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PubMed2004

Health sector policy in the first decade of Nepal's multiparty democracy. Does clear enunciation of health priorities matter?

Nepal experienced a significant political regime shift in 1990 from the partyless Panchyat system to the present multiparty form of democracy. While political instability existed in the decade of the 1990s, reflected in the approximately one government per year, there had been continued enunciation of health policy priorities toward the rural sector, as reflected in the Nepal National Health Policy, 1991 (NHP (1991)) and subsequent plans. The objective of the paper is to assess whether clear enunciation of health priorities have translated into beneficial health outcomes, reflected in reduction of the child death rate, child morality rate, infant mortality rate and increase in the life expectancy rate. This question is assessed empirically over the 10-year period of fiscal year 1989/1990 to 1999/2000 using mainly secondary data published by His Majesty's Government of Nepal (HMG/N), through the perspectives of input-output model and extension of health services, along with an indicative regression of a Nepalese health production function. The results (i.e. empirical observations) suggest that while there have been clear enunciation of health priorities, there have not been significant positive effects on health sector outcomes. The paper ends with a number of recommendations and concludes with the necessity for effective and appropriate implementation.

Adult↗
PubMed2005

Skilled birth attendance: what does it mean and how can it be measured? A clinical skills assessment of maternal and child health workers in Nepal.

The presence of a skilled birth attendant at delivery is important in averting maternal and neonatal mortality and morbidity. It has now shown that even trained traditional birth attendants (TBAs) cannot, in most cases, save women's lives effectively because they are unable to treat complications, and are often unable to refer. Qualified midwives and doctors are often not available in the rural areas and community settings where most women in developing countries deliver. Defining the minimum competency level necessary to meet the definition of skilled birth attendant is important, particularly in countries such as Nepal with limited availability of facility-based emergency obstetric care. Maternal and child health workers are local women aged 18-35 who completed a 15-week course in maternal and child health. As the role of MCHWs has expanded to meet the country's needs for skilled attendance, a 6-week "refresher" course in midwifery skills is offered. The results of this clinical skills assessment of 104 randomly selected MCHWs from 15 districts across Nepal supports the premise that MCHWs with appropriate training have an acceptable level of knowledge and skill, demonstrated in a practice situation, to meet the definition of community level skilled birth attendants. Yet, competency alone will not necessarily improve the situation. To affect maternal mortality in Nepal, MCHWs must be widely available, they must be allowed to do what they are trained to do, and they must have logistical and policy support.

Adult↗
PubMed2004

Pediatric cataract surgery in Nepal.

PURPOSE: To describe the first pediatric cataract surgery case series report from Nepal. SETTING: Tilganga Eye Center, Kathmandu, Nepal. METHODS: This study comprised a consecutive series of 112 eyes of 85 children having cataract surgery with intraocular lens (IOL) implantation. General anesthesia of ketamine combined with peribulbar block was used in all patients. Patients' demographics, cataract type and presenting symptoms, surgical intervention, preoperative and postoperative visual acuities, and follow-up clinical examinations were recorded. RESULTS: Seventy-three eyes (65.2%) of 53 patients had extracapsular cataract extraction with posterior capsulotomy, anterior vitrectomy, and posterior chamber IOL implantation (ECCE+PCAP+AV+PCIOL), and 39 eyes (34.8%) of 32 patients had cataract extraction and IOL implantation with an intact posterior capsule (ECCE+PCIOL). Of all patients, the mean age at surgery was 6.2 years +/- 4.3 (SD). The median age in the ECCE+PCAP+AV+PCIOL group was 4.7 years and in the ECCE+PCIOL group, 11.0 years. The mean follow-up was 5.4 +/- 5.3 months. The most common postoperative complication in the ECCE+PCIOL group was visual axis/posterior capsule opacification, which was seen in 18 eyes (46.2%) compared to 4 eyes (5.5%) in the ECCE+PCAP+AV+PCIOL group. Visual acuity improved with surgery in both groups. The leading cause of poor outcomes was deprivation amblyopia. There were no anesthesia-related complications. CONCLUSIONS: Implantation of an IOL at the time of cataract extraction under combined systemic ketamine and peribulbar lidocaine anesthesia appeared to be well tolerated and produced significant visual improvement in pediatric patients in Nepal. Primary posterior capsulotomy and AV helped prevent visual axis opacification without a significant increase in complications.

Adolescent↗
PubMed2006

Analysis of livelihood security: a case study in the Kali-Khola watershed of Nepal.

This paper examines household livelihoods in highland and lowland communities of the Kali-Khola agricultural watershed in western Nepal on the basis of economic, ecological and social security indicators. Significant differences were found in soil fertility status, pests and diseases management, risk and uncertainties, use of agrochemicals and access to social services. No remarkable variations were found in crop diversification, annual agricultural income and food sufficiency. However, uncertainty and risk in agricultural production is relatively low in highland communities. The findings reveal that agriculture production alone is not a viable livelihood option for agricultural watershed communities in Nepal. The households growing crops with hired labour have relatively sustainable livelihoods in Nepal's agricultural watersheds. Insufficient agricultural land, insufficient working manpower within a family, and lack of access to ecological agricultural services are prime factors in being livelihood insecure in agricultural watershed communities. Therefore, long-term policies and plans need to be developed for the empowerment of local farmers and to support rural livelihoods with adaptable and flexible income-generating strategies, resilient resource management institutions and enhancement of knowledge, skills and social capital.

Agriculture↗
PubMed2005

Municipal solid waste management in Nepal: practices and challenges.

Solid waste management in Kathmandu valley of Nepal, especially concerning the siting of landfills, has been a challenge for over a decade. The current practice of the illegal dumping of solid waste on the river banks has created a serious environmental and public health problem. The focus of this study was to carry out an evaluation of solid waste management in Nepal based on published information. The data showed that > or =70% of the solid wastes generated in Nepal are of organic origin. As such, composting of the solid waste and using it on the land is the best way of solid waste disposal. This will reduce the waste volume transported to the landfill and will increase its life.

Conservation of Natural Resources↗
PubMed2003

Improving meat inspection and control in resource-poor communities: the Nepal example.

Meat is an important source of protein and a valuable commodity in resource-poor communities. In many developing countries, lack of appropriate slaughtering facilities and unsatisfactory slaughtering techniques are causing unnecessary losses of meat as well as invaluable by-products from animal carcasses. Slaughtering places are frequently contaminated and may not be protected against dogs, rodents and insects. Meat products coming from such conditions are often deteriorated due to bacterial infection or contaminated, which may cause food poisoning or diseases in consumers. In many developing countries, regulations concerning meat inspection and/or control are inadequate or non-existent allowing consumers to be exposed to pathogens including zoonotic parasites. In Nepal, buffaloes contribute about 64% of the meat consumed, followed by goat meat (20%), pork (7%), poultry (6%) and mutton (2%). Goat and poultry meat is acceptable to all castes of people while buffalo meat is consumed mainly by the Newar ethnic group. Previously, pork was consumed only by people belonging to low castes, however, in recent years, the consumption of pork has increased in higher castes as the caste system has become more relaxed. Until recently, there were no official meat inspection regulations in the country, however, in 1999, the national government legislated an as-yet-to-be implemented Animal Slaughtering and Meat Inspection Act which mandates slaughterhouse construction and meat inspection and control. Due to the lack of implementation of the Meat Inspection Act and resultant absence of meat inspection, meat from sick or parasite-infected animals is serving as a source of infection to humans as well as other animals. In addition, meat quality is adversely affected by careless handling conditions in the slaughtering places as well as in the meat markets or shops. For improvement in animal slaughtering and meat inspection in both rural and urban areas of Nepal, several strategies are to be recommended. Sustainable capacity building should be introduced including training of veterinarians, meat inspectors and butchers as well as building of slaughter facilities. Government policies on slaughter procedures including ante-mortem examination, meat inspection and stamping of meat should be implemented. Programmes should be instituted with strong focus on prevention and control of meat-borne diseases to reduce infection risk of consumers and meat handlers and to avoid contamination of the environment. Lastly, emphasis should be put on improving the animal husbandry system in Nepal. These same actions can be undertaken in other developing countries to assist with improving meat inspection and control, thus helping with prevention and control of cysticercosis as well as other important meat-borne diseases.

Animals↗
PubMed2001

The torturous road to democracy--domestic crisis in Nepal.

Largely unnoticed by the outside world, an armed Maoist insurgence has wrested control of areas in 45 of Nepal's 75 administrative regions and has resulted in more than 1700 deaths since 1996.(1) State figures indicate that 1000 of these people were Maoist and about 400 were police-120 of whom died in attacks on police outposts in early April and July of 2001 alone. The remainder were "class enemies" of the "People's War"-ie, members of ruling parties. As public security collapses, the consequences for the Nepalese are random imprisonment, torture, and risk of extrajudiciary execution from both sides. Torture has increased greatly as a consequence of the insurgence, but was already deeply rooted in Nepalese authority and used as a primary approach to solving crime. More than 70% of Nepalese prisoners claim to have been tortured while in custody, and at least 50% claim they signed confessions as a result. INSEC (Informal Sector Service Centre), a human rights organisation, documented 1035 cases of state perpetrated torture in the year 2000,(2) which has been suggested to be a gross underestimate of the true figure. The long-term physical, social, and psychosocial consequences for survivors are often severe. The Centre for Victims of Torture, Nepal, a non-government organisation based in Kathmandu, has been studying the effect of torture on survivors, and has implemented Nepal's only treatment programmes for those brave enough to seek help.

Humans↗
PubMed1995

Placebo-controlled trial of co-trimoxazole for Cyclospora infections among travellers and foreign residents in Nepal.

Cyclospora is a coccidian (previously referred to as cyanobacterium-like bodies) that has been implicated in cases of prolonged diarrhoea. The average duration of symptoms is more than three weeks, and no specific treatment has been shown to shorten the illness. A case report suggested that co-trimoxazole may be effective. Expatriate persons with gastrointestinal complaints and cyclospora detected on examination of faeces were recruited from two clinics in Kathmandu, Nepal, between May and August, 1994. Participants were assigned in a randomised, double-blinded manner to receive either cotrimoxazole (160 mg trimethoprim, 800 mg sulphamethoxazole) or placebo tablets twice daily for 7 days. Of 40 patients included in the study, 21 received cotrimoxazole and 19 placebo. There were no significant differences between these two groups in age, sex, time in Nepal, duration or severity of illness, or presence of other enteric pathogens. After 3 days, 71% of patients receiving co-trimoxazole still had cyclospora detected, compared with 100% of patients receiving placebo (p = 0.016). After 7 days, cyclospora was detected in 1 (6%) of 16 patients treated with co-trimoxazole who submitted stool specimens compared with 15 (88%) of 17 patients receiving placebo (p < 0.0001). Eradication of the organism was correlated with clinical improvement. There was no evidence of relapse of infection among treated patients followed for an additional 7 days. Treatment with co-trimoxazole for 7 days was effective in curing cyclospora infection among an expatriate population in Nepal.

Adult↗
PubMed1997

Hepatitis E virus in Nepal: similarities with the Burmese and Indian variants.

Hepatitis E has been the predominant type of acute hepatitis in Nepal both in adults and children, in sporadic and epidemic forms. We examined six hepatitis E virus (HEV) isolates obtained during an 8-year period, from 1987 to 1995, in the Kathmandu valley of Nepal. Analysis of portions of the putative helicase, polymerase and capsid genes demonstrated close genetic relatedness among themselves (> 96.4% identity) and with the Burmese (> 95.5%) and Indian (> 95.3%) isolates, and less so with the African (> 94.4%) and the Chinese (> 91%) isolates within the Asian genotype. Phylogenetic analysis placed the Nepali isolates in the Burma-India evolutionary branch and showed that the oldest isolate, TK78/87 was more similar to the Burmese isolates whereas the most recent isolates were closer to the Indian ones. Assuming no frameshifts, the Nepali isolates showed high amino acid conservation, but also unique changes when compared to other HEV isolates. Amino acid residue 614 of the capsid protein was identified as a possible marker to distinguish the Burma-Nepal-India from the China-Central Asian Republics subgenotype, and the Mexico genotype.

Adolescent↗
PubMed2001

The main determinants of infant mortality in Nepal.

Infant mortality has reached a low stable rate in developed countries while it is still high and on a slow decline in developing countries. There are many factors that contribute to the incidence of a high or low level of infant mortality. Although credit for contributing to the lowering of infant mortality has been given to health programs by public health personnel and to the improvement in socio-economic status by social scientists, in a traditional and agricultural country such as Nepal, both these factors are found to influence infant mortality. Data on infant mortality obtained by the 1991 Demographic Health Survey of Nepal are analyzed in this study. A logistic regression model is used for analyzing the data. Several hypotheses are tested to explain the incidence of infant mortality in Nepal. The various reasons for the persistence of high infant mortality and the difficulties in lowering it are discussed. The findings suggest that among all the variables analyzed in the study, parity, place of residence, immunization, and ethnicity influence infant mortality the most.

Cultural Characteristics↗
PubMed2003

A framework for developing reproductive health policies and programmes in Nepal.

Based on experience in Nepal from 1996-2001, this paper presents a six-element framework to support governments in poor countries in developing and implementing reproductive health programmes. The six elements of the framework are: (i) collaborative planning and programming; (ii) strategic assessment; (iii) policy and strategy development; (iv) guideline and material development; (v) reproductive health programme management; and (vi) policy review. Its implementation calls for collaborative work between policymakers and programme managers at all levels of the health system, external donors and development agencies. Change in Nepal is constrained by poor human and financial resources, extremely difficult geography and strong cultural, religious and social traditions. An informal assessment at district level and below found that information tools, clinical protocols and operational guidelines were highly relevant, though problems with utilisation and motivation were noted. Utilisation of strategy and policy documents and tools was reported to be high at national level, but no causal link can be drawn between instruments in the framework and changes in reproductive health indicators. However, access to the tools described in this article can contribute to improvements in coverage and quality of reproductive health services in the hands of motivated people; improved indicators in family planning use, antenatal care and assisted delivery in Nepal in this period support this view.

Cooperative Behavior↗
PubMed2004

Listening to "felt needs": investigating genital prolapse in western Nepal.

The global prevalence of genital prolapse is estimated to be 2-20% in women under age 45. In Nepal, genital prolapse appears to be widespread, but little published evidence exists to buttress this claim. This paper presents findings of two studies, one ethnographic and one clinic-based, in western Nepal. The ethnographic study involved 16 focus group discussions with 120 community members and key informants, and covered community perceptions and women's experience of prolapse and its perceived causes and consequences. The clinic-based study was conducted among 2,072 women who presented with gynaecological complaints and received a diagnosis. One in four of them had genital prolapse, of whom 95% had self-reported the prolapse. The most commonly perceived causes of prolapse were lifting heavy loads, including in the post-partum period. The adverse effects reported included difficulty urinating, abdominal pain, backache, painful intercourse, burning upon urination, white watery discharge, foul-smelling discharge, itching, and difficulty lifting, sitting, walking and standing. The results confirm prolapse as a significant public health problem in western Nepal. We strongly recommend developing systematic, rotational gynaecological clinics in rural districts, the use of a screening checklist and counselling for prevention and early management of genital prolapse by district health workers for family planning and antenatal patients.

Adult↗
PubMed2005

Anthropology, DOTS and understanding tuberculosis control in Nepal.

This paper argues for the inclusion of ethnography as a research methodology for understanding the effects of public health policy. To do this, the implementation of DOTS (Directly Observed Therapy, Short-course) -- the World Health Organization (WHO) prescribed policy for the control of the infectious disease tuberculosis -- is explored in the context of Nepal. A brief history of DOTS and its implementation in Nepal is outlined, and the way it has been represented by those within the Nepal Tuberculosis Programme (NTP) is described. This is followed by an outline of the research done in relation to this, and the ethnographic methods used. These ethnographic data are then interpreted and analysed in relation to two specific areas of concern. Firstly, the effects around the epidemiological uses of 'cases' is explored; it is argued that a tightening of the definitional categories so necessary for the programme to be stabilized for comparative purposes has profound material effects in marginalizing some from treatment. Secondly, the paper examines some of the implications and effects relating to the way that the 'directly observed' component was implemented. The discussion explores how current debate on DOTS has been played out in some medical journals. It argues for the importance of ethnography as a method for understanding certain questions that cannot be answered by particular, and increasingly dominant, research ideologies informed by randomized controlled trials. This raises important issues about the nature of 'evidence' in debates on the relationship of research to policy.

Anthropology, Cultural↗
PubMed2006

Age at first marriage in Nepal: differentials and determinants.

The aim of this paper is to investigate the differentials and determinants of female age at first marriage in rural Nepal. The life table technique was employed to calculate median age at marriage. The proportional hazard model was used to study the effect of various socioeconomic variables, and to identify the magnitude and significance of their effects on the timing of first marriage. The data were taken from a sample survey of Palpa and Rupandehi districts in rural Nepal. Both married and unmarried females of marriageable age were included in the survey. Median age at marriage was about 17 years for data from only married females, whereas it was about 18 years for data from married as well as unmarried females of marriageable age. Median age at marriage was about 16 years for uneducated females and 19 years for females educated up to intermediate or higher level. The analysis underestimates the median age at marriage for married females, probably due to right censoring. The risk of getting married early decreased gradually with increasing year-of-birth cohort. The risk of early marriage was higher among females of high socioeconomic status compared with those of low socioeconomic status. Females engaged in service married earlier than those engaged in household work. High socioeconomic status families are motivated, for religious and prestige reasons, to get their daughters married at an early age, preferably before menarche. Thus, education, occupation and age at menarche are the most powerful factors in deciding the timing of first marriage in Nepal.

Adolescent↗
PubMed2003

Seasonality in urinary and household salt iodine content among pregnant and lactating women of the plains of Nepal.

OBJECTIVE: To determine the extent and causes of iodine deficiency among women during pregnancy and lactation in the southeastern plains of Nepal. DESIGN, SETTING AND SUBJECTS: Urinary iodine (UI) was assessed as an indicator of iodine status in spot urine samples of women participating in a field trial in three rural communities in the plains of southeastern Nepal. Samples were collected during pregnancy (n=1021) and during lactation at 3-4 months postpartum (n=1028) at a central clinic; 613 women were assessed at both times. Salt iodine (SI) content was assessed semiquantitatively at 6-7 months postpartum in households (n=1572). RESULTS: During pregnancy and lactation, median UI concentrations were 0.756 and 0.483 micromol/l, respectively, indicating mild iodine deficiency. UI and SI concentrations covaried markedly by season and were highest during hot, dry, premonsoon months and lowest during and following the humid monsoon season. Within women who contributed urine samples during both pregnancy and the postpartum period, iodine status determined by UI was not correlated. The percentage of households with adequately iodized salt (30 ppm) ranged from 85 to 44% from the hot, dry to the humid seasons, respectively. CONCLUSIONS: In the rural southern plains of Nepal, iodine deficiency remains a mild-to-moderate public health problem among pregnant and lactating women despite the availability of iodized salt. Marked seasonality in SI content may account for the lack of intraindividual correlation between maternal iodine status during pregnancy and postpartum periods and contribute to periodicity in the risk of iodine deficiency.

Adolescent↗
PubMed2004

Cigarette smoking during pregnancy in rural Nepal. Risk factors and effects of beta-carotene and vitamin A supplementation.

OBJECTIVE: We examined risk factors of smoking and the association between smoking and pregnancy-related and 6-month infant mortality in rural Nepal, where 30% women reported smoking during pregnancy. DESIGN: Cross-sectional analysis of risk factors associated with smoking status and health consequences of smoking, using prospective data collected as part of a randomized community trial to examine the effect of maternal vitamin A or beta-carotene supplementation on maternal mortality. SETTING: Rural, southeastern plains of Nepal. SUBJECTS AND METHODS: A total of 17 767 women contributed at least one pregnancy during 3.5 y of the study. Data on cigarette or bidi (rolled tobacco) smoking were collected using a 7-day recall, twice during pregnancy. Associations between smoking status and maternal diet, morbidity profile, household socioeconomic status and serum concentration of retinol, carotenoids and tocopherols were examined. Further, relative risk (RR) and 95% confidence intervals (CI) were calculated to estimate supplement effects on pregnancy-related mortality, stratified by smoking status during pregnancy. RESULTS: Smokers were more likely to be older, illiterate and poor compared to nonsmokers. Fruit and vegetable consumption among smokers and nonsmokers did not vary. However, smokers were more likely to consume meat/fish/eggs and less likely to consume milk than nonsmokers. They were also more likely to report symptoms of vaginal bleeding, edema, severe headache and convulsions during pregnancy relative to nonsmokers. Mortality per 100,000 pregnancies appeared to be higher among smokers than nonsmokers in the placebo group (915 vs 584, RR=1.57, 95% CI: 0.80-3.08). beta-Carotene supplementation reduced pregnancy-related mortality both among smokers (RR=0.31 95% CI: 0.11-0.89) and nonsmokers (RR=0.41, 95% CI: 0.19-0.89). Similar results obtained with vitamin A supplementation were not statistically significant. Infant mortality up to 6 months was approximately 30% higher among smokers compared to nonsmokers in the placebo group both before and after adjusting for confounding factors. Neither supplement given to women reduced infant mortality. CONCLUSIONS: Cigarette smoking during pregnancy is associated with an increased risk of maternal and infant mortality in rural Nepal. beta-Carotene and to some extent vitamin A may reduce the risk of pregnancy-related mortality, but not infant mortality, among both smokers and nonsmokers.

Adult↗
PubMed2002

A systematic review of current knowledge of HIV epidemiology and of sexual behaviour in Nepal.

OBJECTIVE: To systematically review information on HIV epidemiology and on sexual behaviour in Nepal with a view to identifying gaps in current knowledge. METHODS: Systematic review covering electronic databases, web-based information, personal contact with experts and hand searching of key journals. RESULTS: HIV-1 seroprevalence has been rising rapidly in association with high-risk behaviours, with current levels of 40% amongst the nation's injecting drug users and approaching 20% amongst Kathmandu's female commercial sex workers (FCSWs). HIV seroprevalence remains low in the general population (0.29% of 15-49 year olds). There are significant methodological limitations in many of the seroprevalence studies identified, and these estimates need to be treated with caution. There are extensive migration patterns both within the country and internationally which provide the potential for considerable sexual networking. However, studies of sexual behaviour have focused on FCSWs and the extent of sexual networks within the general population is largely unknown. CONCLUSIONS: Whilst some of the ingredients are present for an explosive HIV epidemic in Nepal, crucial knowledge on sexual behaviour in the general population is missing. Research on sexual networking is urgently required to guide HIV control in Nepal. There is also a need for further good-quality epidemiological studies of HIV seroprevalence.

Adolescent↗
PubMed2003

Pattern of antibiotic use in a trachoma-endemic region of Nepal: implications for mass azithromycin distribution.

PURPOSE: To investigate antibiotic utilization in a rural district of western Nepal that is currently receiving azithromycin as part of a trachoma program and is being monitored by the Centers for Disease Control and Prevention (CDC) for drug resistance. METHODS: Antibiotic purchase receipts were collected for 3 months from all medicine halls, pharmacies, and government sub-health posts in a sub-district of Western Nepal. Supplementary surveys of antibiotic sales were performed in different seasons. RESULTS: Macrolides account for 3.9% of total antibiotic use, far less than quinolones, penicillins, tetracyclines, and sulfonamides. CONCLUSIONS: If trachoma programs in Western Nepal generate transient macrolide resistance in pneumococcus and other bacteria, the epidemiological impact may not be great, as macrolides are not commonly used in the area.

Anti-Bacterial Agents↗