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COUNTRY SITUATION DEMOGRAPHIC Nepal is a landlocked country situated between India and China. It has a total population of 23.15 million in an area of 147,181 square kilometers with a density of 157 persons per square kilometer. According to Population Census 2001, the annual growth rate was 2.25 per cent between 1991 and 2001. Almost equal number of males and females is recorded in the census with a sex ratio of 99.8. Population growth continues to be very high on account of the large size of female population in the reproductive age group (49.2%) and high fertility rate (4.1 children per woman) due to high-unmet demand for contraception (27.8%) and early marriage of girls before the age of 18 years. Adolescent and youth constitute the largest segment of the population (32.48%) in Nepal. The adolescents aged 10-19 years constitute 22.3% in 1991 and it is 23.61% in 2001. This is indicative of the fact that the tendency of young people is on the increase. The country is divided into three ecological zones: mountain, hill and tarai (plains) and is inhabited by more than 100 caste and ethnic groups. About 80 percent of Nepalese people are dependent on agriculture for their livelihood. However, agriculture sector contributes only about 40 per cent of the GDP. The GDP per capita remains very low at US$ 236. Inequality of the means of subsistence and income is widespread. Acute underemployment is considered as the principal cause of large-scale poverty. Economic growth of the country has not improved markedly over the years to outstrip the population growth rate. |
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The topography of the country is another challenge of the country. Hills and mountain areas are not linked with national highways. Houses are scattered and even in few places it takes sometimes more than 24 hours to reach the service center.
Nepal adopted the policy of incorporating population issues into the development process ever since the first plan launched in 1956. Population issues are being considered with priority in the periodic plans of the country as an endeavor towards sustainable development. |
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GENDER About 90 percent of the economically active female population in Nepal is engaged in agriculture and related activities, while less than one percent of them work as professionals and technicians. Those employed in non-agriculture sectors are generally in lower level and low paid jobs. Women are generally involved in household works and unproductive fields. The incidence of violence against women is on the rise. Each year, 5000-7000 girls between the age of 12-20 years are trafficked out of Nepal. Altogether, there are more than 200,000 Nepalese women currently engaged in flesh trade in India. (CWIN, 2002) Domestic violence is rampant but is widely unreported. Women have practically no right over their own pregnancy. Marital rape is considered a normal phenomenon, although the court has recently given a verdict that even husbands can be punished for coerced sex with their wives. Husbands and in-laws usually decide for her about when, how many and how often she should get pregnant. Usually they also make decisions on whether or not to seek medical assistance during her pregnancy, delivery and post delivery. Women are victims of rape, sexual harassment and incest. High son preference has extra pressure for the women giving birth to daughters only increasing the chances of her husband to get associated with other women. The existence of mental and emotional tortures was reported by 93%, and beating was identified as the most common form of physical violence against women and girls (82%), followed by rape (30%), and forced prostitution (28%). (Saathi, One of the organizations working against violence in Nepal) Among 59 prisons of the country, 20% of all women imprisoned (460), were accused of abortion and infanticide and all of them were illiterate and from low-income families. 26% of them were unmarried, 12% were widows and 65% of them were not engaged in any kind of income generating activities. (A study conducted by CREHPA in 1997) Poor, marginalised and internally displaced people (IDP), refugees and youth continue to face discrimination in access to SRH services, contributing to higher maternal mortality and morbidity rates in these communities. Various socio-economic, cultural and political barriers to access, including gender discrimination, anti choice groups also remains high in Nepal. ADOLESCENT There has been high fertility rate among adolescents. About 21% of adolescent women aged (15-19) are already mothers or are pregnant with their first child. (DHS 2001). The survey also indicates that almost one in five adolescent women age 15-19 are already mothers or pregnant with their first child. The contraceptive prevalence rate (CPR) is reported to be at 12.0% only among adolescents (age 15-19) while it is 23.4% among 20-24 age group (DHS 2001). as against6 7% and 15.8 % respectively in 1996. This indicates that the use of contraceptives by these age groups is quite low as compared to other countries in the region. The 2001 DHS also revealed that 40.7% of adolescent's mothers do not receive antenatal care and the majority (85.9%) of adolescent's mothers deliver their babies at homes. A trained health worker assists only 13 % of these deliveries. There is higher incidence of anemia hypertensive disorders, abnormal and premature deliveries and greater fetal demise in adolescent mothers compared to older mothers. NDHS 2001 reports that the significant proportion of maternal deaths (28.5 %) occurred in the adolescent age group. Adolescents and youth are scattered in the community and they are also mobile. The risk taking behavior of the youth and the situation of being away from homes in search of economic opportunities make them susceptible to contact diseases like STI/HIV/AIDS. The NCASC, 2003 reports revealed that the age wise data of HIV/AIDS infection is: 9% in the age cohort of 14-19, 53% in 20-29 age groups. The HIV scenario of Nepal reveals 62% of HIV including AIDS found in adolescents and youth group. Moreover, 66% adolescent girls in the age of group of 10-19 years of age are illiterate whereas the figure is only 24% among adolescent boys. SRH education and services are high needs for these groups and in this respect particular emphasis needs to be on adolescent girls for this purpose, Government and NGOs are required to play a lead role for providing SRH information and services to these groups. Apart from the existing situation as mentioned above, interventions for addressing the needs and concerns of adolescents and youth have been obstructed particularly due to the lack of clear cut effective policies and programs and failure to involve young people in the existing promotional activities; awareness or sensitivity among educators, providers of health and social services, religious and youth leaders and parents about special problems of young people; no involvement of young people in educational programs or services; unavailability of trained manpower for the provision of special services and resource constraints BARRIERS TO THE PROMOTION OF RH Although there is no organised opposition from religious leaders or from the political parties, there are many social and religious barriers that need to be overcome and attitudes changed. In our society, people's perception of women's role at home and outside and their attitude towards them have been shaped, set, reinforced and perpetrated by a strong patriarchal way of thinking along with economic realities. Women are geared to be the weaker sex and not to question their partners' acts. Religion and tradition has accorded higher priorities to a son by making him the bearer of the family name and a responsible person for performing religious rituals. A girl child is looked upon as burden to the family and married off to shift responsibilities. The marriage of a girl child is a holy deed for the parents and an opening of the door to heaven. The practice of discriminating between sons and daughters in education and food habits has negative consequences not only for oneself but also the nation as a whole. The constitution is against any sort of discrimination, but the prevailing outdated laws and practices need to be changed for improving the RH status. INTRODUCTION TO FPAN The Family Planning Association of Nepal (FPAN) founded in 1959 became an associate member of the Planned Parenthood Federation (IPPF) in 1960 and full-fledged member in 1969. Prior to the establishment of the Association the concept of family planning was quite new and considered as a thing that went against religion, tradition and prevailing social values in Nepal. FPAN, in consonance with the social system, focused on information and education as a means of advocating a small family as a norm among the rural masses. The family planning program in the government sector gained momentum only after the establishment of the Maternal and Child Health Division at the Ministry of Health in 1965 and the launching of the National Family Planning and Maternal and Child Health Project in 1969. It was after FPAN started complementing and supplementing the national program. The family planning services in 1960s were limited to distribution of condoms, pills and insertion of loops. All activities were implemented by volunteers because there were no staff members to assist their work. The Association resorted to meetings and print media to educate the people during the time. Since the only electronic media reaching the general public was radio, FPAN initiated a weekly radio program on family planning in 1968. FPAN started more target-oriented and focused programs in the 1970s. A Family Planning Welfare Project was implemented in ten wards of Kathmandu valley in 1972, which started providing sterilization services on request and assistance of USAID. Since these projects required fulltime workers, staff and volunteers were recruited to provide the services. FPAN started publishing family planning magazine and other IEC materials for the target population in the 1970s. Similarly, FPAN programs were expanded from three districts in the 1960s to 15 districts in the 1970s and 32 districts in 2004. The program focus of FPAN has been changing gradually to adjust its program thrust and activities with contemporary demand for FP services by the people. In the 1960s and 1970s, it adopted an integrated approach of amalgamating community development and family planning programs. Consequently, an emphasis was given to disseminating FP messages and delivering services to the needy people in the 1990s in compliance with the changes in behaviour and attitudes of the people. In this endeavor, it has been giving greater emphasis to service delivery since 1992 to meet the unmet demand for family planning and reproductive health services. Community development programs were curtailed substantially and new programs, including STI/HIV/AIDS, counseling and services, sexual and reproductive health education and services to adolescent and youths, maternity services and strong advocacy on safe abortion were added in the 1990s. FPAN contributes 25-30 percent to the national family planning programs and its program activities are ever expanding meeting the unmet needs of family planning, including STI/HIV/AIDS prevention, control and management. Founder Members
The HMG/N policy and plan have given more emphasis to foster partnership programs with NGOs and private sector and its health sector development partners for STI/HIV/AIDS prevention, control and management. The policy, plan and priority areas of HMG/N are reviewed briefly as below. Long-term Health Plan of Nepal (1997-2017) His Majesty's Government of Nepal (HMG/N) formulated the second long-term National Health Plan (1997-2017) in 1997, aiming to create a socio-economic environment for enabling Nepalese citizens to lead a healthy life through preventive and curative health services. Importantly, the plan focuses on preventive aspect of all reproductive health services in a package. It places greater emphasis on community involvement, increasing access to PHC outreach, sub-health posts, health posts, PHCC and district hospitals as well as establishing functional referral linkages between all levels. The following targets were identified in the National Health Plan to be attained by the end of the Tenth Five-Year Plan and by the end of a twenty-year period.
Source: Ministry of Health 1997, Ministry of Health and New Era, 2001, NPC, 2002 Note: These figures are taken from the 10th Plan Base Paper and could be changed in the final plan. STI/HIV/AIDS prevention and control program is placed under the reproductive health package, which includes family planning, safe motherhood, child health, prevention and management of complication of abortion, human sexuality, sub-fertility management, adolescent reproductive health and life cycle issues and problems of elderly people. However, the plan does not pay much attention to the alarmingly growing epidemic of HIV/AIDS. The program activities for HIV/AIDS prevention and control are loosely integrated with the reproductive health package. The growing expansion of the HIV/AIODS epidemic was not realized during the plan formulation period. However, the long-term plan of the government has emphasized on community participation, equitable access and inter-sectoral collaboration in all aspects of the reproductive health package. In order to ensure supplementary and complementary roles of the NGOs and private sector in the implementation of the reproductive health package in a sustainable way and to expand coverage and quality of services, the plan has identified the need for strengthening NGO/ private sector partnership with HMG/N. The following strategies adopted by the plan for an effective and efficient provision of quality RH services have given enough scope for the NGO and private sector to supplement and complement the national RH program including STI/HIV/Aids prevention and control.
Following the long-term Health Plan (1997-2017), the national reproductive health strategy of Nepal, formulated in 1998 emphasized the prevention and management of STI/HIV/AIDS and other reproductive health issues through the integrated reproductive health package introduced at hospitals, primary health centers (PHC), health posts, sub-health posts, outreach clinics, TBAs and FCHVs. The national reproductive health strategy has no clear-cut policy, strategy or activities for HIV/AIDS prevention and control. It is loosely integrated with reproductive health package. However, it lays stress on some preventive aspects and syndromic treatment of STI/HIV/Aids at various levels as follows:
NATIONAL ADOLESCENT HEALTH AND DEVELOPMENT STRATEGY 2000 Adolescent specific health services were virtually non-existent in Nepal before the International Conference on Population and Development (ICPD) 1994. However, selected programs focusing on drug abuse and HIV/AIDS prevention and control were implemented by few NGOs. Following the adoption of ICPD Program of Action (1994), the fourth international conference on women in Beijing (1995), WHO/ south East Asia Regional Strategy for Adolescent Health and Development (1996), and the Second Long Term Health Plan (1997-2017) of Nepal and the National Reproductive Health Strategy of Nepal (1998), HMG/N formulated a National Adolescent Health and Development Strategy in 2000. As in the National Reproductive Health Strategy, STI/HIV/AIDS prevention and control among adolescent is only loosely integrated with reproductive health package. The strategy aims to increase access to and utilization of friendly health care services in order to reduce the incidence of STI/HIV/AIDS among adolescents through integration of adolescent health services into existing health care delivery system. It also seeks to involve and establish links with youth clubs, NGOs and the private sector to expand and improve STI/HIV/AIDS education and services. The major activities proposed in the document are to provide adolescent friendly health services through existing static and outreach service outlets to initiate peer counseling program in schools/ clubs and workplaces to increases knowledge of STI/HIV/AIDS, to increase communication between parents and adolescents on STI/HIV/aids education, to increase STI/HIV/AIDS knowledge in adolescent (married 15-19) from 24.3 percent in 2000 to 50 percent in 2006 and 75 percent in 2011. NATIONAL HIV/AIDS STRATEGY 2002-2006 In the past sexually transmitted diseases were diagnosed and treated by the department of venereal diseases in all major hospitals. As the STD problems arose in the country, a STD control committee was formed by HMG/N in 1986. The committee was later upgraded to a semi-autonomous organization of National center for STDs and AIDS Control (NCASC). HMG/N formulated a short-term AIDS control plan in 1988 and a medium-term plan (1990-1992). In 1992, a National Aids Coordination committee, chaired by the Minister for Health, was established bringing government and non-governmental organizations for STDs and AIDS prevention and control together. Reviewing the experience of both the short-term and medium-term plans, HMG/N formulated a second long-term (1993-1997) plan. The NCASC lunched a HIV/AIDS control strategic plan (1997-2001) in 1997. However, these short and medium term plans and strategic plans had no clear-cut objectives and programs for HIV/AIDS control at national level. The HIV/AIDS prevention and control programs were loosely integrated with the RH package. In 2000 NCASC has only a 1.4 million budget, which was too low and demonstrated that HMG/N took it as a symbol or token rather than real commitment (MEH and REGHED, 2000). To make up for the shortfalls of past plans and strategies, HMG/N formulated a comprehensive National HIV/AIDS strategy in 2002, to bring all sectors into the mainstream and constituted the National AIDS Council chaired by the Prime Minister, to proclaim political commitment. Overall, the national HIV/AIDS Strategy intends to expand the number of partners in the national response of controlling the HIV/AIDS epidemic and to increase the effectiveness of the response by focusing on priority areas. Due emphasis is given to the need of care and support for people already infected and affected by HIV/AIDS. Similarly, commitment is sought not only from the Ministry of Health but also from all concerned agencies within and outside the government and better-coordinated support is likewise solicited from external development partners. Decentralization of HIV/AIDS programs and activities at local level is given enough emphasis. In response, local governments (DDC and Municipalities) are expected to include program activities from their own local development plans. INGOs, NGOs, CBOs, civil society as well as the private sector and external development partners are invited openly to supplement and complement the national HIV/AIDS control program. The strategy sought multi-sectoral involvement for building an adequate response to the HIV/AIDS epidemic with primary focus on its prevention. Rights based response is advocated with a specific focus on the rights of people infected and affected by HIV/AIDS, in particular the rights to confidentiality. Resource allocation will be made for defined priorities based on the vulnerability of various affected groups and communities. People and communities will be empowered to protect themselves from HIV infection within a supportive environment. Equal access to basic care and services is emphasized for all persons infected and affected by HIV/Aids. Similarly, gender consideration has been considered central to the development of program and interventions, and due consideration is given to universal precautions to counteract the possibility of HIV transmission through medical interventions. HIV testing is considered as voluntary with guaranteed confidentiality and adequate pre and posttest counseling both in the public sector and the private sectors. Emphasis is given to the participation of the people living with HIV/AIDS in the programs including formulation of policies, strategies, programs and projects. The major strategies of the government for STI/HIV/AIDS prevention, control and management are as follows:
The safe abortion policy 2002 was developed in the context of 11th Amendment of the Muluki Ain 2020 B.S. (The law of the land 1959), the basic Code for the kingdom of Nepal. This amendment reformed the restrictive abortion framework, which prohibited abortion and characterized it as an offence against life. His majesty Government of Nepal amended the Nepal Abortion Bill in March 2002 and Royal Assent was given on the Bill on 26th September 2002. The Eleventh Amendment provides provision for safe abortion upon voluntary consent of the women on the following grounds:
Strengths
In consonance with the new changed context at national and international levels in the field of reproductive health, FPAN has gradually been shifting its emphasis from mere family planning to comprehensive sexual and reproductive health programs. Accordingly, the major program thrusts of FPAN will concentrate on five major areas (Advocacy, Adolescents, AIDS, including HIV, Access to marginalized and under- served groups and Abortion). To enlist public, political and financial support in the field of reproductive health, various seminars, workshops and orientations will be conducted addressing four major issues (SRH rights of men, women and young people, resource mobilization, accessibility of SRH services to the marginalized population and socio-cultural barriers). FPAN will work towards providing information, education and services to adolescents and youth on issues covering early marriage, gender-based discrimination and violence, unwanted pregnancy, unsafe abortion, STI/HIV/AIDS and sexual abuse. FPAN will work towards providing STI services which ultimately contributes towards reducing the incidence of HIV/AIDS in the operational areas. The Association will work towards providing safe abortion services to women as universal rights of women. Services and education on sexual and reproductive health, including family planning will be provided to marginalized and internally displaced people in the rural settings of FPAN's operational areas.  |
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