Nepal

Annex-2

Millennium Development Goals (MDGs)

The progress made towards achievement of health related MDGs is given here:

GOAL 1: ERADICATE EXTREME POVERTY AND HUNGER

TARGET 2: Halve, between 1990 and 2015, the proportion of people who suffer from hunger

Source: a HMG/United Nations Country Team of Nepal, 2002 (a.t: 1992 data; a.2: 1997 data).

b Extrapolation based on the trend between 1975 and 2000.

c Nepal Micronutrient Status Survey (NMSS) 1998/99.

d Department of Health Services (DOHS)/New ERA 2002; UNICEF 2005 (calculated for the age group based on NDHS 2001 data).

STATUS AND TRENDS

One of the causes of hunger is inadequate food security. Several studies have underlined the finding that sufficient overall production is a minimum condition for food security, but it is not a sufficient condition on its own. Food security cannot only be examined from a national perspective but must be looked into at the micro-level to encompass household and, preferably, intra-household levels. This is particularly so in Nepal, given the discrimination against girls, women, the elderly, and the disabled. The World Bank defines food security as 'access by all people at all times to enough food for an active, healthy life'. Food security must be viewed in terms of availability (production of food); access (economic and social access to food); and utilisation (proper processing of food items into food).

Overall, the agricultural sector has not been able to exhibit impressive performance and especially in recent years, the situation has deteriorated because of the insurgency (Sharma 2003). Surprisingly, food production improved and surplus food grains have been reported since 2000 (DOA 2002), although food availability remains uneven. For example, some of the hill and mountain regions have been vulnerable to food insecurity.

Because a key feature of food security is access to sufficient food by all people at all times, various health, nutrition, and consumption surveys examine access. It is possible that households not producing sufficient food can be consuming sufficient food through exchange systems, such as by the purchase/ exchange of food, or by borrowing food or money to purchase food. In Nepal, especially in the hills and mountains, one way of ensuring food access within families with less food self-sufficiency is labour migration. A study shows that on average, a household can provide itself with food from its own farming activities for only 6-7 months, and as a result many households resort to labour migration either to foreign countries or to urban areas of Nepal (Adhikari and Bohle 1999).

Another way of understanding hunger is to look at child malnutrition. Malnutrition is a serious impediment to children's overall development. The most common forms of malnutrition are: protein-energy malnutrition (PEM), iodine deficiency disorders, and deficiency of iron and Vitamin A. The 1998 Nepal Micronutrient Status Survey reported that 90 percent of Nepalese children are suffering from one or another form of malnutrition. There are wide disparities in malnutrition across regions and ecological zones. For instance, in the mountains, stunting (a child being short for his/her age - a sign of chronic under-nutrition); being underweight (a child having low weight for his/her age); and wasting (a child being thin for his/her height, an indicator of acute malnutrition) are more prevalent than in the Terai. Likewise, the rate of stunting in the rural areas is much higher than that in the urban areas.

The major direct cause of general malnutrition, also referred to as protein-energy malnutrition, is inadequate availability of calories, which is the result of low food intake and a high burden of disease, or more commonly a combination of both. Underlying causes are inadequate access to food, insufficient basic health services, an unhealthy environment, and inadequate care of children, pregnant, and lactating women.

The nutritional status of children less than five years old has seen only modest improvement since 1975, when the first nationwide survey was conducted. It is clear that the proportion of underweight children has reduced hardly at all when the baseline value for 1990 and the status in 2001 are compared. For instance, between 1975 and 2001, stunting among children aged 6-59 months was reduced from 69.4 percent to 49.3 percent, a reduction of only 0.6 percentage points by year. If this reduction rate is maintained, the rate of stunting will be 44 percent in 2015. This is far higher than the goal of reducing the stunting rate of 60 percent in 1990 to 30 percent in 2015. This means that unless the reduction rate is significantly increased, it is highly unlikely that Nepal will attain the MDG goal.

As for the proportion of the population below the minimum level of dietary energy consumption, a lack of reliable current data has made it difficult to assess the exact status and trends in this regard, thereby warranting additional work in this area. However, given the modest reduction in child malnutrition over the last decades, it seems unlikely that Nepal will achieve the target of reducing by 50 percent the proportion of people who suffer from hunger by 2015.

SUPPORTIVE ENVIRONMENT

After the political change in 1990, the government vigorously pursued liberalisation policies, and especially by the mid-1990s, it was realised that the benefits of these policies needed to be channelled to the poor. A number of measures were adopted to gradually remove subsidies, deregulate price controls of agricultural inputs and products, and encourage the private sector's involvement in producing and marketing agricultural products and inputs.

The basic premise of the APP, implemented since 1997, was the overall economic development triggered by high growth in agricultural production. The APP set out to improve food security and poverty through a number of measures. These entailed increasing the income of poor and small farmers through employment creation from agricultural growth and the intensification of small farms with high-value crops; removing the greatest barriers to the poor's participation in the growth process; empowering the poor and needy, particularly women, in the growth process; and implementing supplementary activities for food security such as short-term food aid, the distribution of food aid through NGOs, the implementation of Food-for-Work programmes by WFP, GTZ, and DFID, and food stock maintenance.

Also, several micro-level initiatives have aimed to increase food security in targeted areas since the mid-1970s (Food-for-Work). Under the food aid programme, the government provided subsidies to the Nepal Food Corporation (NFC) to transport food-grains to designated 'remote areas' with a high incidence of poverty and hunger. Similarly, several programmes are in operation that target children by providing them with schooling and food assistance. One such example is the Primary School Feeding Programme, which provides midday snacks to encourage enrolment and daily attendance, particularly of girl students, in government-run primary schools.

In an effort to improve the nutritional status of children, major policy initiatives include three national-level nutrition strategies developed in 1978, 1986, and 1998. A National Nutrition Coordinating Committee has been created, and Nutrition Focal Points have been set up at key ministries. In addition, several noteworthy programmes include the Expanded Programme of Immunisation, the Control of Diarrhoeal Disease Programme, the Acute Respiratory Infection Control Programme, and the Decentralised Action for Children and Women. The National Vitamin A Programme has proven to be quite effective, mainly due to the successful mobilisation of Female Community Health Volunteers (FCHVs). Likewise, the Anaemia Control Programme has been effective in reducing the rate of anaemic women and children. A national deworming programme, covering all 75 districts since 2004, shows initial signs of success in reducing anaemia among children (UNICEF 2005).

CHALLENGES

While a number of small-scale and targeted food-assistance programmes and projects are in operation, including subsidies for food-grain transport to remote areas, initiatives to provide mid-day meals in a significant number of primary schools, and food assistance for natural and other disasters (Perry 2000), food security has never constituted a major plank of policy making and programming (Mishra 2001). The food assistance programme remains cost-ineffective due to geographical constraints and high operational costs, and the centralised distribution system.

Given the widespread rural poverty in Nepal, non-improving agricultural productivity, and massive food deficits in parts of the country, the goal of halving hunger-affected people between 1990 and 2015 will be a daunting task. Multiple types of malnutrition remain a common problem among rural children as iron-deficiency anaemia affects almost all children at pre-school levels. In spite of some successful interventions such as the Vitamin A programme and the expanded programme on immunisation, improving child nutrition is a tremendous task, warranting different interventions at multiple levels.

Conflict and the resulting violence emerge as a major challenge to achieving the goal of reducing hunger and malnutrition. Lately, various successful initiatives such as infrastructure building and Food-for-Work programmes have been hit hard. There have been several incidents of food-grains meant for beneficiaries of the Food-for-Work programmes being taken by the insurgents. In rural areas, the fear of violence has severely disrupted the normal mobility of people, thereby hampering food distribution of the Nepal Food Corporation, for example. As a result, food insecurity has become more challenging, and has widened the disparities across regions.

The MDG Needs Assessment exercise has made it clear that the estimated amount of resources required for the implementation of the MDG hunger/agriculture intervention packages is considerably higher than the government's current budgetary allocation. It should be noted that the needs assessment exclusively reviewed agriculture-related interventions, and not interventions directly aimed at addressing malnutrition, such as promotion of, and education on, improved childcare and feeding. Neither did it include interventions aimed at reducing child disease and improving hygiene and sanitation, which are covered under other MDGs.

GOAL 4: REDUCE CHILD MORTALITY

TARGET 5: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate 

Source:a National Family Health Survey (1996) (1989 data).

b NFHS 1996.

c NDHS 2001.

            d Nepal Demographic Health Survey 2006.

            e Nepal Fertility, Family Planning and Health Survey 1991. f HMIS/DOHS 2003/04

            f  EPI Fact Sheet 2005, WHO-SEARO

STATUS AND TRENDS

Remarkable reductions have been seen in child mortality rates in Nepal over the last decades. From a staggering infant mortality rate (IMR) of 200 per 1000 live births some 30 years ago, the IMR today is 48 per 1000 live births (NDHS 2006). The under-5 mortality rate (U5MR) was found to be 61 per 1000 live births in the same survey. The most likely causes of the decline in IMR are improvements in the management of diarrhoea, improved immunisation, Vitamin A supplementation, and the improved management of acute respiratory infections, especially pneumonia. If this progress continues, it seems likely that Nepal will achieve this target for 2015. However, it must be emphasised that the country's child mortality rate (U5MR) is the fifth highest among all the countries of the WHO South East Asian Region (WHO 2005).

It must also be noted that any further reduction in IMR is increasingly dependent on saving more newborn lives. While the overall health of children has improved and as the overall child mortality has declined, the proportion of neonatal deaths has increased from 40 percent of infant deaths in 1987 to 60 percent in 2001. Nepal's newborn mortality is the third highest in the world, as is its percentage of low birth weight babies and it has the fourth lowest percentage of births attended by skilled personnel. Of every 1000 newborns, 34 die within the first month of life (NDHS 2006).

It is estimated that nearly 30,000 children die each year in Nepal during their first month of life, with two-thirds of these dying during their first week (National Neonatal Strategy 2004). Hospital-based data² suggest that the major direct causes of neonatal death in Nepal, as elsewhere, are infection, birth asphyxia /trauma, prematurity, and hypothermia. There is a constellation of underlying causes including poor pre-pregnancy health, inadequate care during pregnancy and delivery, low birth weight, and inadequate newborn and post-partum care. Fundamental to these is the low status and priority given to women and newborns. Appropriate care for the normal newborn is not widely understood or practiced. Traditional attitudes and practices dominate newborn care and are often hazardous.

The data also suggests considerable differences by geographical area and by groups. Infants in rural areas are exposed to a risk of death 1.4 times higher than those in urban areas. Similarly, children in the mountain region are twice as likely to die before they reach the age of five as children in the other economic zones. Furthermore, data from 2001 showed that the Mid and Far-Western regions had higher infant mortality at 103 and 84 per 1000 live births respectively, compared to the Eastern region at 61. The Western region's IMR, at 59, was less than the national average of 64. Large variations can also be seen observed by district. The IMR in the worst districts are over 6 times higher than those in the best districts (UNDP 2004). Ethnic disparities are suggested by the data, particularly of the socially disadvantaged groups, and of women. Compared to the average IMR of 67.3 per 1000 live births in males and 68.4 in females of higher castes, IMR was 70.4 in males and 69.8 in females among ethnic groups. Dalits are in a much worse situation with IMR of 88.3 in male and 84.5 in female (CBS 2003).

The mortality rates reflect gender disparities. Girls are nearly 1.5 times more likely to die between their first and fifth birthdays than boys. This most likely reflects gender discrimination in child rearing and health care seeking practices, since biologically, boys are more likely than girls to die in this age group.

Immunisation against measles and major diseases also showed a significant increase, although here again, there were wide disparities in access to immunisation in terms of groups, with recent data showing the lowest coverage for Muslim and Dalit children.

SUPPORTIVE ENVIRONMENT

The progress in reducing child mortality is mainly the result of increased awareness and accessibility to programmes that prevent child deaths. These include a community based Integrated Management of Childhood Illness (IMCI) package. This package has four child survival programmes: control of diarrhoeal diseases; control of acute respiratory infection (ARI); immunisation and nutrition including micro-nutrients; and a community component. The decade under review has seen progress in controlling communicable diseases. Immunisation has been significantly improved, and deaths due to diarrhoeal diseases have declined. Deaths due to ARI have also declined in recent years. Campaigns promoting micro-nutrients such as Vitamin A together with deworming tablets for children between 6 and 59 months biannually have fared well, and iodised salt is now easily available. The biannual Vitamin A supplementation is said to have prevented the deaths of 22,000 children per year in Nepal.

With regard to immunisation, Nepal has been conducting campaigns to meet disease specific targets in the last several years. The tetanus campaign coverage was good and the reported number of neonatal tetanus cases has gone down. Nepal can be said to have virtually eliminated neonatal tetanus, although the official validation exercise will only be conducted in November 2005. No case of wild polio has been reported since November 2000. A nationwide measles campaign was conducted in 2004/05 and reached over 95 percent of children between 9 months and 14 years. As a result, the number of measles outbreak has gone down from 137 in 2004 to 1 as of July 2005 (WHO Nepal-IPD 2005)

The Health Sector Reform Strategy and Implementation Plan (NHSP-IP), which formulated the goal, "To achieve (the) health sector MDG in Nepal with improved health outcomes for the poor and those living in remote areas and a consequent reduction in poverty," provides operational guidelines for its implementation. The strategy will work in tandem with the PRSP (2002-2007) to provide an equitable, good quality health care system in partnership with the Ministry of Health (MOH) and external development partners. The Essential Health Care Package (EHCP) of the Health Sector Reform Strategy pays special attention to child health and includes perinatal, neonatal, infant, and childhood healthcare.

The main interventions for reducing neonatal mortality that address the care of pregnant women and their newborns are implemented through MOH's National Safe Motherhood Programme, to which many donors contribute. The National Safe Motherhood Programme aims to address maternal and neonatal mortality reduction in an integrated approach to maximise synergies between the two and to increase cost-effectiveness. Since 2001, essential newborn care training has been integrated in the facility based refresher training of doctors and nurses. A National Neonatal Strategy was developed in 2004 to increase the profile of newborn care. An integrated maternal and newborn long-term plan is expected to be developed in 2005. While the National Safe Motherhood Programme approach has consisted of facility strengthening complemented by community mobilisation, the effectiveness of community mobilisation approaches have often been the subject of debate. Community field interventions/ trials in Nepal have confirmed the effectiveness of community approaches in improving knowledge and changing behaviours for birth preparedness and reducing neonatal mortality. Field-based trials are also ongoing to see whether FCHVs and other peripheral community health workers can be trained to perform a set of activities for early detection of infection in neonates. Newborn care has also been incorporated in the Community Based-Integrated Management of Childhood Illness training package. Furthermore, acknowledging the need to increase the number of available skilled health personnel throughout the country, the government has developed a skilled birth attendance policy and several other measures described in the chapter on Goal 5.

CHALLENGES

During the period under review, under-five and infant mortality rates have declined substantially. This can be attributed to the interventions described above. However, neonatal mortality - death in the first month of the baby's life - in Nepal stands at 39 per 1000 live births and accounts for 60 percent of infant deaths. So, lowering the neonatal mortality rate is vital if Nepal is to continue to reduce the under-five and infant mortality rates³.

Though most of the complications leading to neonatal mortality are preventable, currently there are few interventions addressing these issues. Low birth weight (LBW), which contributes to perinatal death, is linked to low maternal weight, height, and body mass index, the birth of a previous preterm infant, and a birth interval of less than two years. With improved maternal health and the service of a skilled birth attendant during delivery, most deaths can be prevented. This means that neonatal mortality can be reduced by improving the health and nutrition of the mother and ensuring that the mother gives birth with a skilled birth attendant. This inter-relationship is important to highlight the challenge of reducing U5 mortality.

The contribution of immunisation has been of immense significance in reducing child deaths. Nevertheless, the percentage of fully immunised children was 60 percent, with 8 percent of children under-five not immunised at all in 2003 (CBS 2004), thus pointing to disparities in service coverage. The challenge for Nepal would be to maintain the high coverage rates achieved through nationwide campaigns for polio, tetanus, and measles immunisation, and to continue to increase coverage rates of fully-immunised children through the routine system. The ongoing security problems may present a challenge to maintaining past performance and to making further improvements.

Addressing child malnutrition, the underlying cause for half the child deaths, remains a challenge in Nepal. About half of children under three years of age are stunted, or are too short for their age, and most children suffer from some type of micronutrient deficiency. The fact that the situation has not shown significant progress in the last 30 years suggests that the strategies to combat child malnutrition need to be revisited.

In Nepal, there is a serious problem with access to drugs. Policies are needed to include the promotion of rational drug use such as the use of antibiotics. New drugs are sometimes not available due to their prohibitive cost. Another inhibitive factor is that, while private establishments providing clinical services are mushrooming, their services are unaffordable to many. Often the poor are compelled to avail of these services as specialists are less easily accessible in public facilities. Thus, sometimes, people are forced to make catastrophic payments for ill-judged treatments. The other danger is that patients may turn to quacks and untrained indigenous healers, often with unfortunate consequences.

Although deaths from diarrhoea and ARI have reduced, deaths from accidents and injuries are emerging as an important cause of U5 mortality globally. While the incidence of this problem in Nepal is not known, injuries and even deaths caused by explosives including landmines are increasing due to the ongoing conflict. This is compounded by the difficulty in getting timely and adequate treatment due to insecurity, curfews, the looting of medicines and supplies, and the destruction of health facilities. Numerous children have been traumatised or emotionally affected after witnessing brutal atrocities associated with the conflict. The increased workload of women due to male out-migration may also make appropriate child care an even more difficult task for women.

The healthcare system needs to be improved if it is to deliver effective and efficient service. Training for healthcare practitioners is required, as well as better organisational management and inter and intra-sectoral coordination. Furthermore, timely referral between healthcare institutions remains a challenge. The financial implications of fulfilling these critical requirements are immense. The projected cost of the child health intervention package is estimated to be Rs. 2368.1 million (US$ 33.8 million) for 2005; which will more than double to Rs. 4967.5 million (US$71.0 million) in 2010; and further increase to Rs. 7594.5 (US$108.5 million) in 2015.

Another issue to be highlighted is the need for stronger coordination among the concerned actors, based on clear-cut responsibilities. While decentralised management is a policy measure, the roles and responsibilities of the central and district authorities are not clear at present, resulting in confusion in the functioning of the local facilities.

GOAL 5: IMPROVE MATERNAL HEALTH

TARGET 6: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

Source:a UNDP Human Development Report 1992 (1988 data).

b NFFS 1991.

c NFHS 1996.

d NPC 2002.

e Heat Sector Strategy - An Agenda for Reform, MOH 2004.

f  NDHS 2001.

g CBS 2004.

h MOH 2005.

i MOH 1993, Safe Motherhood Plan of Action (1994-1997) j NDHS 2006.

STATUS AND TRENDS

It should be highlighted at the outset that data on maternal mortality is highly problematic in Nepal, as measurement of the maternal mortality ratio (MMR) suffers gravely from under-reporting and misclassification, and even household surveys are subject to wide margins of uncertainty due to such issues as variability of the sample, the small number of events, and differences in methodology.

The baseline figure for the MMR itself is conflicting. While the survey-based MMR for 1991 for the period of 10-14 years before the survey was 515 deaths per 100,000 live births, another source indicated a figure as high as 850. The ratio for 1990 to 1996 was 539 deaths per 100,000 live births, for the period 0-6 years before the survey. Then the available figure is the National Planning Commission estimation of 415 in 2002⁵.  Now National Demographic Health Survey 2006 has estimated maternal mortality ratio of 281 per 100,000 live births. Therefore, it is difficult to draw any precise conclusions about the trend in maternal mortality in Nepal. Available data suggested that the target of reducing maternal mortality is achievable. However, such assessment suffers from serious data problems.

More recently, deliveries by skilled birth attendants (SBAs) ⁶have been proposed as a proxy indicator for the maternal mortality ratio. This indicator shows an increase from 7.4 percent deliveries (by skilled attendants and other health workers) to 19.8 percent in 2004. The rate of progress suggests that there is a significant challenge in meeting the target for this indicator by 2015.

In Nepal, over 80 percent of deliveries take place at home. Most of the births are assisted by family members and neighbours, with only one-fifth of deliveries attended by health workers (CBS 2004). Births attended by skilled birth attendants (doctors, nurses, and auxiliary nurse midwives) are as low as 11 percent (NDHS 2001). Another 10 percent of births were attended by traditional birth attendants (TBAs), who may be trained or untrained, however they do not qualify as skilled birth attendants. There was a gradual increase in the number of deliveries conducted by trained TBAs from 2 percent in 1995 to more than 11 percent in 2003/04. It was found that some ethnic groups prefer TBAs for delivery. Home deliveries are usually opted for in anticipation of the care and support from family and community. Besides, pregnancy and childbirth are still perceived as natural phenomena, not requiring formal health services (UNICEF 1998).

The causes of maternal deaths are severe bleeding, sepsis, toxaemia, obstructed labour, and the consequences of abortion. Unsafe abortion and maternal death can be due to a lack of access to reproductive health care, including family planning. Most maternal deaths can be prevented if women have access to essential obstetric care services.

Antenatal attendance is low with only 14 of women attending the recommended four antenatal visits, and only about one seventh of adolescent mothers attending the antenatal clinic. Only 17 percent of women receive a postnatal check within 48 hours (NDHS 2001) which indicates an opportunity lost in monitoring the health of the mother and the newborn.

Family planning, a pillar of reproductive health, has affirmed its unequivocal contribution to mothers' health and the reduction of sickness and death. Although universal awareness was presumed, the NLSS 2004 reported that only 77 percent of married women between 15 and 49 years, had knowledge of any modern family planning method. There is higher awareness among the rich and educated urbanites. About 46 percent reported having used family planning methods, and 39 percent currently use some form of contraceptive. The most popular method is surgical contraception, followed by three-monthly injections of Depo Provera.

Although the total demand for contraception was 67 percent, only 39 percent of the demand could be met. The use in urban area is 1.7 times higher than in rural areas. Only 9 percent of adolescents between the ages of 15 and 19 are currently using modern methods, although 40 percent are already mothers. Thus, the need to address the issue of adolescent sexual and reproductive health is critical in bringing about behavioural changes towards responsible parenthood. The present trend shows that the CPR has been increasing at a rather modest pace, with a high level of unmet demand, underlining the need for greater attention to access to achieve the target of 67 percent in 2017, as stated in the Safe Motherhood Plan of Action.

SUPPORTIVE ENVIRONMENT

The Second Long Term Health Plan (1997-2017), the Health Sector Strategy 2002, and the Nepal Health Sector Strategy Implementation Plan all support the goal of, "Achieving the health sector MDGs with improved health outcomes for the poor and those living in remote areas and a consequent reduction in poverty." Safe motherhood and neonatal health are key elements of the essential health care package. In addition, the Vulnerable Community Development Plan (2004) addresses social exclusion issues in the health services and its effects and implications for vulnerable groups.

The National Reproductive Health Strategy was formulated and adopted in 1996 to strengthen and expand basic maternity care services, including family planning, improved access, coverage and quality of overall reproductive health programme, and the promotion of research and inter-sectoral collaboration and the upliftment of women's status. The National Adolescent Health and Development Strategy 2000 aims to improve the access and coverage of the overall programme with quality assurance for adolescents - who make up more than one-fifth of the population - covering information, education, and counselling on human sexuality towards developing responsible sexual behaviour and responsible parenthood.

The Safe Motherhood approach has been adopted for improving maternal health in a holistic way, and the National Maternity Care Guidelines were developed in 1996. Since then several policy documents guiding the implementation of the National Safe Motherhood Plan have been developed - the Safe Motherhood Policy, the Fifteen-year Safe Motherhood Programme Plan, the National Safe Motherhood Training and Information Education and Communication Strategy, and the National Neonatal Strategy, defining the basic care for women and newborns during pregnancy, delivery, and the post-natal period at all levels. The primary intervention for reducing maternal mortality is universal access to assistance at birth by a skilled birth attendant and provision of Essential Obstetric Care (EOC) supported by access to family planning and management of unwanted pregnancies.

Some vital ongoing measures supported by the National Safe Motherhood Programme include measures to increase the availability of essential obstetric care (EOC) services through the establishment of pilot EOC facilities in 15 districts; and a gradual increase in the utilisation of Comprehensive and Basic EOC, in particular among marginalised groups. The programme has also supported complementary community awareness-raising programmes consisting of birth preparedness activities to reduce the 'first two delays' to accessing EOC. Community EOC funds have been raised through community support and transport schemes developed. The National Safe Motherhood Programme focuses on neonatal service provision within the Safe Motherhood training package.

The Ministry of Health (MOH) has prioritised skilled birth attendance as the major strategy for reducing maternal deaths. While the national SBA policy was drafted only in July 2005, NG has provided cost-sharing incentives to promote SBAs with the provision of nationwide transport for delivery in health institutions, free delivery services in 25 of the poorest and most conflict-affected districts, and incentives to health workers providing delivery services in institutions and for home births. The abortion bill was passed in 2002 and the implementation of comprehensive abortion care services has been vigorous with services now available in 65 districts.

I/NGOs and the private sector, including social marketing organisations, have contributed significantly to family planning and maternal-child health programmes. The public-private partnership has increased access to reproductive health services, and more focus on rural areas is called for. Media coverage on the issues governing maternal mortality has also helped mobilise public opinion in support of gender equity to improve maternal health and reduce maternal mortality. At the community level, mothers' groups have been mobilised to set up emergency funds, particularly where female community health volunteers are active. In the Tharu community, the community leader (bhala-manas) has organised the bullock cart ambulance to ferry pregnant woman to the health facility. Support groups have been formed and some even organise adult literacy classes. There are possibilities for community empowerment and mobilisation, where positive change will reduce maternal illnesses and death.

CHALLENGES

The fact that more than 80 percent of deliveries take place at home is a serious obstacle to reducing maternal and neonatal mortality. Despite a network of health institutions available all over the country, many problems remain. These include poor quality of health infrastructure and services, in particular delivery by skilled attendants and EOC; unsatisfactory access to reproductive health information and services; low level of access to and quality of antenatal and postnatal care, and non-affordability of delivery in hospitals and primary institutions. All of these results in many women delivering with family members and some with no assistance whatsoever. The policy of promoting public-private partnerships has limited benefits due to concentration of private services in lucrative areas. Lack of stringent measures for quality control and pricing for life-saving interventions in response to complications pushes the poor to desperate financial decisions.

As the focus of the National Safe Motherhood Programme for many years has been on TBA training, the paradigm shift to skilled attendance and EOC is fairly recent. Many vital policy issues are only just being addressed, such as the skilled birth attendance policy. The proportion of SBA-attended births is an important indicator in assessing progress in improving maternal health. However, the definition and the core competencies of a skilled birth attendant have been the subject of much debate. The indictor that has been in use in the national Health Management Information System (HMIS) is, "Deliveries by a trained health worker," and includes skilled birth attendants (doctors, nurses, and auxiliary nurse midwives) and other health workers, who do not meet the criteria of 'skilled birth attendant'. Although the government has initiated new strategies to promote skilled birth attendance through providing free delivery services in 25 of the poorest districts, this remains a challenge in the remainder of the country. While human resource availability at health facilities is a problem, more serious is its unequal distribution, with most skilled attendants concentrated in Kathmandu and the other larger cities. In this regard, it is expected that a human resource development plan will be developed, but difficulties in its implementation are anticipated, especially in fulfilling vacant positions in the rural and remote areas. Given the slow acceptance of skilled birth attendance as the primary intervention for reducing maternal deaths, no programme interventions in support of this strategy have been implemented. WHO has set the target of SBA attendance during delivery of 50 by 2010 and 60 percent by 2015 for countries with very high maternal mortality ratio. Even this appears ambitious in Nepal's case.

As discussed above, most maternal deaths are preventable with the provision of skilled attendance during delivery, a well-organised referral system to basic and/or comprehensive obstetric care, safe abortion, a sound efficient family planning programme, and a strong health system. In addition, efforts are required to make families aware of the importance of pregnancy and delivery-related services and to bring about behavioural changes. Implementing these interventions, however, implies that a significant amount of resources will need to be allocated. The projected cost estimate for maternal health intervention packages is Rs. 899.7 million (US$ 12.9 million) for 2005. This will double to Rs. 1,828.9 million (US$ 26.1 million) in 2010, and will more than triple in 2015 to Rs. 2,755.1 million (US$ 39.4 million)⁷.

Another challenge is to increase contraceptive use and to involve men in promoting and supporting the reproductive health decisions of their wives and children. This is not easy in a patriarchal social structure with persistent gender discrimination. It is also critical to provide adolescents with sexual and reproductive health knowledge and information to bring behavioural changes toward responsible parenthood.

In recent years, the conflict has impeded progress, leaving many health facilities vacant or unsupervised. There are reports of insurgents looting medicines from pharmacies or porters carrying supplies. Frequent strikes and roadblocks are reported to have resulted in the deaths of pregnant women who were delayed on their way to hospitals. According to a study (Thomas and Aitken 2004) on the impact of the conflict on safe motherhood, an additional 10 percent delay was added to the normal delay women experienced in seeking and receiving essential obstetric care (EOC).

GOAL 6: COMBAT HIV, MALARIA AND OTHER DISEASES

TARGET 7: Have halted by 2015 and begun to reverse the spread of HIV/AIDS

Source:a National Centre for AIDS and STD Control (1999 data). b UNAIDS, FHI/NCASC 2003. c NDHS 2001.

STATUS AND TRENDS

Although the estimated prevalence rate of HIV infection is 0.5 percent in the age group 15-49 (UNAIDS, FHI/NCASC 2003), with a male to female ratio of 3 to 1, epidemiological data suggests that Nepal has entered the stage of a concentrated epidemic. This means that the HIV/AIDS prevalence consistently exceeds 5 percent in some sub-populations such as female sex workers (FSW) and injecting drug users (IDU). Among high-risk groups, seasonal labour migrants make up 40 percent of the nation's HIV-infected population, followed by clients of sex workers (18 percent) (FHI/ NCASC 2003 estimate). The number of children orphaned by HIV/AIDS is estimated to be 13,000 (UNICEF 2002).

The dynamic of the epidemic follows a predictable course. A rapid increase occurs in the most vulnerable group, e.g. the FSWs and IDUs as the first step. It spreads via the 'bridge population' of the clients of female sex workers (such as truck drivers, labour migrants, the uniformed services, businessmen, students, and partners of injecting drug users). HIV /AIDS spreads from this bridge population to the general population including the wives and the partners of the clients. Men who have sex with men (MSM) are also considered a high-risk group, as they may be married and by engaging in unprotected sex, may consequently infect their wives as well. Though small in number, blood or organ recipients also expose themselves to the risk of HIV infection.

The interaction of these high-risk groups with a much larger and low-risk general population through unprotected sex has the potential to cause an explosive epidemic that may, within a decade, affect the economically productivity in the age group 15-49. It has been estimated that by the end of the decade, 100,000-200,000 young adults will be infected by HIV, and 10,000-15,000 may die of AIDS, making it the leading cause of death among the 15-49 age group (Chin 2000). Children separated from families are also subject to sexual exploitation and exposure to HIV/AIDS (Cross and Osborne 2002). In Nepal, there are 80,000 migrant children in the cities (ILO 1995) engaging in work such as rag picking, stone quarry labour, and domestic labour (CWIN 2002).

Key facts and figures regarding HIV /AIDS in these sub-populations are summarised below.

Female sex workers (FSWs)

     HIV prevalence among FSWs: about 2 percent in the Kathmandu Valley (FHI 2004); and 3 in 16 Terai highway districts between Jhapa and Rupandehi (NCASC/FHI 2003).

     Consistent condom use among FSWs: about 56 percent with clients; less than 20 percent with husbands and boyfriends (FHI/CREHA 2004).

     An estimated 50 percent of Nepalese FSWs in Mumbai brothels are HIV positive (FHI 2004).

     The number of ex-FSWs returning with HIV infection: 5000-25,000 in the Kathmandu Valley (CREHPA/New ERA 2001, Seddon 1998); 300 in Pokhara; and 700-6900 near highways (CREHPA 2003, SC-US 2002, ADRA 2003).

     About 58 percent of street FSWs and 25 percent of brothel-based FSWs are illiterate (NCASC/FHI 2005), which limits their access to prevention information, treatment, and care services.

Injecting drug users (IDUs)

     HIV prevalence among IDUs - 68 percent in Kathmandu; 22 percent in Pokhara; and 35 in Jhapa (FHI 2000, 2003, 2004) with nationwide prevalence of 35 percent (FHI/ NCASC 2003 estimate).

     IDUs make up 14 percent of Nepal's HIV cases (NCASC 2004), but some estimates suggest IDUs account for one-third of HIV infections in the country (FHI 2004).

Clients of female sex workers

     An estimated 600,000 to 1.3 million Nepalese migrate to India for seasonal work (CBS 2001). As much as 10 percent of those men migrating to Mumbai have been found to be infected with HIV (Poudel et al 2003).

     HIV prevalence among migrant labourers returning from Mumbai is estimated at 7.7 percent (FHI 2002).

     An estimated 75 percent of all truckers and 51 percent of migrant workers reported having sex with FSWs, of which only 40 percent used condoms. HIV infection varied from 1.5 to 4 percent (FHI 1999).

Young people 

      15 percent of 14-year-olds and 50 percent of those aged 19 have had sexual encounters, according to a study of young factory workers (Puri 2002).

      Adolescents with risk-taking behaviour such as substance abuse, multiple partners, irregular condom use, unsafe abortions, and forced sex were found by the same study (Puri 2002).

Vulnerability to HIV continues especially among mobile populations, such as seasonal labour migrants and their spouses, trafficked women and girls, and children outside the family system.

Knowledge about HIV /AIDS is higher among the younger and more educated population. While the condoms are used for contraception by 2.9 percent of currently married women and 6 percent of currently married men, with 39 percent having used contraception at some time, inconsistent condom use is a serious problem. In terms of gender differences, men have more knowledge of HIV /AIDS (72 percent) than women (50 percent). However, the percentage of women who have heard of HIV/ AIDS nearly doubled from 27 percent in 1996 to 51 percent in 2001 (NDHS 2001).

Unfortunately, those infected with HIV are subject to stigmatisation and exclusion. There is an acute lack of HIV /AIDS counselling, care, and support. Most of the 62,000 people living with HIV /AIDS are not aware that they are infected and may engage in unsafe sex. Possible stigmatisation and exclusion prevent them from taking advantage of the voluntary counselling and testing (VCT) services provided in 23 sites (3 government, 20 NGO sites targeting the high risk groups⁹ ) including Youth Friendly Services (YFS); and Sexual and Reproductive Health Services and Information, and seeking treatment if infected. Some NGOs also provide partial (non-comprehensive) VCT services. For the Prevention of Mother to Child Transmission (PMTCT), a national programme was recently launched in three government hospital sites. In terms of antiretroviral therapy (ART) programme, about 100 people are receiving the therapy, which is available only in two hospitals. A target of 3000 patients provided with ART has been set under the Government National Operational Plan for 2005.

The trend shows that unless programmes are implemented on a war footing, a generalised epidemic with high mortality in the most economically productive group will begin and will start a vicious circle. The spread of HIV/ AIDS will increase poverty and vulnerability, which in turn causes more infection and has serious impacts on the country's socioeconomic condition. The achievement of the Goal on HIV /AIDS appears very remote.

SUPPORTIVE ENVIRONMENT

The Nepal Health Sector Strategy Implementation Plan (2004-2009) has set the goal of, "achieving the health sector MDGs in Nepal with improved health outcomes for the poor and those living in remote areas and a consequent reduction in poverty." It includes the Essential Health Care Package that promotes AIDS /STD (sexually transmitted diseases) control. In addition, the National Policy on AIDS and STD Control was adopted in 1995, with 12 key policy statements focusing mainly on multi-sectoral, preventive activities in partnership with NGOs in an integrated and decentralised manner. It underlined the promotion of safe sexual behaviour, counselling, confidentiality, screening of blood for transfusion without any discrimination in terms of age, sex, and infection. The national strategy on HIV/ AIDS 2002-2006 has the overall objective of containing the HIV/AIDS epidemic among vulnerable groups, and focuses on young people, mobile populations, FSWs, MSMs, IDUs, and children. In the strategy, five priority areas are clearly identified: 1) prevention of STI/HIV infection among vulnerable groups; 2) prevention of new infection among young people; 3) ensuring treatment, care, and support services; 4) expansion of the monitoring and evaluation framework through evidence-based effective surveillance and research; and 5) the establishment of an effective and efficient management system for an expanded response.

Various efforts have been undertaken to establish an adequate institutional framework to address the threat of HIV/AIDS. Nepal has established a high-level National AIDS Council (NAC), to be chaired by the Prime Minister to generate a multi-sectoral response. Its National AIDS Coordination Committee (NACC) came under the Health Minister, who approved work plans and guided the implementation of the national strategy for 2002-2006. The steering committee, chaired by the Health Secretary, reviewed programme activities, while programme implementation was delegated to the National Centre for AIDS and STD Control (NCASC), supported by external development partners (EDP). There is continuing effort to maintain relationship and communications between the government, the NGO community, and the donor community as well as among NGOs to make progress for the development of new coordination and institutional capacity development mechanisms for a national response to the HIV epidemic.

The National Action Plan for 2005-2006 is expected to produce greater impact in terms of access to services and involvement of multiple partners, especially in affected communities. Approximately 65 percent of the resources needed for the Action Plan have already been pledged by external development partners, such as DFID, the Global Fund to fight AIDS, TB and Malaria, USAID, and the UN System. This support will make possible the scale-up of targeted prevention interventions, which will pursue a comprehensive package of services that include peer education, STI management, voluntary counselling and testing, condom distribution, and community sensitisation, among the priority communities. In addition, increased resources for HIV treatment, care, and support will expand the numbers of people with HIV who need to receive antiretroviral treatment to 30 percent.

The Plan will also aim to strengthen government and non-government implementation capacities. Improved facilities and equipment and better trained staff in HIV and AIDS at the district level will be an important aspect in the implementation of the Plan, in order to ensure that communities receive quality health care. Civil society organisations are key stakeholders in the implementation. Institutional development activities that will build on their existing technical experience and will improve resource mobilisation and management will be a major focus in the annual plan.

CHALLENGES

The original HIV surveillance system was introduced in 1991 in 7 sites. It covered 5 population sub-groups (FSW, patients with sexually transmitted infections, IDU, antenatal care attendants, and tuberculosis patients) at six-monthly intervals. However, the sites, the interval between the rounds, and the subgroups targeted were changed after a few rounds. Since 1995 the surveillance has been limited to the patients with STI and no round has been conducted for the past two years (UNICEF 2005). However, the government adopted a second generation surveillance system that has monitored sub-groups (IDUs, FSWs, truckers, male clients of FSWs, MSM and migrants) in Nepal since 1998, and has also collected both behavioural and sero-prevalence (i.e., testing positive for HIV antibodies) data.

People living with HIV /AIDS (PLWHA) have limited access to care, support services, and treatment; and have less opportunities for creating sustainable livelihoods. A comprehensive care and support service package for PLWHA is missing. Few organisations provide community care and support. PLWHA that have some resources often run community care centres providing nutrition, referral, HIV testing, counselling, and psychological support for PLWHA and their families.

Lack of educational awareness among women has been posing a significant challenge for the prevention of HIV /AIDS infection among women. Many women do not have control over their bodies and thus are subject to pressure to engage in unprotected sex. Furthermore, as a result of the breakdown of family units and social networks caused by the conflict, it is anticipated that the pressure on women who are now heading households has intensified, which could put them at a higher risk of exposure to HIV/AIDS through unprotected sex in exchange for money. The ongoing large-scale movement of the population, especially male youths, add further complications.

Despite policy commitment to multi-sectoral programmes and NCASC serving as the technical review authority which advises on policy and funding issues and acts as secretariat to the NACC, HIV /AIDS is still seen as a 'medical' issue, resulting in limited involvement from other ministries. While the fund flow continues from foreign sources, the capacity for multi-sectoral involvement, especially among ministries, and the monitoring and evaluation system seem structurally inadequate. This is a critical gap given the multi-faceted problem of HIV /AIDS.

Improved coordination and the increased efficiency and effectiveness of various programmes are urgently called for, as the estimated resource requirement is very high. The figure derived by an exercise in 2002 on the resource requirement of the national HIV/AIDS strategy for the period 2003-2006 was US$ 51 million, depending how the strategy was operationalised (Country Report for Nepal Jan-Dec 2002 for UN General Assembly Special Sessions - mimeographed). For the period of 2005-2015, the total cost involved for HIV /AIDS interventions is estimated to be Rs. 4830 million (World Bank 2004). A positive development in this respect is that US$ 14.7 million has been pledged for the annual estimated budget of US$ 22 million, which leaves a gap of $7.4 million for the period between July 2005June 2006 (MoH 2005). In the absence of a national HIV /AIDS sub-account as part of overall National Health Accounts (NHA), monitoring the flow of resources is yet another challenging task.

TARGET 8: Have halted by 2015 and begun to reverse the incidence of Malaria and other diseases

Source: a HDR 1996 (1992 data). b NPC/UNDP 2004 (b.1 and b.2: 2003 data).

d Rana 2001 (d.1: 2002 data). e NDHS 2004 (1: 2003 data).

STATUS AND TRENDS

Malaria control services including drugs are provided free to nearly 17.3 million people - or 74 percent of the population - at risk of infection in 65 districts. Priority is given to 12 high-risk districts, accounting for about 25 of the total population. This has been further classified into 'Stratum 1' with a very high incidence of falciparum malaria, and 'Stratum 2', which accounts for 20.6 percent of the total population. Both are covered under the 'Roll Back Malaria' (RBM) global initiative by Early Diagnosis and Prompt Treatment (EDPT).

The incidence of malaria cases has gone down to 65 in 2000 from 115 in 1990 which again increased to 78 per 100,000 people in 2003. The high-risk population in districts covered by preventive measures was 9.75 percent in 1996, before going down to 6.94 percent in 2002, and up again to 11.4 percent in 2003. An analysis of service statistics indicates a resurgence of P.  falciparum malaria, increasing from 6 percent in 2000 to 11.75 percent in 2004. Resistance to routine drugs is on the increase. Malaria is expected to be contained in the Terai and is not seen higher than 1400 metres above sea level, but high prevalence has been observed in the hills and mountainous districts recently. From 2001 to 2004, the number of malaria cases in infants under one has steadily increased from 1 case to 9 in the Eastern Development Region and 5 to 33 cases in the Central Development Region. No cases were reported from the Midwestern Region in 2004, which was probably due to under-reporting caused by the conflict.

Not only is progress slow, but the situation has also become worrying because of the increase in the incidence of P. falciparum, drug resistance, and malaria incidence in infants. Unless urgent measures are taken, the goal will not be achieved. On the other hand, there is the potential for 'quick wins' with the use of modern technologies.

Tuberculosis contributes to 7 percent of the total burden of disease¹⁰ . According to a WHO estimate, little more than two-fifths of the total population suffers from TB, of which 60 percent belongs to the economically productive age group. Almost half the 44,000 people suffering from TB have infectious diseases that can spread unless treated. The use of Directly Observed Treatment Short Course (DOTS) has made remarkable strides in the cure rate of TB. Although reduced, death rates are still in the range of 6000 to 8000 year. As long as prevalence of HIV /AIDS is low, the decline in the incidence of TB will be permanent, and the target to reverse the trend of tuberculosis and to halt it by 2015 will be achieved. Thus from a death rate of 43 per 100,000 in 1991, the death rate is expected to go down to 13 per 100,000 by 2015. But given the anticipated HIV/AIDS epidemic, an opportunistic infection like tuberculosis will go on the attack. It is estimated that 10 percent of HIV /AIDS patients will progress from TB-infection to full-blown tuberculosis every year (DOHS 2004).

It is noted that even if the rate increases by 0.1 percentage points each year, prevalence in 2015 will reach 1.4 percent. This means a reversal of the gains otherwise expected, preventing the meeting of Target 8 on tuberculosis. If it were not for the prevalence of HIV /AIDS, progress in tuberculosis control would be satisfactory. A short course of anti-tuberculosis chemotherapy under DOTS has revolutionised the cure rate since 2001.

SUPPORTIVE ENVIRONMENT

The inclusion of malaria in the Essential Health Care Package shows the priority it has received in government programmes. The Vector Disease Research and Training Centre in Hetauda has contributed to research and training. In 2003, Global Fund for HIV /AIDS, Tuberculosis and Malaria (GFATM) approved a five-year grant of US$ 7.6 million to augment the implementation of malaria control activities in Nepal. The Global Fund (GF) programme sets out to reduce the incidence of malaria in twelve target districts. Its goal is to reduce the malaria burden and elevate the health status of the population in high-risk districts by working through community-based action and partnership supported by an effective Primary Health Care (PHC) system. A successful implementation of the plan will help to attain this goal.

The Roll Back Malaria global initiative aims to reduce morbidity and mortality from malaria by more than 90 percent by the year 2010 from the baseline level of 2001.

The Nepal Tuberculosis Centre is well organised and DOTS is available at all the health facilities down to the sub health post level, with good public/private participation. Functioning laboratories for sputum examination and the setting up of regional centres with assistance from I/NGOs for quality control are necessary supportive measures. The multi-drug resistance (MDR) problem is decreasing in newly-registered cases and is a sign of an effective DOTS programme. The TB programmes have benefited from harmonised donor support, and the Global Fund for HIV/AIDS, Tuberculosis, and Malaria has agreed to fill the financing gap for the TB programmes for 2006-2010. In addition, the Global Fund is expected to fill in the implementation gap to combat malaria in 12 districts identified as high-risk. The project has begun to distribute Insecticide Treated Nets (ITN) free of cost to the poor and at subsidised rates to the non-poor.

CHALLENGES

The overall malaria situation has deteriorated recently as a result of the conflict. People from non-endemic regions of Nepal have been compelled to move to endemic parts of the Terai for security. In addition, conflict-related poverty is increasingly forcing people to seek poorly paid seasonal work in highly endemic parts of India. About 1 million Nepalese cross the border each year for seasonal work and many return infected. This phenomenon has important implications for the development of drug resistance in Nepal.

Critical weaknesses in management capacity have threatened to undermine the impact of existing GF. There are no laboratory facilities in some endemic areas. Microscopes are lacking or they are not maintained properly. There is a lack of motivation in peripheral workers resulting in low slide collection, and non-examination of slides due to unfilled laboratory posts. Of the 66,500 malaria patients reported as treated in 2003, just 9500 were laboratory-confirmed cases. This is serious as it can contribute to drug resistance. Therapeutic efficacy for sulfadoxine-pyrimethamine (SP) against falciparum malaria during epidemic years in three of the most affected districts revealed that treatment failure ranged from 56 percent to 87 percent.

The pace of Indoor Residual Spraying (IRS) is not only very slow, but doubts have been cast over the quality of the insecticides. Sometimes the spraying pumps are poorly maintained and spare parts are unavailable. Malaria surveillance is weak, and the capacity to detect outbreaks in a timely manner is low.

Tuberculosis generally affects the poor, and the malnourished living in over-crowded spaces, which is particularly common in the context of rapid urbanisation. The prevalence of HIV/AIDS is a serious challenge, and 10 of AIDS patients contract full-blown TB every year. Resistance to drugs due to irregular and indiscriminate use is another challenge.

Nepal also needs further resources if it to achieve the Target. The financial requirement for both malaria prevention and treatment is expected to increase from Rs. 166.2 million (US$ 2.4 million) in 2005 to Rs. 274.9 million (US$ 3.9 million) in 2015 (NPC 2004).

2. There are no population-based studies that describe the pattern of neonatal death in Nepal

3. Infant mortality refers to death under one year of age; neonatal mortality refers to death in the first 28 days of life.

4. The 2004 CBS figure covers all types of health practitioners (doctors, nurses, auxiliary health workers, maternity child health workers, village health workers, health assistants, senior auxiliary health workers, and auxiliary health workers).

5. Although this is a widely quoted figure, UN agency estimates are much higher. WHO, UNICEF, and UNFFA have recently developed an approach to estimate maternal mortality for countries with no data and to correct available data for under reporting and miscalculation with the purpose of drawing attention to the existence and likely dimensions of the problem. It does not provide precise estimates and is only indicative of orders of magnitude. The MMR estimate at 2000 is 740 within the range 440-1100

6. A 'skilled birth attendant' is an accredited health professional-such as a midwife, doctor, or nurse-who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirths, and immediate postnatal period and in the identification, management, and referral of complications in women and newborns (WHO 1994).

7. These estimates do not include the resource requirement for the neonatal health package, which is dealt within MDG4.

8. Given the paucity of data, the indicator ‘contraceptive prevalence rate (CPR) including condom’ was used instead of the MDG global indicator ‘condom use rate of CPR’. From the HIV /AIDS prevention perspective, the CPR data needs to be interpreted with caution, as it covers all forms of contraceptives and thus does not give condom use rate related to infection. Also, given paucity of data, indicator 16 was modified to CPR including condom, rather than condom use rate of CPR. The original indicator may be better as CPR inclusive of all forms of contraceptives would not give condom use rate related to infection. Indicator 17 can be modified to proportion of orphan-hood in children 1-10 years caused by HIV /AIDS rather than number of children orphaned by HIV /AIDS.

9. There are still very few VCT sites targeting the general population.

10. Burden of disease means death, illness, and disability accounting for more than two-thirds (68 percent) of infectious diseases, maternal and perinatal disorders and nutritional deficiency disorders (MOH Second Long Term Health Plan 1998).