Patricia McCormick’s vignette of life for women in rural Nepal highlights particular burdens women bare due to a lack of health resources and knowledge. It poetically and simply engages with some of the key challenges to health in Nepal—the extreme geographical challenges, the weather’s role in increasing geographic separation, the role of women, and the lack of resources.  However, this tale is changing as the Nepali government have, over the past thirty years, aimed to distribute health resources and knowledge. Even through extreme political instability, the changing Nepali government worked to understand the factors that cause maternal and infant mortality within the nation. In 1996, the Nepali Department of Health Services conducted the Nepal Family Health Survey, which would result in the Safe Motherhood Program in 1997. The aim of this program was to increase women’s access to health care and elevate her status (SHARMA, SAWANGDEE, and SIRIRASSAMEE 2007, 671–692). The Department of Health Services followed this up with the Nepal Maternal Mortality and Morbidity Study in 1998. To monitor key health factors, The Nepal Demographic and Health Survey was again conducted in 2001 and 2006, as well as, the Maternal Mortality and Morbidity Study conducted in 2008/09. From the analysis of these surveys it can be concluded that, “in spite of the violent conflict, Nepal made progress in 16 out of 19 health indicators over the period of 1996-2006” (Devkota and Teijlingen 2010, 6). The maternal mortality rate has been reduced from 539 to 281 per 100,000 (Devkota and Teijlingen 2010, 4)

There used to be a time when Nepal’s health statistics were the worst in the world. The country’s maternal and child mortality figures were off the charts, and worse than many countries in sub-Saharan Africa.

Nearly 1,000 mothers out of every 100,000 died at child-birth because the simplest delivery techniques and knowledge were not available with rural midwives, or remote area health posts. Child marriage was so common that many mothers gave birth at 15, were severely anemic, under-nourished and over-worked.

Children died of simple infections and vaccine-preventable diseases. Diarrohoeal dehydration and acute respiratory infections meant that one in every five children did not live to be five years old. Three-fourths of all children were undernourished (‘A Nation’s Health 2012, 1).

Published in August 2012, Nepali Times article ‘A Nation’s Health’, reviews the state of national healthcare in Nepal reviewing both the achievements of the past twenty years and the continual challenges. The main success it cited was the incredible reduction in maternal deaths, despite little change in rural healthcare facilities. The article cites the higher levels of literacy (in particular among young girls), the raising of the average marriage age, the improved levels of nutrition, the increased transportation infrastructure, and the tens of thousands of Female Community Health Volunteers for the improved statistics (‘A Nation’s Health’ 2012, 1).

Similarly the article ‘Access to Health: Women’s Status and Utilization of Maternal Health Services in Nepal published in the Journal of Biosocial Science cites the following factors contributed to the overall increase in women accessing care: “programme interventions such as outreach worker’s visits, radio programmes on maternal health, maternal health information disseminated through various mass media sources and raising women’s status through education” (SHARMA, SAWANGDEE, and SIRIRASSAMEE 2007, 671). In particular, the educational status of a woman and home based health worker visits showed an important relation to the woman accessing care. However, it was also found that the socioeconomic and demographic factors had a stronger association with the use of maternal health services. This includes the household economic status, number of living children and place of residence. The article concluded that variables such as the effect of distance to the health facility, availability of transportation, and quality of the services a woman has access to are important factors that were not included in previous studies. Likewise, a woman’s control over family financial decisions, her own decision-making power, and freedom to move are important issues as to what a woman’s status might be in the community/family (SHARMA, SAWANGDEE, and SIRIRASSAMEE 2007, 690).

Hari Prasad Bhattarai points out the importance of the social constrictions women face in Nepal in his journal article ‘Cultural Diversity and Pluralism in Nepal: Emerging Issues and the Search for a New Paradigm’.

The women, dalits, and ethnic minorities in particular are more underprivileged in this regard. Women among them are the most deprived groups. They are not yet economically independent. They have either to depend upon people belonging to high castes or to their male counter parts. More importantly, they have marginal existence in the spheres of politics and other public domains of decision-making. In spite of four decades of development efforts, poverty remains high and the incidence is pervasive for some particular groups (Bhattarai 2004, 321–322).

His article cites the continual challenges the new Nepali government faces to include the diverse groups contained within its state borders, and furthermore continue to raise the status of women among differing cultural and social backgrounds. The article only touches on the fact that women have little to no representation in traditional government and governing bodies. However, this is changing as the Nepali government sought to integrate rural communities into the health system, finding it almost impossible without the help of women.

The Nepali government recognized the distribution of health knowledge and resources is highly important to the geographically challenged and ethnically diverse nation. There is a long history of the government encouraging community participation in public health activities. Interestingly the early community volunteer programs would highlight the important role women play in the health of a community. The first community health program based on volunteers was introduced in 1980 in 16 districts, originally named the Community Health Leaders (CHL) program. 5,000 volunteers were chosen to represent their community, all of them were men expect in one district (Houston et al. 2012, 82). Upon reviewing the CHL program, it was discovered, “that it was not as effective as expected in improving health practices, in part because of Nepal’s socio-cultural environment, where women were reluctant to discuss their personal health issues or seek services from men” (Houston et al. 2012, 83). However, the single district that had recruited women as volunteers was discovered to be better at relaying messages, and the program was revised to only recruit female volunteers.

The Female Community Health Volunteers program (FCHV) was established in 1988, initiated in 27 districts, with the idea that one volunteer would be stationed in every ward, eventually expanding to all 75 districts for a total of 48,000 volunteers by 1993. The objective of the program was “supporting the national goal on health through community involvement in public health activities. This includes imparting knowledge and skills for empowering women, increasing awareness on health related issues and involvement of local institutions in promoting health care” (Houston et al. 2012, 83). This ward-based program was revised in 1992 to a population-based program, in order to account for the “different population densities in the country’s various ecological zones” (Houston et al. 2012, 83). Leading to a current total of 50,000 FCHVs in Nepal, 97% of them are based in rural areas  (WHO Country Office Nepal 2012, 1).

Although the program was increasingly more successful in the distribution of educational messages, the FCHVs continued to struggle “to show impact on behavior” (Houston et al. 2012, 83). However, in 1993 the FCHVs were given a direct role by the Ministry of Health in the distribution of Vitamin A capsules to all children 6-59 months old, twice a year. The National Vitamin A Programme (NVAP) would, “establish the FCHVs as tangible service providers and simultaneously elevated their status in the community’s eye and raised their motivation. The community’s positive feedback proved to be a powerful incentive for FCHVs to continue their work” (Houston et al. 2012, 83). According to a recent USAID report the FCHVs, “have made Nepal the first country to deliver vitamin A supplements every six months to 3.5 million children nationwide (ages six months to five years) preventing at least 12,000 child deaths annually” (USAID 2012, 1). Since this initial program, the FCHVs have been established as tangible service providers and the point of contact for many community health resources. They became responsible for the distribution of paediatric cotrimozazole tablets to treat childhood pneumonia, providing iron tablets to pregnant women, administering misoprostol to recently-delivered women, managing diarrhea in children, and have recently taken on the community new-born care package (Houston et al. 2012, 83).

Each of these programs was phased in, as originally there was great hesitation in allowing semi-skilled workers to provide antibiotics and other pharmaceuticals. However, a comparison between two programs implemented to treat pneumonia in children under 5 would prove the effectiveness of the FCHVs direct interventions. In the first program the FCHVs assessed, diagnosed, and treated children with pneumonia. The second program, followed the same diagnosis and assessment procedure, but were asked to refer the children to local healthcare facilities for treatment. The first program resulted in a better management of pneumonia in children, due to its ability to reach “poor people, those living in remote areas and for times when other providers were not available” (Houston et al. 2012, 85). Eventually expanded to all 75 districts there has been, “programmatic evidence and survey data has shown repeatedly that FCHVs, literate and illiterate, are able to correctly classify a child as having pneumonia, and provide correct treatment for age” (Houston et al. 2012, 86). The importance of this research is that it cements the importance of these female workers within the health community and within their own communities, raising their status and respect.

Besides the responsibility given to the FCHVs, as semi-skilled workers, on behalf of the health ministry, another key factor in the success of the program is the proximity of the volunteers to the community they serve, both physically and culturally. The FCHV program is unique in that it does not require the volunteers to be literate. This allows for females from lower socio-economic groups, ethnic minorities, and remote areas to be accepted into the program and perform the important duties instilled in the FCHV role. In a 2007 report, “by USAID, New ERA and the MOHP, 38% of FCHVs were illiterate,” furthermore, “the report suggests that illiterate FCHVs have performed as well as their literate colleagues”(Houston et al. 2012, 83). 42% of all FCHVs never attended school. 16% attended school but did not complete primary school, and 16% completed primary school (Houston et al. 2012, 83). The program has the remarkable turnover rate of only 4% per year, despite the volunteers not receiving money or payment for the wide range of services they provide (Houston et al. 2012, 83). Many countries have community health workers, but the success of this program is based on the presence of FCHV in all wards of the country, the degree of responsibility given to the semi-skilled worker, and the allowance of non-literate women to participate and become volunteers (Houston et al. 2012, 86).

These women fill a large gap that is created by a lack of human resources in the health sector. According to a recent study by the BMJ (British Medical Journal), Nepal continues to have the worse doctor to population ratio in Asia, citing a ratio of only two doctors per 10,000 people with only 27.2% (193 doctors), working outside of Kathmandu districts (Zimmerman et al. 2012, 1).

The Nepali Times recognised the important role women are playing in combating maternal and child health issues, exclaiming, “Tens of thousands of Female Community Health Volunteers scattered across rural Nepal have done more for the improvement in maternal and child survival than anyone else.” (‘A Nation’s Health’ 2012) However, the program continues to face challenges. There continues to be a backlog of FCHVs who have not received their initial training. The volunteer’s performance is related to the availability of supplies and support, it is only the lack of supplies that prevented “FCHVS from treating one fifth of the children who came for diarrhea treatment, according to the latest Nepal Demography Health Survey.” (WHO Country Office Nepal 2012, 5) Similarly, the study indicated, “that FCHVs need additional training on issues relating to pregnancies, delivery and child health care to promote community-based maternal and newborn care.” (WHO Country Office Nepal 2012, 5) While 85% of women who had seen a FCHV during pregnancy also received antenatal care from the FCHV, only 30% of FCHV mentioned the use of a skilled birth attendant, 11% mentioned preparing for possible emergencies, and 4% discussed a birth plan. (WHO Country Office Nepal 2012, 2)

The lack of skilled birth attendants continues to present a challenge to the health and wellbeing of pregnant and delivering mothers. Conducted in 2011, the latest Nepal Demographic and Health Study also indicated that, “although 58 percent of babies are received antenatal care from a doctor or nurse/midwife for their most recent birth, only 36 percent of babies are delivered by a doctor or nurse/midwife, and 28 percent are delivered at a health facility indicating that Nepal has a long way to go to meet the Millennium Development Goal target of 60 percent births attended by a skilled provider.” (Population Division Ministry of Health and Population et al. 2011, 13) Nepal currently has approximately 2,400 skilled birth attendants, according to a recent article in the Kathmandu Post this number needs to reach 6,500 in order to meet current needs. (Gautam 2012, 2) The same article reports that in order to encourage women to deliver in a health facility the government provides financial incentives, “Rs 1,500 in the mountains, Rs 1,000 in the hills and Rs 500 in the tarai regions as travel costs for each delivery.” (Gautam 2012, 2) However, it also cites that “none of the mothers who delivered in hospitals knew that they got the money as a transportation incentive.” The lack of personnel leave hospitals with little time or ability to counsel mothers after their delivery, which is where the continued training of the FCHVs in how to advise and educate mothers on pre-natal and post-natal care will continue to bridge the gap between mother and health facility.

It was this gap between mother and facility that would nearly cause 170 women out of 100,000 that will die during pregnancy and childbirth in Nepal this year, according to WHO.

These challenges reach across the nation, the fact that “Nepal is an Asian country with a population of 28 million; its mountainous topography and poverty (annual gross domestic product $300 (£193; €245) per capita)” continue to “create barriers to adequate healthcare.” (Zimmerman et al. 2012, 1) The complex nature of maternal health in Nepal is both a positive example of internal initiatives to create and implement change, and a continual battle to elevate the status of women in a society whose traditional nature is patriarchal.

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