Nepal’s health challenges
«Ranked 157 out of 187 in the Human Development Index , the country is still seeing the consequences of 10 years of violent conflict between forces loyal to the King and Maoist insurgents, despite the signing of a peace accord in 2006.»
«As a nurse/midwife, I try to raise awareness among women of their own health. Many mothers-in-law, who themselves had to go back to work in the fields within days of giving birth, don’t believe things should be any different for their daughters-in-law. This is why I have to make pregnant women aware of the need to rest before and after delivery and the importance of adjusting their diet during this period. Attitudes are changing, but there’s still a lot to be done. Many women don’t know what they are entitled to or where to find the care they need. They don’t know what they need as women. »
It is often husbands and parents-in-law who make the decisions, including with regard to sexual and reproductive health
The ongoing political disputes and the anticipation of a new Constitution since 2008 prevent the interim government from tackling the country’s economic and social problems. From the healthcare perspective, the Nepalese government set out a very advanced healthcare system in its Constitution. However, in reality the huge social and geographical disparities hinder an effective implementation of the system and the quality of care and access to it remain inadequate. The economic burden imposed on families by the use of maternal health services is still very high and the availability of these services at healthcare facilities is frequently poor.
Doctors of the World has been working in Nepal for over fifteen years, through projects ranging from community development to combating HIV and tuberculosis.
Since 2007 Doctors of the World has been active in isolated communities in Sindhupalchok district, particularly among women of childbearing age. The aim of our programme is to increase the use of public sexual and reproductive health services and to reduce factors contributing to maternal and neonatal mortality.
The Doctors of the World project sets out to ensure the availability of high-quality health services at community level (renovating and providing equipment for health centres, training health workers and facilitating referrals to other healthcare facilities). It also aims to build capacity among women in relation to access to health services. The element which makes this project original and sustainable is the involvement of women in micro-finance activities and education sessions on preventing and managing pregnancy, childbirth and the postnatal period.
Socio-economic determinants affecting access to healthcare Nepalese society is divided into castes and is still very much shaped by patriarchy. Women are severely restricted in relation to health, education and control of their bodies and life choices. It is often husbands and parents-in-law who make the decisions, including with regard to sexual and reproductive health, while the women are traditionally confined to their maternal role and are limited in their options in terms of developing income-generating activities. Dissuaded from seeking pregnancy and postnatal care, 63% of them give birth at home. In rural areas, where they are intensively involved in agricultural labour, women have little or no time for information meetings or sessions on prevention which the community consider to be unproductive.
Using micro-finance training workshops to raise awareness about sexual and reproductive health
Health education and micro-finance training sessions take place monthly and are organised by group leaders who have already received training. Women meet and share their experiences related to pregnancy, antenatal care, contraceptive methods and other issues. Younger women, as well as men and adolescents, can also attend these meetings as observers.
The section on micro-finance focuses on managing household budgets and expenditure and also covers methods for borrowing and saving money and the distribution of interest which is not reinvested. The loans are essentially allocated to income-generating activities (for the purchase of seeds or farm animals, for instance), but may also be used to pay for medical care.
In addition to these monthly meetings, a major health campaign is held annually in each VDC. Health messages are disseminated in the form of song and dance competitions, and medical consultations are available for pregnant women. It is an opportunity to educate groups beyond those involved in the micro-finance initiatives.
Doctors of the World has also made available an obstetric emergency fund within the cooperatives, which provides women with money in the event of a pregnancy-related emergency (transport by ambulance etc.).
Supporting women in their desire for independence
At the heart of the Doctors of the World programme in Nepal is support for raising awareness about the importance of using sexual and reproductive health services. According to a knowledge test about sexual and reproductive health realised in June 2012, an average of 61% of family decision makers (husbands, mothers in law) attending the microfinance group now know at least 3 danger signs in pregnancy. 58% of them also have some knowledge on neonatal complications and 96% of women, 90% of mothers-in-law and 94% of husbands agree that a woman should go to at least 4 antenatal consultations.
Women say that the monthly meetings mean they feel more able to talk about their personal experiences of pregnancy. They all agree that they no longer want to keep quiet about their health issues and wish to put an end to the silence which prevented them from getting on with living their lives.
riding in a horse-drawn cart to the maternity unit
«A local proverb says that a pregnant woman already has one foot in the grave. Our everyday work is devoted to changing this situation»
MdM has been running a programme to improve maternal, newborns and children’s health by facilitating access to health centres in the city of Mao in the Kanem region of northwest Chad since 2009..
«Tradition dictates that pregnant women must not eat too much to avoid having a big baby. They have to give birth at home and stay shut away for 40 days. With the help of the local staff, we raise awareness about ante-natal care and encourage them to go to health centres. »
«A local proverb says that a pregnant woman already has one foot in the grave. Our everyday work is devoted to changing this situation » insists Oscar Pale, programme coordinator in Mao. The health indicators reflect a harsh reality. Chad ranks second in the world for the number of women dying in childbirth: 1,100 deaths per 100,000 live births (source: UNDP 2010. In France: 8 deaths per 100,000). Midwife Anne Gouezec regularly goes to meet women in the surrounding villages. Some twenty kilometres of scrub away in a deserted and lunar landscape is the remote village of Sombori. More than an hour from the health centre, traditional beliefs are well entrenched here, as Anne explains: « Tradition dictates that pregnant women must not eat too much to avoid having a big baby. They have to give birth at home and stay shut away for 40 days. With the help of the local staff, we raise awareness about ante-natal care and encourage them to go to health centres. It’s a long term work and it's not always easy. »
Involving the community
For the past week now, pregnant women from Sombori have been able to get to the health centre in a horse-drawn cart funded by MdM. A rudimentary means of transport perhaps, but suited to the reality of the village. Moreover, the horse and cart are the responsibility of a local committee elected by the villagers. « It's a great project because the committee takes its duties very seriously,” Anne is pleased to report. “It is responsible for the upkeep of the cart and feeding the horse. There is a kind of subscription fee for the cart. Each family has to pay 750 CFA francs (1 euro) or give one coro i.e., 2 kilos of millet. It's a community management system that is sure to last. »
Off to a good start
One evening when she was leaving the village, Anne saw the cart returning with nine women who had taken their children to be vaccinated. «We need to continue to develop awareness in the villages,» insists Anne. «In one year, the number of deliveries in the health centres has risen from 7 to 17 a month. We're really off to a good start! ». Back in Mao, Anne has been called out to the hospital in Mao to attend a delivery. Before setting off, she tells us: “Yesterday, I delivered a baby girl who is severely deformed and she’s not expected to live. Her mother took her in her arms and accepted it as God's will. Some might see a kind of fatalism. But I think it gives them the strength to meet life’s challenges. It is such examples of resilience that have led Anne to see her work in a different light.
for pregnant women
«Encouraged by the positive results and given the satisfaction of the authorities, we launched a new programme in September to support the policy for free healthcare for some sections of the population. A transition programme, it is a natural extension of the previous one implemented after the post-election crisis the country underwent in 2011.
From August 2011 to August 2012, Médecins du Monde donated drugs and medical supplies to the hospital in Guéyo and 16 other healthcare facilities in three districts. The area has a population of 400,000 with 20,200 pregnant women and more than 58,000 children aged under 5 years.
MdM has refurbished 14 maternity units in the facilities and health workers have received training/re-training, particularly in Emergency Obstetric and Neonatal Care.
The objective of Médecins du Monde is to support the national health policy up until the introduction of the Universal Health Insurance scheduled for 2014.
Within the framework of the new project, drugs and medical supplies are no longer given directly to the healthcare facilities by the NGO but are distributed in compliance with the process set up by the State. This will not only enable global and comprehensive cover for 45 health centres as opposed to the previous 17 but will also serve to reinforce the state system. The project includes a range of activities, focussing in particular on improving transport between health centres and referral hospitals for women with complicated deliveries. Unable to afford the cost of transport, which can be as much as 150 euros, still too many women die from lack of access to the treatment they so badly need.
Some ten specialists (midwives, pharmacists, nurses) have been recruited or their employment extended to supervise the activities held in the community and at public healthcare facilities. As Dr Joseph Zahiri, the Ivorian MdM medical coordinator says, it is a real challenge: « Supervision implies our staff being fully involved. Everybody must go beyond their expertise and support health workers with treating their patients. They must also forge close ties with the local Ministry of Health representatives and pass on to them information collected in the field. »
«97% of the villagers surveyed had no knowledge of any of the risks related to pregnancy. So, health education and training of health workers have been identified as priorities for action. »
in the region for a year
Besides the main target audience for the session – women of reproductive age – there are a few men but several grandmothers who have such a crucial role to play in helping practices to evolve have come along too.
«The women are more willing to come to ante-natal consultations and I am called on more often to attend deliveries. »
Priority on health education
In this region of the world which has one of the highest rates of maternal mortality in Southeast Asia with 580* deaths per 100,000 live births, most women and families live in remote, rural areas. In the districts of Mounlapamok and Soukhouma (50 and 62 villages respectively), access to healthcare facilities remains an issue because of distance and a lack of road infrastructure and so 90% of villagers have home deliveries. In order to encourage women to go to the health centres, it is essential to improve their knowledge of the risks related to pregnancy. To achieve this, MdM has trained a community worker to take charge of organising health education sessions in each district.
23-year old Vong visits two villages a day to advise women and teach them the danger signs to look out for. Here, the information session is kicking of in Huay Yang with an attentive group of around fifty people. Using a series of illustrations, a Q&A session lasts for over an hour in a cheerful atmosphere: “What do you eat when you are pregnant? Why is it better to have a baby in a health centre? What signs should you look out for during pregnancy or after delivery?” asks Vong, ably assisted by Chanheung, head of the mother and child unit at the district hospital. Chanheung's experience as a midwife and her in-depth understanding of the region’s customs and traditions ensure the health education sessions run smoothly. Her participation is rounded off by the involvement of close to 150 volunteers trained by MdM to promote maternal health in their villages.
Free ante- and post-natal care and staff training
On the bank of the Mekong River stands a green and white building, one of the six health centres in Mounlapamok district. Long deserted by the region's inhabitants as health is a luxury they simply cannot afford, attendance rates at the Nadee dispensary saw a significant increase in October 2011 after MdM introduced a system of health vouchers giving pregnant women access to healthcare free of charge.
And for good reason. Mothers are now reimbursed a fixed amount for four pre-natal and two post-natal consultations, labour and delivery and transport to the health centre. “MdM ensures the effective application of a decree instituting free healthcare by coordinating between the Ministry of Health and the province’s health authorities and funding costs in both districts,” points out Isabelle, the programme coordinator. And this is in addition to financing minor renovations to the centres and supplying obstetric equipment. “The delivery room in Nadee has been tiled and equipped with bed nets and a well ten metres away will shortly be connected to the sink in the centre,” she adds. Improving quality of care also requires training health workers at all levels of the health system. So, like Tounoula, a community midwife from each dispensary will be given a year of training at the school in Paksé, the capital of the province. “Training is supervised by MdM,” says Maëlle, the project medical coordinator. And lastly, a staff member trained by MdM follows-up on consultations every week at the centres and the hospital. The programme's strength lies in its ability to establish a link between the villagers, the health centres and the hospital by improving the knowledge on health of all those concerned, in order to guarantee its sustainability, and also in time to extend cover to young children and increase hospital referrals.