National 4 (Spotlight Weekly)

'Literacy And Gender Equality Are Vital Population-Management Tools'

— J. BILL MUSOKE

J. BILL MUSOKE, Country Representatives of the United Nations Population Fund (UNFPA), has been in Nepal for more than couple of years. Musoke, who has been involved in the implementation and execution of the UNFPA's major programs, spoke to KESHAB POUDEL on various population-related issues. Excerpts:

UNFPA has been supporting Nepal in the area of population management for a long time. How do you see the state of population in Nepal?

UNFPA started supporting His Majesty's Government to implement population programs since 1970. Since then it has worked with various line agencies of HMG to integrate population issues in their sectoral policies and programs as population is a multi-dimensional subject with direct link to all socio-economic aspects. UNFPA is guided by the Program of Action of the International Conference on Population and Development (ICPD) 1994 which HMG has fully supported and ratified. According to the 2001 census of Nepal, the total population is 23.1 million and is projected to be growing at the rate of 2.24 percent per annum. If this growth rate prevails, Nepal's population will double within 31 years. This will adversely affect the Nepalese economy and increase pressure on limited resources like food, water, and environment, with growing demands for education, health services, drinking water and other basic services.

How do you see life expectancy?

Although detailed analysis is to emerge, preliminary results suggest that Nepal has made significant improvement in life expectancy, which seems to have crossed the 60-years marks and for the first time women in Nepal may have outlived men since the beginning of the 21th century. During 1991-2001, the crude death rate declined from 13.3 to 9.6 per 1000 population and the crude birth rate from 33.5 to 30.5 per 1000 population. Infant mortality rate is 64 per 1000 live births.

What is the fertility rate?

The total fertility rate (TFR) is estimated at 4.1. There is almost universal knowledge of modern family planning and availability of at least three methods of family planning in all the health facilities in the country, while the contraceptive prevalence rate was estimated to be around 39.3 percent in 2001. Maternal mortality rate is estimated at 539 per 100,000 live births. In Nepal, adolescents comprise more than one fifth of the total population. Nearly half of the adolescent girls (15-19 years) and 20 percent of adolescent boys of the same age group are married. Adolescent populationwill shape the future population of Nepal in the next generation. One fifth of these girls are already pregnant or mothers with their first child. About 50 percent of them do not receive adequate obstetric care, while 19 percent of maternal deaths occur in this age group.

How do you see the implementation of the ICPD?

Nepal is striving to implement the Program of Action (PoA) of the International Conference on Population and Development (ICPD) 1994. It has created separate ministries like Population and Environment, Women and Social Welfare to effectively design, implement and monitor population programs including reproductive health and gender-related policies and programmes. Nepal supported the Programme of Action in the Fifth Asia and Pacific Population Conference in 2002 at Bangkok and will be presenting its progress in the 10-year review of the ICPD in 2004 (ICPD+10). Total Fertility Rate has declined over the last decade from 5.1 children to 4.1.

What does Nepal need to do to sustain it?

As a result of HMG's efforts to manage its population growth, including bringing down the fertility rate, the average number of births per women has fallen from 5.1 in 1991 to 4.1 in 2001. However, given the current economic environment and the current level of poverty and the fragile ecosystem, this rate is still considered to be on the higher side. Therefore, HMG needs to contain this growth to manageable levels. This, it is already doing with the assistance of multilateral and bilateral agencies such as, USAID, DfID, UNDP, UNICEF, and UNFPA to mention just a few. But let me caution you here, bringing down fertility rate is only one dimension of managing the population, there are other issues such as migration, specially international migration, that Nepal needs to look carefully in years to come.

Will Nepal's population decline in the coming decade?

Population growth is a multifaceted phenomenon, which cannot be attributed nor controlled by a single action, but rather by a series of actions throughout the entire spectrum of society. Therefore, in addition to the population programs designed together with the donors, the government must put in place and sustain a conducive environment for donors to be confident enough to invest in these programs. Such measures may, among others, include promulgation of policies for the youth, women, elderly, marginal and disadvantaged population groups, good governance, especially clear and efficient civil service, with properly equipped and maintained facilities. One of the greatest weapons in managing population is a 'literate' population and the removal of gender inequality. Improvements in the health sector, including implementation of the National HIV/AIDS Strategy, will go a long way in assuring the population of its future survival.

What is the indication of decline in fertility?

In short, I wish to state that we should not be deceived by statistics, because even when fertility reaches replacement level, population continues to grow due to the built-in population momentum - due to high fertility in the past such that the number of people of reproductive age continues to rise for several decades, before a stationery population is achieved. Therefore, we should aim to slow down population growth in an effort to achieve a balance between population growth and available resources.

UNFPA is working with District Development Committees. How are such programs different from previous ones?

UNFPA's Fifth Country Program, which commenced in 2002 for five years, coincides with HMG's 10th Plan/PRSP. The goal of the proposed programme is to contribute to the attainment of a higher quality of life for the Nepalese people through improved reproductive health and a balance between population dynamics and socio-economic development. The program proposed to work with six District Development Committees (Saptari, Rautahat, Mahottari, Kapilvastu, Dang and Dadeldhura) in a more focused manner to implement a Population and Reproductive Health Integrated (PARHI) Project.

How different are UNFPA Nepal's programs now than previous ones?

The program is slightly different in that it draws upon and is designed on the basis of the Country Assessment (CCA), the UN Development Assistance Framework (UNDAF), the PRSP and 10th Plan as well as the Local Self Governance Act and other donors programs in an effort to avoid duplication. The development of this program has followed the "rights-based approach" and been a "bottom-up" process. It, therefore, takes cognizance of some of the most elusive problems in delivering development assistance in Nepal, such as, capacity of major stakeholders, management and delivery of RH services. Moreover, UNFPA's decentralized project strategies, policies, procedures, and tools are developed and identified by the people themselves in the districts. UNFPA is supporting HMG to implement population and reproductive health program in six districts in line with the Local Self Governance Act to see how the population can be managed at local level while working with local bodies and grassroots level organizations.

What is your impression of the involvement of the community?

I am convinced that the program is wholly owned by the communities it is intended for because it has been designed by the community and envisages skills training for service providers, provision of supplies and equipment and increasing the number of family planning service delivery points (SDPs) with increased family planning method mix and ensuring the availability of contraceptives. Other services targeted†include maternal/neonatal care, family planning services, RTI/STI and HIV/AIDS prevention and adolescent sexual and reproductive health while emphasis will be given to strengthen PHC outreach and improved utilization of health services through bilization of grassroots level health workers such as FCHVs, MCHWs, VHWs, and NGOs/CBOs and local governance bodies.

Will the new program strengthen local governance?

The project aims at strengthening the capacity of the local governance bodies to enable them to integrate population, RH and gender issues in their development plans and to enable them to plan, implement, monitor and supervise their development interventions more effectively as per the spirit of LSGA. The selected districts have one of the lowest human and gender development indicators in Nepal. We have targeted specific programs for girl's education and education of disadvantaged populations together with some activities targeted to empower women. We have planned PARHI taking into account of the activities of other development partners so that synergy of development interventions maximizes the impact. In short, this program introduces a new and integrated approach which addresses population and development issues in a holistic and coherent manner at local level.

How do you view the fertility trends in rural and urban areas?

This not an easy question. However, if we take a very narrow sense, then I would refer you to the recent revelations from the Demographic and Health Survey and the 2001 Census. Both of them reveal a general decline in the total fertility rate from 4.6 in 1996 to 4.1 births per women. The same studies also reveal very sharp differentials between the urban and rural populations. For example, the TFR for rural is 4.4 children per woman while for urban is 2.1, which is attributable to the sharp differences in knowledge as well as availability and utilization of services in the rural areas. Another factor responsible for the difference lies in the social cultural practices in rural versus urban areas especially as they relate to gender inequality and equity as well as literacy levels, where the women
fare poorest.

What new programs has UNFPA brought into Nepal?

The Fifth Country Programme builds on and consolidates the achievements of the past programmes but as earlier explained we are now putting more emphasis and focussing on doing business directly with the beneficiaries. The PARHI project is an innovative approach, which many other donors are trying too. We are also following a rights based approach and taking an active interest in the UN System coordinated activities especially those agreed towards the implementation of the Millennium Development Goals and plans of action of the 1990's conferences.

How has UNFPA been working in Nepal?

UNFPA realises that population issues are tangential and† a concerted effort is required. Realizing the cross-cutting nature of the issue, under the Fifth Country Programme, we have built up partnership with other development partners such as the European Union to implement a youth project with seven Non-governmental organizations, the Austrian government to support a women's health, education and local resources project and working closely with DFID and USAID to implement the population programme. Similarly, UNFPA and other UN agencies is involved in national effort to stop trafficking while UNFPA currently chairs the UN Theme Group on HIV/AIDS.

What are the major targets of the Fifth Country Program?

UNFPA assistance to Nepal's population program began in 1970. The UNFPA Fourth Country Program (1997-2001) targeted human resource development aiming to improve the coverage, access, quality and continuity of gender sensitive RH services in Nepal. The National RH Policy and Operational Guidelines and the RH clinical protocols for each level of service delivery were developed and disseminated along with the development of appropriate tools for managers at all levels while HIV/AIDS prevention was integrated in IEC messages. The RH Research Strategy and the National Adolescent Health and Development Strategy have also been developed. Likewise, we supported strengthening the capacity of the Ministry of Population and Environment, Central Bureau of Statistics on mainstreaming gender issues in 2001 census and integration of population and health issues in curricula through schools to university level. We also assisted Tribhuvan University in establishing a central department on population studies that produces middle level human resources to cater to the teaching and research needs in the field.

What are the highlights of the Fifth Country Program?

The Fifth Country Program supports two sub-program areas: reproductive health and population and development strategies, which are in line with the government's own objectives. Just like HMG's 10th Plan/PRSP, the UNFPA program aims to contribute to the attainment of a higher quality of life for the Nepalese people through improved reproductive health and a balance between population dynamics and socio-economic development.

How do you see the state of maternity facilities in Nepal? What has UNFPA been doing to improve them?

If I understand maternity facilities as you do, it is the place where women go to give birth. However, the fact is that only 14 percent of the women in Nepal give birth in a maternity. Either they have too much trust in their relatives at home or they abhor the maternity facilities. I am afraid the latter may be true since I have found more of the maternity facilities I have visited in a sorry state, and as such might have contributed to keeping the women at home.

What are the contributions of UNFPA in the area of health infrastructure?

During the past two country programs, UNFPA provided support in strengthening the infrastructure of the health facilities through the construction of facilities for maternity, waiting homes, family planning counselling, and training facilities across the country. It was our hope that these facilities would assist the Ministry of Health especially the Department of Health Services to effectively provide accessible and quality Reproductive and other services. Unfortunately, some of these facilities have not made a difference while other are not being used as originally planned. Government and external donor partners are gradually furnishing these facilities. UNFPA and GTZ jointly completed the furnishing two facilities in far western part of Nepal. However, the government must take the lead by improving the management and staffing of these facilities such that they become attractive to the people they were built for.

How do you see HIV prevalence in Nepal?

The total number of HIV/AIDS infection cases reported officially shows a cumulative total of 2782 HIV positive cases as of April 2003 out of which 638 have progressed into AIDS. However, WHO/UNAIDS estimates of the actual number of people living with HIV/AIDS in Nepal is much higher - approximately 34,000 HIV/AIDS cases by the end of 1999 with 2,500 AIDS related deaths occurring in the same year. Among all HIV positive cases, 8.7 percent are found in 14-17 years age group and 5.5 percent are female.

Do you have any estimates over the number of female sex workers in Nepal?

It is estimated that there are 25,000 female commercial sex workers, 20 percent of them are younger than 16 years old. Lack of knowledge and awareness about sexual/reproductive health, gender discrimination, girls trafficking, consequences of early marriage, unsafe abortion and STI/HIV/AIDS are major concerns to be addressed. Higher mobility of people across the porous border with an estimated 5,000 to 7,000 girls trafficked annually for flesh trade, isolation and extreme poverty of general population provide a grooming field for rapid spread of the epidemic to the general population and this is a matter of serious concern.

How do you see the prevalence of the HIV infection?

The prevalence of HIV infection among sex workers and injecting drug users has significantly increased, demonstrating a shift from a low level epidemic to concentrated epidemic which will require an all out response to prevent the epidemic from spreading into the general population.

How has UNFPA been supporting the government?

As already said, UNFPA currently holds the chair of the UN Theme group on HIV/AIDS. UN system in Nepal is working with HMG to design and implement appropriate strategies, policies and programs to contain the spread of HIV/AIDS in this country. A national strategy on HIV/AIDS is already in place but we are assisting the government to chart out a roadmap for the effective implementation of strategies and policies so that Nepal can effectively deal with the menace of the epidemic.