, legally recognized as the representative organisation of vulnerable communities. In order to implement the provision of the 10th Plan, the Nepali Parliament issued an Act in 2002 to establish the National Foundation for the Development of Vulnerable Nationalities (NFDIN) which had a broad mandate to ensure the social, economic and cultural development and upliftment of vulnerable peoples, as well as their mainstreaming and equal participation in national development. 5.2.3 Dalit organisations: The movement of Nepali Dalits against discrimination and social injustice began more than five decades ago. There are today over 60 agencies in Nepal working on Dalit issues. All political parties have sister Dalit organizations though these are more governed by political interests. At the national level, the Nepal Dalit Sangh is lobbying the passing of a Bill in favour of Dalits. The National Dalit Council and Dalit Commission play a lead role in advocacy for policy and legislative reform to address Dalit rights. Others like the Dalit Welfare Council and many grassroot NGOs target specific Dalit communities for support through scholarships, incentives, literacy and skills development programs. 5.2.4 Children's organisations: There are hundreds of examples of children's clubs and organisations across Nepal, where children have been actively engaged and taken leadership in improving community efforts on critical social inclusion issues such as increasing enrolment of girls and Dalit children, confronting child labour and trafficking, challenging child marriage and participating in health centres management. Child clubs, Child Rights Forums and Child Rights Awareness Groups have been formed in many schools and through these forums, children are being involved in the decision making process of health related activities. Similarly, child clubs have started playing a dynamic role in VDC meetings. Over the years, children have been actively participating in the electronic media particularly on Frequency Modulation (FM) Radio and TV, as well as print media. 5.2.5 Special interest groups: A large number of welfare organisations provide service for varied disabilities. Support is mostly institution based and in a welfare mode with very limited examples of social inclusion. The weakness of Nepali NGOs and the dominance of international NGOs and EDPs in service delivery are in part functions of organizational culture and the relationships within and between NGOs and NGOs and HMGN. The private sector is also institutionally young. Networks are not 35 VCDP Health June 2004 10/06/2004 strong and there is heavy reliance on external connections particularly with India. (Institutional Assessment of Nepal Health Sector, World Bank Verulam Associates for Core Group ofHealth Sector Reform Committee, 2002- Page 4) 5.3 International agencies Numerous I/NGOs in Nepal support district and community program for girls and Dalits education. Furthermore agencies such as PLAN, Action Aid have made significant contribution to social inclusion. The results all confirm that communities have the capacity to mobilise themselves, if the process is right. 5.4 Multilateral and bilateral agencies Development aid for health today is rising both in quantity and diversity. Amongst the UN agencies, UNIFPA is a lead player with women's and girls' reproductive and sexual health and rights as the number one global priority for the agency. Similarly, strategic shifts of UNICEF towards decentralization has enabled effective convergence with the local governance structures and the DACAW program today is well established in 15 districts demonstrating a positive example of mainstreaming the interests of the poor and marginalized particularly children and women. The World Bank has been a major donor for health care service, providing loans to HMG for national health programs. A exceptional contribution has been the policy advocacy for social inclusion in the Tenth Plan and the support for further analysis to provide the frame work for ensuring that the needs of socially excluded groups are addressed appropriately in all planning and sector interventions. DFI) is also a lead agency and along with the Bank, has supported HMG for social assessment and has been supporting other programs for social inclusion. This project follows a SWAp where donors have ???? resources in an effort to achieve a more cohesive pragmatic synergy and greater impact. UTNDP has been the lead player in Nepal for decentralization and has established programs in 60 districts building capacities of local bodies and setting up local development funds. Gender mainstreaming and social development is the second major area of support. 6. MONITORING AND EVALUATION 6.1 Monitoring and evaluation Since this plan focuses on social issues, it is essential that monitoring and evaluation assess process and progress as well as output and outcome indicators. Indicators can come in two forms: (1) technical and (2) self-reflective indicators using a community-owned and operated monitoring system. The main recommendation regarding monitoring and evaluation is that progress on the VCDP and various other interventions be evaluated during the first year of implementation as a basic requirement for scaling the project up. The monitoring framework and indicators presented in section 9 would provide baseline fro monitoring and evaluation. Therefore in the first year a baseline survey should be carried out as per the information collected by Community Health Information Management System carried out by the NGOs. Health Management Information System (HMIS) must collect data disaggregated by gender, age, disability, caste (Dalit/non-Dalit) and ethnicity (Janajati/non-Janajati). (Refer to section 8.2.3 for further details). Strong monitoring and evaluation is critical for the government and donors to assess the progress of VCDP, to learn from past experience and to actively improve the output performance. VCDP: The MoH and its various offices are responsible for monitoring the VCDP recommendation and the indicators. While disaggregated data for caste and ethnicity is not available as yet, in order to correctly monitor outcomes of the Health Monitoring Information System (HMIS) must produce such disaggregated data for all levels in Nepal. (Please refer to Monitoring Framework for VCDP implementation, Section 9.) 36 VCDP Health June 2004 10/06/2004 To monitor social development, inclusion and unintended negative effects, annual external evaluations must be conducted. The evaluation team should include social development experts, health experts, anthropologists and gender specialists. The annual extemal evaluations should be supplemented by independent evaluation by a group of indigenous and dalit representatives. Such evaluation must also include the 'process' aspect of the program's implementation and performance. For the overall monitoring of health centres management, SMCs and local communities must be given responsibility. District and local level NGOs and dalit and indigenous people's organisations may be included in monitoring inputs and outputs and can assist local communities and inexperienced MCs in the formulation of rigorous and culturally- appropriate monitoring techniques. Mechanisms to monitor the implementation of the agreed plan: Health Management Information System (HMIS) data and appropriate M&E systems will be developed/strengthened and implemented to ensure accountability of all stakeholders. HMIS will collect data disaggregated by gender, disability, caste (Dalit/non-Dalit) and ethnicity (Janajati/non-Janajati) and use social inclusion indicators (e.g. issues such as shifts in decision making patterns, gender relations, inter-caste behaviour). At the health centres level, there may be need for more detailed classification of gender, caste and ethnic categories. These can be aggregated into user -friendly key categories for the central level reports. Community Managed Information System (CMIS) data will support HMIS under MOU with local groups for collection of disaggregated data. Mechanisms such as social audits and social mapping will track health centres participation and drop out rates by gender, caste and ethnicity of children and women from socially marginalised communities, monitor discriminatory behaviour/practices, support local women recruitment and feed such information to the CMIS system. 6.2 Implementation Vulnerable Community Development Plan should include an implementation schedule with benchmarks by which progress can be measured at appropriate intervals. Pilot programs may be needed to provide planning information for phasing the project component for Dalit and indigenous peoples with the main investment. The aim must be the long-term sustainability of project activities subsequent to completion of disbursement. It is anticipated that almost all the activities will be initiated within Year 1. National policies, regulations, guidelines and directives will be reviewed, revised, and implemented within the first year of the project. (A) Funding at the Community Level: (i) NRs. 100,000 as a one-time incentive will be provided to all community-managed health centres. (ii) All government-managed health centres will get an initial basic grant for the first year. In order to receive the basic grant during year 2, the Management Committee (MC) will need to follow the health centres grants plan. In addition, health centres will be eligible for higher levels of funding if they are able to go beyond the basic level of accountability (audited account statements) and fulfil the higher accountability requirements for level I or level II. Which should be developed in consultation with key stakeholders. (B) Funding at the Central Level. Central funds will be used (probably on an outsourcing basis) for: (i) providing technical expertise on integrating positive images of diverse socio- cultural and religious groups into the ongoing BCC, IEC and capacity building and curriculum development process; (ii) It is recommended that development of the program should be initiated in Year 1 developing a framework for sanctions against discrimination which will be carried out within six months by the Monitoring and Inspection Section of the MoE. 37 VCDP Health June 2004 10/06/2004 7. RECOMMENDATIONS ACTION PLAN . . . ^ * - fOCUS . - DURATIONI W RESPONSBILE BUDOET (S) .-* . - .- 1 . . .RESOURCtNEED AGENCY (rwugkAtAw Programme componewb Yearl Y ..aa1 Ye a|h IS t 3 thl . .gacs) CENTRAL LEVEL63 ADVOCACY AND COORDINATION a. Advocate mainstreaming gender and social inclusion in - For detailed recommendations for responsible unit and officials see MOH 10000.0 health services: figure 3. * Appoint gender and social development advisor at MoH level reporting to secretary MoH to replace current gender focal point b. National Advocacy workshop on Conflict and Health with - Core strategic components in HSS on how they can be best supported / MOH and 3000.00 focus on specific constraints for girls and women, Dalits and and implemented in the current conflict situation on: Resource EDPs Janajatis in conflict areas allocation for vulnerable groups; Geographical priorities; Gender responsiveness in health care; Pro-poor arrangements; Social exclusion practices in health c. Sensitising Behaviour Change Communication - Translation of the IEC materials into the main IP mother tongues in ,/ MOH-NGO 5000.00 Programmes towards women, Janajati and Dalit health and Far- and Mid-Western Region. socio-cultural factors (production of IEC master matedals; - IEC materials should address specific Janajati, Dalit, gender related information posters, pamphlets). health issues. * It should be included in the Health Sector Reform- - Dissemination '/ Communication Strategy Evaluation 1/ d. Advocate for a policy directive for the increase of women - Review existing directives / DoHS 8100.00 from Dalit and Janajati representation in SHPMCs, preferably so that the profile of the committee resembles the - Propose revision of directives and initiate dialogue with DoHS to / caste, ethnic and gender profile of the community DHO's on process of ensuring diversity in SHPMC's membership. Link established through the social mapping process to block grants. e. Review health related training given by other line - Review existing modules MOH, Ministry 10000.00 ministries such as Education and Labour. Include information of Education, on local health and social inclusion issues in community level - Develop materals and modules on social inclusion and rights of / Sports and NFE and education staff training in coordination with Janajats, Dalits and women In general and health Issues work with Ministry of concerned ministry representative organisations to obtain local specific information for Labour, NHTC NFE curricula using Participatory Learning Action methodology - Provide technical support to Introduce modules v/'Yr3- 5 63 With inputs from Nielson, L.C.; Shrestha, S.M, 2003, "Draft report: Social Assessment of the Nepal Health Sector Reform ", World Bank, Nepal 38 VCDP Health June 2004 10/06/2004 ˝"- .~~; ACTIONPLAII f-o1 - --' - - - i - ' ' DURATIONI '= tLE T UDCEt IL 'k , _- _ := - r_ ~~ ~ R!Si URCE NEED - - 4AHNCY (rough rdcw PmtWmmm components [ Year I Year 2 Year 3 thfo1IyIUOH figures) RESEARCH a) Building the knowledge base on traditional healers and - Mapping of key practices in selected districts and conducting district V/ MOH 7450.00 practices consultations with traditional healers and practices * Identification of cooperation and coordination issues enhancing local health resources available. * Incorporation of traditional medicine and institutions (e.g. traditional faith healers) into daily work practices of - National level consultation to prioritise future convergence actions V Government health services through training and joint field level consultations. b) Documentation of forms of abuse women employees - Qualitative interviews in 10 selected distncts with high Dalits, Janajati MOH 2000.00 and clients face through health service providers population and Terai with lowest Gender indicators CAPACITY BUILDING a) Production of instruction manual/social safe guard - Review of Intemational declarations V MOH, NHTC, 12,000.00 (master) for NGOslMOHlDDC/ VDC employees working in NGO Janajati and Dalit locations. - Development and Pre-Test of Manual / * Review of International declarations and programme - Training of Health staffs at the field levels V safe guards from UN organizations on Janajati and Dalit health issues, including synthesizing inputs from the above workshop. b) Human Resource Development to be coordinated with the - Support Affirmative Action through advocacy to Public Service / MOH, HR Unit 247100.00 MoH institutional and management capacity development Commission programme as part of the health sector programme - Review functioning of LPSC / * Advocate for Public Service Commission to offer special - ToT for all health staff on Gender and Reproductive Health courses to help women qualify * Review & design diversitycrtera for health staff recruitment - Curricular revision of ongoing course for SHPMC and district level staff $ * Support Affirmative Action for Dalits, Janajati and poor to include gender, Dalit, Janajati issues women at all levels c) National Meet of FCHVs from all regions representing - Identify constraints V MOH 20000.00 different castes and ethnicity in order to * selection criteria and process of FCHV selection - Plan National Meet / * inclusion of gender, Janajati, and vulnerable groups - Facilitate National Meet and orientation specific issues in the training curriculum of FCHV - Set up local men's group on Gender based violence both with men and / adolescent boys on confronting all forms of violence against girls and women 39 VCDP Health June 2004 10/06/2004 I~|| '-ATIONl-M FOCUS A. | tRE SPON4- 'BfI(ET (5) - w E:5:1 -- FtUS I tRiM AGENGC- fv** Programn componeia - * . Year1 Y90 Year2 ar3 thmiughM WH 6BS) DISTRICT LEVEL ADVOCACY AND COORDINATION a. Strengthening Regional Social Inclusion in Health - Workshop focus on accessibility, 2) utilisation and 3) social exclusion / MOH 2500.00 Stakeholder workshop with representatives from central and impact of health care provision related to marginalised women, and local women, Janajati and Dalit organisations, DDC, Janajati and Dalit communities, 4) Gender inequity issues as cross VDC and local l/NGOs representatives on ethnic, pro- cutting concern. poor and gender issues in HSS related to the situation in - Sensitize training of health employees on communication skills and $ Far-West and Mid-Western Region. specific health needs of vulnerable groups. RESEARCH a. Health Insurance for Vulnerable Communities: The - Expert consultation to identify appropriate models for future health ,/ HFEUS 15000.00 insurance models should be assessed/designed according to: insurance schemes. Examine Dalit, gender and Janajati issues. * Equity, social impact and coverage Upscale existing insurance schemes for poor $ * Potential adverse health impacts by gender, caste, - Strengthen the move towards the sector wide programme ethnicity, location - Provide specific allocations for specific issues * Degree of progressiveness and income protections - Develop public-private partnerships measures inherent in the models. - Introduce pilot scheme in 10 districts through public-pnvate partnership CAPACITY BUILDING a. Training programme for I/NGOs, VDC and DDC staff in - Develop a pilot introductory training programme (TOT) for l/NGOs NEFEN, 2000.00 Far and Mid-Westem Regions . NHTC * Sensitise HSS programme implementation on Janajati, - Facilitateexpertconsultation / Dalit issues. - Evaluation of Pilot training V/ - Scaled up training programme to other regions. / b. Intersectoral linkages mainstreaming social inclusion - Training to local Dalits and Janajati women and adolescent girls / DHTC 1000.00 issues on health in education and labour through PLA as part of the NFE programme. CONFLICT RELATED a. Enable emergency assistance - Establish networks for emergency travel, medicines, and immediate DHO, EDP, 2000.00 medical care NGOs, Private - Ensure women, Dalit and Janajati access to such assistance / / Sectors b. Establish conflict support funds as per Project Appraisal - Create a fund which people without resources can access to for health / MOH, EDP, 50000.00 Document care, with specific guidelines for priority in access for women Dalits, Pnvate and Janajatis. Deposit cash in bank accounts and to maintain Sectors accessibility, negotiate agreements with local moneylenders for loans, which would be repaid from the bank account, in emergencies. - Allocate extra budget for services required as a result of the conflict. / Health facilibies (hospitals, HP, SHP) will require addibional funds for services. 40 VCDP Health June 2004 10/06/2004 .'''ACMONp U ' ' G_ . 7. - DpTIN - ' ItNSBILE BUE - - .RESOURCE NEKO--. AGENY (uh e P?ogramme components - - .. Year I Year 2 JYear 3 through IOH | Wm5) c. Psychosocialserviceforconflictsurvivors:Create"safe - Negotiate with all parties for a protected woman and child friendly V7 DHO, 15000.00 space" for health service delivery in conflict areas space in the community. Setup and equip safe spaces MOWSC, * Pilot in 10 districts - Network with other line ministries i.e. education, women and children ./ / NCWB affairs COMMUNITY LEVEL CAPACIY BUILDING a. Development of training programme for community - Develop a training course for married Janajati and Dalit women with DOHS, DHTC, 30000.00 women as assistant health workers in close relation to minimum 8 grade to ensure staffing sustainability in the PHC facilities NGOs, CBOs the BCC and EHCS tasks of FCHVs. situated in Dalit and Janajati dense locations. - Conduct training in local languages / - Evaluation of Trainings .7 - Replication in other Janajati ad Dalit locations .7 I_Yr3to5 1 RESEARCH a. Evaluation of local bodies: their role as implementer of - Design methodology .7 M&E Section, 10000.00 govemment policies since 1999 towards disadvantaged MLD, NGO groups, including IP and Dalits and women. * The local bodies' ability and willingness to deal with - Carryout evaluation ./ issues of marginalized and ethnic groups and women. * Identifying potential support issues to improve the capabilities of the local govemments to promote - Review findings with stakeholders ./ Janajatis language and culture, reduce discrimination against women an Dalits. * How can coordination be strengthened - Use the recommendations for capacity building of local bodies through M MLD b. Social assessment of the community drug scheme - Carryout assessment in selected districts . Research 8000.00 * The assessment will include: i) community coverage, ii) Units with social inclusion aspects, iii) social impact and equity University aspects 41 VCDP Health June 2004 10/06/2004 ACTION PM. ' FOCI 1 cDURATlONI OW F iii BUDGET (S) mf .$-˘. s . -, - I - - 4- -lESOURCE NEED N3e i; (rou VIiRNdcafb Programme components - . Yrl Year2 Yur3 a j 11gues) PROGRAMME a. Establish block grants scheme for SHPMC to form - Develop criteria for grants to SHPMC for making formal agreements / DHO, Local 50000.00 agreements with selected local community groups (CBOs (MoUs) with community level women's and adolescents' groups or Bodies, particularly women and adolescent groups). others NGOs, Priority to community women's groups such as Mothers - Develop criteria for selection of community groups for MOUs / Club, Women Health Groups, Saving and Credit Groups Establish block grant mechanism in selected Pilot distncts with high / etc. DaliVJanajati population . b. Establish community based Adolescent Reproductive - Establish adolescent girls and boys groups as peer educators on / Family Health 50000.00 Health Counselling Centre for peer support. See table gender and RH rights Department, Community Based Reproductive Health Services for Young - Life skills based training to local youth volunteers NGOs and People - Pilot in five distCcts with high indicators of early marriage, violence on RCOs imTrain motivators suppoe vulnerable communities for women and children, HIV/AIDS, trafficking and low NER of girls. 5 rt improving health-seeking behaviour cete in eac disric Yr Wh5 centres _ each_district 42 VCDP Health June 2004 10/06/2004 Fig. 3. Recommendationsfor Mainstreaming Gender and Social Inclusion in Health Services ISocal Devebpment Reportingt° Genderfocal toint Gender and Social L O i = -vi _ _ SePrtaryDevelopment Advisor Social Indusion | Reporting to Gender and Social DoHS Expert Deneral Inndusion Expert Divisions & I Social indusion focal point in each Gender and Sodal Centres |7 reporting to Social Indusion Expert Indusion Focal Point Districts: | District Health Officer reporting to Regional WDO as Gender Gender and Social DHO Health Directorate focal point Indusion Focal Point Women's groups, Mens' groups, Children's dubs Adolescent groups (existing in some, to be further developed) Note: (a) Gender and social inclusion tasks must be stated in the job descriptions of identified health officials both in written form and during orientation. (b)Evaluation procedures of job performance must incorporate tasks performed for gender and social inclusion. (These recommendatons are in addition to the recommendations made in the Gender Assessment in the Health Sector prepared by MWCS W, MGEP/UNDP report of January 2002.) 7.1 Core recommendations for actions at the community level The present effort of handling over the Sub-Health Posts to Local Management Committees (LMCs), a form of de-concentration, is a first step towards the eventual devolution to the local bodies. The MoH will deepen the present de-concentration by transferring further responsibilities an resources to the district health office. It will work with the Ministry of Local Development in developing a decentralisation strategy to gradually increase the role of the local bodies/Local Management Committees to take on additional responsibilities of overseeing the new arrangements. ( Draft Aide Memoire and Wrap up meeting of Joint World BanklDFID Appraisal Mission of Nepal health Sector Program Project, June 8, 2004) 7.1.1 Establish block grants to Sub Health Post Management and Operation Committee (SHPMC) for support from CROs particularly women's and adolescent community groups for implementation of NHSP-IP SHPMC would sign MOUs with community groups to fund them to carry out the following actions for social inclusion: (1) Social mapping of catchments area: all households would be identified in terms of their caste/ ethnic identity and households with specific health constraints for women and children (i.e. HIV/AIDS/STD/FPI/TB/disability). (2) Establish formal linkages with other local women groups for networking and advocacy on local specific gender issues. (3) Establish community based Adolescent Reproductive Health Counselling Centre (See chart "Communitv Based Reproductive Health Servicesfor Young People "for details). Establish adolescent girls and boys groups for: a) Peer educators on gender and RH rights: Sensitise girls and boys selected from Dalit and Janajati communities on leadership and information on basic health issues and RH issues b) Life skills based training to 43 VCDP Health June 2004 10/06/2004 c) Motivators in vulnerable communities for improving health-seeking behaviour d) Providing information to vulnerable communities (4) Orientation of SHPMC on gender, reproductive health and sexual rights of women and girls. To reduce gender inequality, men and women positions of authority require orientation on the gender dimensions of health. Health professional in particular need to be sensitised on the social and non-biological aspects of health. Orientation should include: a) Understanding how different gender and socio-cultural factors impact women and girls health. b) The consequences of women and girls gender roles and socio-cultural belief and practices on access, participation and decision-making regarding their health. c) Conceptual clarity and tools to address reproductive and sexual rights of girls and women and the violations of these rights (violence and abuse, forced sex and pregnancies, denial of access to information and services) (5) Training to local Dalits and Janajati women and adolescent girls through PLA as part of the NFE programme. Given the strong linkage between women education, increased family planning and child survival, women and girls from vulnerable communities should be enrolled in NFE classes through a special grant. Curricular would focus on reproductive health issues and gender linkages with education are essential for cross-sectoral linkages. (6) Social audit64 of funds and activities to enable community members to be more informed on: * Access of vulnerable households specially women and children from Janajati, Dalit families to services and special benefits * Discriminatory behaviour and practices by service providers, community members to girls and women and members of Dalit families * use of grant funds from VDC and other special entitlements for Dalits, Janajatis and women * review of decision-making process within SHPMC to ensure inclusion of representatives from vulnerable households and their specific concerns. (7) Documentation of local traditional healing practices for curriculum of health workers: collect and document local information on the history and culture of Dalits, Janajatis and linguistic minorities, specially their health related practices, myths and belief patterns related to women and child health (8) Identification of local women volunteers from Dalit/Janajati groups: Assisting SHPMCs to identify and recruit local women for access to information and services by Dalit, Janajati households. 64 Social audit is a framework which allows an organisation to build on existing documentation and reporting and develop a process whereby it can account for its social performance, report on that performance and draw up an action plan to improve on that performance, and through which it can understand its impact on the community and be accountable to its key stakeholders. The essence of social auditing is therefore: accountingfor what we do and listening to what others have to say so thatfuture performance can be more effectively targeted at achieving the chosen objectives. http://www.cbs-network.org.uk/socacaud.html 44 VCDP Health June 2004 10/06/2004 (9) Community based Health Management Information System (CMIS): tracking local specific health issues by gender, caste and ethnicity of children, adolescents and women from socially marginalised communities. Child and Adolescent Clubs would be particularly appropriate for carrying out baseline surveys. (11) Advocacy against discriminatory practices: raising awareness and sensitising health care providers, local bodies, school authorities, teachers and youth on social inclusion issues and on national policies and directives for sanctions against discriminatory behaviour and practices against girls and women and Dalits /Janajatis seeking health services. Social audit by community-level groups would identify gender based violence, discriminatory behaviour and practiced against girls and women, Dalits and Janajatis by health service authorities, teachers and community members. These will be reported to the relevant grievance cell for action and then be monitored for implementation by enforcing sanctions against discriminatory practices and behaviour. (12) Honouring good practices in social inclusion: acknowledge and honour local bodies, health posts, teachers, students and others who have demonstrated initiative and good practices in social inclusion in health services: * developing criteria for good practices and informing SHPMCs on selection process * arranging for wide media coverage on honoured persons (13) Set up local support group on gender based violence both with men and adolescent boys on confronting all forms of violence against girls and women. Initiate community based meetings at regular intervals to dialogue on: * Gender roles and socially prescribed practices and rules that support unequal relationship between men and women, girls and boys * Orientation on gender and health- basic information on Pre and anti natal care, child birth and fathers' role/support * Develop and introduce BCC on gender specific health consequences for women and girls particularly: * All forms of violence * RH and sexuality * Labour * Access to health information * Decision making on health issues * Include men and boys in social mapping and audit, per educators for school awareness programmes * Design male leadership campaign for promoting girls education and female literacy through NFE using successful models of PLA 7.1.2 BCC in bilingual languages The Local Self-Governance Act (LSGA) of 1999 and the Poverty Reduction Strategy Papers (PRSP) both empower local administration together with civil society, NGOs and relevant ethnic and linguistic foundations, committees or commissions to support language and cultural preservation activities. This VCDP takes the view that the responsibility for ensuring access of 45 VCDP Health June 2004 10/06/2004 non-Nepali speaking community members to the health services recognizes and celebrates diversity should be shared between the state (central and local governments) and society. In communities where a large minority/or majority speak another language: (1) Ensure that at least one sub health post staff is fluent in local language and available to assist in communicating patients' health problems to health provider and in communicating instructions from health providers to patients. If the language has a script ensure that signs and key health communication materials are available in that script. (2) develop the necessary training modules in the use of local languages to support BCC through bilingual medium of instruction to increase sensitivity to culture, language health practices and specific issues related to health of indigenous people, (3) identify and accredit national and local NGOS to deliver these modules and (4) bring multilingual, multi ethnic and multi cultural representation in all BCC materials (5) Ensure reaching these campaigns to all socially excluded Janajatis and Dalits particularly women (6) Provide funding these organisations to go to districts to train local health workers where communities have demand for bilingual instruction. Civil society, non-governmental organisations and local government would have the responsibility to work together to develop modules based on local languages and cultures for the community to use. While the State is therefore involved in the formation of an inclusive and equitable national health policy, society must configure this in a locally meaningful way and take charge of the culturally sensitive fine-tuning and the successful implementation at a community level. (1) Collecting and documenting information on their own history and culture for use in the National training curriculum and text books of health staff at all levels. It is suggested that the National Dalit Commission or the National Federation of Nationalities (Nepal Janajati Mahasangh) be provided with some funds to enable them to make modest grants to communities wishing to do this. 7.1.3 HMIS disaggregated data (1) Health Management Information System (HMIS) must collect data disaggregated by gender, age, disability, caste (Dalit/non-Dalit) and ethnicity (Janajati/non- Janajati). At the sub-health post level, there may be a need for a more detailed classification of categories. These can be aggregated into user-friendly key categories for the reporting mechanisms. (2) Use HMIS data collected by local groups under Moue with SHPMCs for baseline information in the collection of disaggregated data. (3) Public private partnership: Partner with philanthropic association and business houses to support sub health post/PHCC for drugs and facility 46 VCDP Health June 2004 10/06/2004 occCal Inclusion in Primary Health Se on issues of gAdvocacya gender, sexual _ against an~~~~d reproductive rights o/ / discriminatory \ ~girls and women Ices / HMISw data pracices \/ soaa/n diaggregated bieri age, gender, ethnicity and \ caste / / s ocal bao T ~ ~~~~~~~ spport to MC*** 03a cgroups for CMIS** _Aimplementation of/ NHSP Note:/MaagementommitteeTheLoclHealt Institun Operationgracn _ \ ~~~~~~~~~~~for cunTicum Committee which is to be formedfat the sub health post, health post and primary health c mappingo workersyoclwme\ e Beaviou r\ catchmen f dnero nm DaliV 0 Change area ofsu Janajattig-ps fO- Hnu Communica~trio\V MCHW, A ,/deostrated in bi-lingual r goodelprradn ca ein x ~~~~~~socdal inclusion In 4 languages 2/0health / evelo'p \ zErainig to\ / policy and \ / lclJanajt d moai'tie to reduce / SeuplCal J Dald women as } d iscriminat!o n / mnsandby / Integrate \ ~healt /adgne-ased group toconfo ( natioal tramng ) volu\nte gender-based Srong\paiean socially