Nepal is rich in culture, but challenged by an unstable political climate, a high incidence of natural disasters and mountainous terrain. Most of Nepal’s 28 million people live in remote villages that are difficult to reach and lack public health services. As a result of these challenges, this landlocked country in South Asia faces several major health issues, such as low access to family planning and other sexual and reproductive health products and services, safe water, adequate nutrition, TB and infectious diseases treatment and prevention.
On April 25, 2015 an earthquake caused large-scale damage and destruction. Several weeks later, a second massive quake struck, resulting in the greatest natural disaster Nepal has faced in recent history. Nearly 9,000 people died, 22,309 injured and 700,000 families displaced, with many still living in temporary shelters.1) The earthquakes magnified many pre-existing issues in healthcare access, affordability and availability, and as relief operations continue, there is still more work to be done.
Nepal has achieved considerable progress in many health areas over the last decade: confirmed cases of malaria decreased by 40% between 2005 and 20102); the maternal mortality ratio fell 5.4% between 2005 and 20153); and access to improved sanitation increased by nearly 16%4). However, challenges remain in each of these health areas, especially with regard to family planning and safe abortion.
In 2002, PSI/Nepal began work in HIV/AIDS prevention, child survival and family planning in support of the Government of Nepal’s National Reproductive Health and HIV/AIDS Prevention Strategies. Currently, PSI/Nepal works with local partners to implement sexual and reproductive health programs, including in family planning, maternal health, menstrual health and hygiene, as well as water, sanitation and hygiene.
PSI/Nepal estimates that in 2015, its products and services helped avert 26,744 DALYs, including, by health area:
- 24,687 Family Planning DALYs
- 7 WASH DALYs
- 2,050 Safe Abortion DALYs
PSI/Nepal’s family planning programs also provided 128,310 couple-years of protection.
See a PSI/Nepal success story in family planning below.
Reproductive Health and Family Planning
PSI/Nepal’s Women’s Health Project (WHP) was launched in 2009 to support the Government of Nepal’s (GoN) Millennium Development Goal of improving maternal health, by increasing access to long-acting reversible contraceptive methods and reducing maternal mortality. The project leverages social franchising through a network of private sector clinics on the supply side, and interpersonal communication and mass media on the demand side. PSI/Nepal supports the Family Planning 2020 1) (FP2020) global partnership, which calls for the rights of women and girls to decide freely, and for themselves, whether, when, and how many children they want to have. Under FP2020, the Government of Nepal has committed to increasing the contraceptive prevalence rate for modern methods from 47% in 2014 to 50% by 2020, and to balancing the use of permanent methods, long-term reversible methods and short-term methods. 2)
Despite recent improvements, the maternal mortality ratio in Nepal, at 258 deaths per 100,000 live births3), is still high. Unsafe abortions resulting from unwanted pregnancies remain a significant cause of maternal deaths. Restricted access to safe abortion services and limited awareness of the legality of abortion prevent women from easily accessing services. Since 2002, Nepali law allows termination of pregnancy at up to 12-week gestation, at up to 18-week gestation if the pregnancy is a result of rape or incest, and at any time with the recommendation of an authorized medical practitioner if the life of the mother or her mental health is at risk or if the fetus is deformed. Only 38% of women age 15 to 49, however, believe that abortion is legal in Nepal, and 59% report knowing a place where a safe abortion can be obtained.
PSI/Nepal is taking a market development approach to reproductive health services, working with both the Ministry of Health and Population (MoHP) and the private sector to strengthen family planning and safe medical abortion services provided at public and private facilities. In 2009, PSI/Nepal formed a network of private sector providers and began building their capacity to deliver quality family planning services. Later branded the OK network, it now comprises 230 providers, including auxiliary nurse midwives and obstetricians and gynecologists. These are spread out in 30 districts and provide quality products and services at affordable prices to poor and underserved Nepalese populations. In 2014, PSI/Nepal also launched a national family planning hotline in partnership with the Logistics Management Division of the MoHP and the Patan Hospital.
PSI/Nepal is also supporting the Government of Nepal to expand long-acting family planning method provision and medical abortion services in 160 public health facilities in 12 new districts, where services are not currently available. To generate demand for these services, PSI/Nepal launched the Smart Shanti national communication campaign in April 2017 to raise awareness about safe abortion and IUCDs at the community, regional and national level.
Sexual, Reproductive and Menstrual Health
In Nepal, menstrual hygiene is a critical but often overlooked component of girls’ sexual and reproductive health, and many teen girls do not understand the changes taking place with their bodies during puberty. With a lack of hygienic sanitary materials and disposal options, limited privacy and clean water, girls are left to manage their periods in uncomfortable and unhygienic ways. These challenges are exacerbated by cultural attitudes that view menstruation as something impure and shameful, leading to widespread stigma, harmful practices, such as chhaupadi, and the exclusion of women and girls from many aspects of social and cultural life.
In 2016, PSI/Nepal began working in partnership with Cristina Ljungberg of Giving Wings Foundation and Maverick Collective, to better understand the barriers preventing teen girls from accessing menstrual health and hygiene products and knowledge. The project aims to create the first girl-centered solutions to effectively address barriers to healthy menstrual health products and practices in Nepal. The initiative aims to improve the health and lives of Nepali girls by designing an innovative program that:
- Improves girls’ menstrual health and hygiene by designing tangible solutions; and
- Improves the environment they live in to reduce stigma, negative perceptions and unhealthy practices around menstruation.
PSI/Nepal is now working to engage adolescent girls in generating important insights from their own experiences, and analyzing evidence on menstrual health and hygiene. The insights gained will help PSI and its partners design more effective, evidence-based programs and policies to improve the health of teen girls in Nepal, and will serve as a model for how menstrual hygiene can be incorporated into reproductive health programs for girls around the globe.
Water, Sanitation and Hygiene
Although access to improved water sources in Nepal has increased, the safety of household drinking water is uncertain and household water treatment is rarely practiced. Access to safe water per household remains low at 44%, and the majority of households (85%) do not treat drinking water. To address these issues, the Government of Nepal has set a national target for providing a basic level of water services and access to improved sanitation for all by 2017.4)
Together with the Netherlands Development Organization (SNV), PSI/Nepal is implementing the USAID-funded Health and Hygiene Activity (HHA), a five-year project from 2016 to 2021, in five districts of mid-western Nepal. The project aims to improve community health status by improved integration of hygiene in health service delivery.
Working closely with local stakeholders and communities, PSI/Nepal is bringing together people, systems and infrastructure to provide sustainable, affordable infrastructure development for health clinics and to improve hygiene behavior. PSI/Nepal uses provider behavior change communication (PBCC) to address health providers’ individual biases and barriers to adopting particular behaviors, which in turn helps them better serve their clients. By targeting providers’ WASH behaviors, HHA will build their capacity to communicate lasting behavior change to the communities they serve.
The malaria burden in Nepal has declined significantly over the last decade and the Government of Nepal has set an ambitious vision of a malaria-free country by 2026. With funding from The Global Fund to Fight AIDS, TB and Malaria, PSI/Nepal partnered with the Nepali government from 2006 to 2014 to reduce the number of people at risk by offering prevention and control programs. Through these programs, nearly 4.4 million long-lasting insecticide treated nets were distributed to households in 31 at-risk districts; 12,594 private health providers were trained in malaria prevention, detection and management; and nearly 6 million people were reached through interpersonal communication (IPC) and school-based behavior change communication (SBBCC) activities.
While HIV prevalence is low among the general population in Nepal, like many of its South Asian neighbors, HIV prevalence is higher among key populations, including men who have sex with men (MSM) and transgender (TG) populations. The Global Fund’s Multi-Country South Asia Regional HIV/AIDS Program provided a three-year grant, from 2011 to 2013, to reduce the impact of HIV on MSM and TG populations in seven South Asian countries: Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan and Sri Lanka. As the principal recipient, PSI/Nepal established coordinating mechanisms for the program and procured health-related commodities for distribution in Afghanistan and Pakistan, where over 365,000 packs of condoms were distributed to MSM and TG populations.
Following the 2015 earthquake, PSI/Nepal used its existing network of community health volunteers, healthcare providers and local community-based organizations (CBOs) to distribute a household water purification product. Through Procter and Gamble’s (P&G) Children’s Safe Drinking Water Initiative, PSI/Nepal distributed nearly 214,000 of P&G’s Purifier of Water sachets in several of the most affected districts. Trained health volunteers and CBOs also conducted outreach and distributed communication materials on water treatment and hygiene. This initiative reached an estimated 4,000 households in districts that were hardest hit by the earthquake, including Dhading, Nuwakot, Kavre, Sindhupalchowk, Kathmandu, Lalitpur and Bhaktapur.
- The Maverick Collective | Cristina Ljungberg
- United Nations Population Fund (UNFPA)
- Ministry of Health and Population, Government of Nepal
- Department of Health Services, including key partnerships with Family Health Division, Child Health Division, NHEICC, National Health Training Centre Epidemiology and Disease Control Division
- Department of Drug Administration
- Nepal Society of Obstetricians and Gynecologists (NESOG)
- National Chemists and Druggists Association
- Multiple local non-governmental organizations operating at the District Level
- Mapping the FP Consumer Journey for Youth in Nepal
This brief describes qualitative research to identify where the market is failing specific youth segments of voluntary family planning consumers in urban, urban slum, and rural areas of Nepal. A primary objective was to identify determinants of access, such as key influencers, motivators, experiences and barriers. Data collection also focused on gathering user insights related to method preference among the market segments.
- Mapping the consumer journeys of Nepalese youth to access voluntary family planning & contraception
Family Planning (FP) is one of Nepal’s Ministry of Health’s priority programs. The existing program aims to foster equitable access and utilization of quality FP services throughout the country. Between 1996 and 2006, Nepal showed progress in improving the modern Contraceptive Prevalence Rate (mCPR) from 26% to 43% (DHS 1996 & 2016), but this momentum has not been maintained. Between 2011 and 2016 use of modern methods has remained stagnant, as has the percentage of young women aged 15-19 who have given birth. It is clear that Nepal's FP market is failing sub-regions and certain market segments.
- Shaping the Family Planning Market by Strengthening the Public Sector
PSI considers total market approaches to be critical for achieving universal health coverage, especially when it comes to contraception. This program brief presents cases, supported by several different donors, which take into consideration the total family planning market.
- Simplified Asset Indices to Measure Wealth and Equity in Health Programs: a Reliability and Validity Analysis Using Survey Data from 16 Countries
Many program implementers have difficulty collecting and analyzing data on program beneficiaries' wealth because a large number of survey questions are required to construct the standard wealth index. We created country-specific measures of household wealth with as few as 6 questions that are highly reliable and valid in both urban and rural contexts.
- Reaching Muslim Women of Nepal Through the Private Sector
The Women's Health Program (WHP) has been implemented in 50/75 districts across Nepal since 2009 with the objective of increasing utilization of FP services through PSI/Nepal's social franchise network and ensuring method mix and more choices for long-term methods.
- Motivating Community Based Mobilizers for Generating Demand for Family Planning Services for the Women’s Health Project (WHP) in Nepal
Under the Women’s Health Project, PSI/Nepal has more than 400 trained voluntary non-medical community mobilizers (also known as Didi in local community) in 50 districts of Nepal. They conduct household level interpersonal communication sessions on family planning (FP). According to Nepal Demographic and Health Survey 2011, 43% of married women use any modern contraceptive method and 1.3% use an intrauterine contraceptive device (IUCD). In order to achieve PSI/Nepal’s goal to generate demand for underutilized methods such as IUCDs through household visits, it is important to keep Didis motivated.
- Health Facility Assessment of Availability of Different Modern Family Planning Methods in 4 Districts of Nepal
Family planning is a priority health area of the Government of Nepal. By end of 2015, all public sector district hospitals and primary healthcare centers (PHCCs) and 60% of health posts (HP) are required to offer at least five modern methods of contraception. PSI/Nepal’s Women’s Health Project is supporting Ministry of Health and Population (MoHP) to achieve this national goal by strengthening the existing public facilities service delivery system and supporting to increase the use of long-term family planning methods in the public sector. With the purpose of measuring the existing public sector family planning service delivery system, PSI/Nepal conducted a baseline assessment that gauged the availability and functioning of essential infrastructure; number and training status of providers; quality and quantity of essential equipment, supplies and commodities; and status of service provision.
- Improving Provider Behavior Change Communication and IPC: Best Practices from the Women’s Health Project
This brief describes the challenges faced, strategies developed, and lessons learned by the Women's Health Project. It also proposes a set of best practices for improving productivity of interpersonal communications (IPC) agents and increasing providers' skills and motivation.
- Equity Monitoring for Social Marketing: Use of Wealth Quintiles and the Concentration Index for Decision-making in HIV Prevention, Family Planning, and Malaria Programs
It is essential that social marketing organizations monitor the health equity of their programs and improve targeting when the poor are not being reached. This study compares two measures of health equity, concentration indices and wealth quintiles, using a defined reference population, and considers benefits of both measures together to inform programmatic decision making
- Nepal Research Brief: Contraception
While clients’ attitudes toward the IUD are known in different contexts, little is known about providers’ knowledge and perceptions of the IUD in developing countries. This brief seeks to provide evidence of cognitive barriers that may prevent Nepalese providers from recommending IUDs. Nepal’s permissive IUD service policies afford the opportunity to explore these findings among a variety of cadres and sectors.