September 09 2005

--Ms JUNKO SAZAKI

Ms. JUNKO SAZAKI, Representative UNFPA, spoke with KESHAB POUDEL on various issues related with reproductive health in the context of MDGs. Excerpts:

Nepal has been facing internal conflicts, how do you see the achievement made by Nepal in the area of MDG+5?

Nepal's poverty has declined. There has been improvement in other areas as well. Literacy has gone up so is the schooling of children. Other socio-economic indicators such as infant and child mortality and total fertility rate have declined. Life expectancy at birth and contraceptive prevalence rate has gone up. Access to drinking water has increased and there is growing awareness on gender and HIV/AIDS issue in the country. Improvement in some indicators does not mean complacency for not doing better. Despite all these gains, Nepal still ranks lowest in almost all socio-economic indicators in the region. Its maternal mortality is one of the highest in the world. Almost one-fifths of the school going age group are still not attending school and the girls' enrolment is lower than the boys' enrolment. Male involvement in responsible parenthood is minimal. Women's status is low and varies across numerous caste-ethnic groups. A large share of the adolescent and youths do not have access to sexual and reproductive health information and services. We at UNFPA maintain that until and unless we provide universal access to quality RH services and ensure RH rights, most of the MDGs may not be attainable - more so for MDG on halving poverty (MDG 1), gender equality, equity and women's empowerment (goal 3), maternal health (goal 5), and HIV/AIDS (goal 6). There are various assessments of affects of conflict. Also, the numerous field visit reports, reportage of journalists and visitors' point to the fact that conflict has embedded every day life and has affected development interventions. We are increasingly concerned by the fact that able-bodied (adults and youths) have already left or are leaving the hinterlands due to conflict and only elderly, women and children are left behind. Fields are not cultivated and remain barren and people's subsistence is affected. Lack of other alternative mode of employment in the rural areas is likely to deteriorate the poverty level more so on nutritional status which is dismally low in Nepal. Influx of people to and from India exposes them to risk of contacting HIV/AIDS and Nepal could be a hot-bed of spread of HIV/AIDS given its socio-economic and geographical situation. Lack of free mobility of people, services and medicines is affecting medical supplies to service delivery points. Service providers are not in the facility. Schools have become war zones and many schools have been closed. Infrastructures created by decades of efforts are destroyed and supplies of services and goods restricted. The culmination of these effects is likely to be downward spiral in the gains we have made in the early days of restoration of democracy. This is a serious issue. Current conflict is having a huge toll in Nepal's development and if the situation continues further, MDGs will not be attainable.

As UNFPA has been supporting Nepal in the areas of reproductive health, women empowerment and HIV/AIDS, how do you evaluate the situation?

UNFPA has been supporting HMG for more than three decades. Reproductive health and Population Development Strategy are the two major sub-programmes of HMG/ UNFPA’s 5th Country Programme. Out of the total budget of the Country Programme, 70-75% of the budget is allocated for reproductive health programme. Gender mainstreaming and advocacy are the cross cutting issues of the country programme.  UNFPA works in partnership with the line agencies in their existing system while it provides financial and technical support to the implementing partners. UNFPA is working with Ministry of Health and Population, Ministry of Education and Sports, Ministry of Women, Children and Social Welfare, Ministry of Agriculture and Cooperatives, Ministry of Forest and Soil Conservation and Ministry of Local Development. Besides, UNFPA also supports national NGOs in RHIYA project in collaboration with European Union and the organization also works in partnership with professional societies, the national federations, media, I/NGOs and donors, who are working in the area of reproductive health, gender issues and women's empowerment. In the area of RH, UNFPA has contributed a great deal in the National FP programme. The CPR in 2001 shows 38.9% compared to 24 in 1991 (DHS 2001). Similarly, UNFPA has supported HMG in the capacity building of the implementing partners such as in providing RH services, training and management. With UNFPA support the government has produced RH strategy/policy, RH Clinical Protocols, RH Management Guidelines. training manuals of MCHW and ANMs. Under the UNFPA’s support the Management Division has institutionalized the health management information system, which produces regular Annual Report of DoHS. UNFPA is supporting Safe Motherhood programme, Adolescent Sexual and Reproductive Health (ASRH) programme, STI/RTI and HIV/AIDS through different projects at the national and district level. In the Safe Motherhood program UNFPA has played a crucial role in advocating for increasing access to skilled birth attendant at different levels, including policy makers, donors and stake holders. Overall the awareness on RH issues has increased in the general population. However, a lot of efforts need to be put in improving the quality of services. In the current country programme UNFPA is supporting the Population and RH Integrated project in 6 selected districts with the main focus on the FP, SM, ASRH, STI/RTI and HIV/AIDS in line with the LSGA such that the programme will be show a substantial impact. UNFPA is supporting the Ministry of Women, Children and Social Welfare and the Ministry of Health and Population in mainstreaming gender in the regular plans and policies of the government. We are supporting the gender focal points to build their capacity in mainstreaming gender in their respective organizations. The Department of Women Development is making grassroots women and girls aware of their rights and empower them to improve their reproductive health. UNFPA is focusing the Population and Reproductive Health Integrated (PARHI) project in six districts – Saptari, Mahottari, Rautahat, Kapilvastu, Dang and Dadeldhura. UNFPA is supporting the Ministry of Education and Sports to integrate Reproductive Health in the formal and non-formal education. The Ministry of Health and Population is leading the preparation of the Population Perspective Plan and the preliminary draft is ready. UNFPA is supporting three public universities to teach population, gender and development courses to produce mid career professionals, who can understand and make use of population and development dynamics in the country. In order to improve the Reproductive health of youths and adolescents EC/UNFPA Reproductive Health Initiative for Youths in Asia (RHIYA) is working with seven national NGOs to address the concerns of vulnerable deprived youths in 19 districts.

How do you see the linkage between RH and poverty reduction?

Empirical research clearly demonstrate a link between poverty and reproductive health. Poor reproductive health fosters poverty in many ways. Poor women have many children throughout their lives. The use of modern methods of family planning is lower among poor segments of the society. Deliveries of poor women are less likely to be attended by skilled birth attendants and they have children at younger ages. Fewer pregnancies lead to lower maternal mortality and morbidity and often to more education and economic opportunities for women. Her ability to earn income can lead the family out of poverty. Enabling people to have fewer children helps to stimulate development and reduce poverty both at the household and at the macro-economic level.

How important is RH for Nepal in achieving Millennium Development Goals?

MDGs, particularly the eradication of poverty and hunger cannot be achieved if questions of RH are not squarely addressed. It means stronger efforts to promote women’s rights and greater investment in quality reproductive health including family planning. Utilizing reproductive care generates enormous socio economic and demographic benefits to the poor, allowing them to escape poverty. Reproductive health and family planning are essential components of any effort for Nepal to meet its MDG targets. With reproductive health, the poor become able to take better care of their children and to invest more on their children’s education and health; maternal mortality and morbidity are lowered; and the incidence of HIV/AIDS and sexually transmitted diseases (STDs) lowers dramatically. These benefits collectively manifest in society as slow population growth, low unemployment or underemployment, high female labour participation, high economic growth, and low extreme poverty. On the one hand, the poor are severely disadvantaged in terms of access to reproductive health care, while on the other high numbers of children per household aggravate poverty. Nepal’s high rate of maternal mortality deprives children of the care and guidance that those mothers would provide, and the increased burdens of household chores impact children’s ability to go to school, particularly for girls. Poor households in Nepal are trapped in by the so-called ‘demographic poverty trap’ - characterized by high fertility and a high ratio of children to adults. Due to high numbers of children, low incomes, and the high percentage of income that must go to food, poor households cannot afford to educate their children. Lacking education and with their health compromised by inadequate nutrition, the children of the poor find it difficult to escape, and poverty perpetuates from poor households of this generation to the coming generation. Allowing poor couples and individuals to control their fertility to be responsible for their children’s health, education, welfare breaks the inter-generational poverty cycle to a large extent. If Nepal does not address the reproductive health issues of poor, it is very unlikely to meet its Millennium Development Goals.

How has the UNFPA been supporting Nepal to achieve the targets?

UNFPA has been supporting Nepal to achieve the goal of the International Conference of Population and Development (ICPD) held in Cairo in 1994 towards universal access to quality RH services, universal primary education, sustainable development and gender equity, equality and empowerment of women. The ICPD places emphasis on improving the quality of life of every individual and it puts focus on women and expanding their choices and opportunities and respecting their human rights. Reproductive health rights is the key to improving maternal health as well as universal primary education and achieving gender equality and the empowerment of women. The ability of women to control their own fertility is absolutely fundamental to women’s empowerment. Since ICPD conference of Cairo in 1994, UNFPA has widened its area of programme/work in RH in a holistic manner encompassing the components of reproductive health other than family planning. UNFPA strongly advocates and supports the implementation of ICPD recommendations. The current as well as previous HMG/ UNFPA country programmes have been formulated as per the ICPD recommendations as Nepal is a signatory who has committed to work towards meeting the ICPD goal. Similarly, meeting the ICPD goal contributes to achieving the MDG goals because improved status of reproductive health means - improved maternal and neonatal health (MDG 5 and 4): prevention and care of RTI/STI and HIV/AIDS contributes to combating HIV/AIDS (MDG 6); adolescent sexual and reproductive health care contributes to improved maternal health and prevention and care of STI, RTI and HIV/AIDS (MDG 5 and 6) and promotion of reproductive right, gender equity, equality and women empowerment is directly linked with MDG 3. In order to mainstream gender in the RH programme DoHS has developed a training package in gender training for service providers and have produced a cadre of master trainers and trainers in the area with UNFPA support. Furthermore, UNFPA promotes girl education by providing scholarship to the marginalized groups under its PARHI project which contributes to MDG goal 2. Overall improvement in RH directly contributes to poverty reduction (MDG goal 1). The current HMG/ UNFPA country programme has two pronged approach: i) Support to the National programme in the formulation, review/update of RH Strategies/policy, protocols, guidelines and training manual at the central level: national FP programme and national FCHV programme and ii) support to 6 selected districts in line with the Local Self Governance Act (LSGA) of decentralization which is the Population and Reproductive Health Integrated (PARHI) project. UNFPA's programme contributes in meeting the targets of MDG goals, specifically MDG goals 1, 2, 3, 4, 5 and 6 either directly or indirectly by i) improving access to quality RH services to women, men and adolescents, ii) strengthening capacity for planning, implementation, monitoring and evaluation of implementing partners in line with LSGA, iii) increasing access/exposure of women, men & adolescents to information in RH encompassing FP, SM/neonatal health, ASRH and STI/RTI and HIV/AIDS. Gender and advocacy are the cross cutting issues of the country programme. In the area of HIV/AIDS it is integrated in all UNFPA assisted projects and programmes, trainings, manuals. UNFPA is also supporting stand alone project to prevent HIV/AIDS. Currently, UNFPA is supporting models for scaling up youth friendly services to prevent SRH and HIV among young people in Nepal.

How do you see the demographic pattern in Nepal?

Decade's investment in developing and improving health service delivery and continuous support from major donor agencies including UNFPA helped Nepal to make significant strides in socio-economic and demographic indicators after the restoration of democracy. The data from the 2001 Census, Nepal Demographic Health Survey, 2001 and the latest data from the Nepal Living Standard Survey (NLSS 2) attest to the fact that overall poverty has declined, total fertility rate has come down to 4.1 per woman, and contraceptive prevalence rate has increased to around 40 percent among currently married women. Both the total fertility rate and contraceptive prevalence rate in urban areas resemble that of the more developed countries. With spread of education and globalization facilitated by advancement in Information Technology, has engulfed the adolescent population which will have implications for socio-economic and demographic transformation of Nepali society in years to come. Utilization of health services is slowly increasing, average antenatal visit is now close to 1.8 per pregnant woman, infant and child mortality has further declined and life expectancy at birth seems to have surpassed 60 year mark. What seems to be more significant is that women's life expectancy has surpassed men's as we enter the millennium. This is something everyone should be proud of given the low social status of women in this country. Nepal is in the midst of transition from high fertility, high mortality to low fertility and low mortality regime, fertility remaining high but gradually declining. The tempo of fertility decline can be further accelerated by targeted interventions in pockets of poverty – isolated, marginal and disadvantaged groups living in remote and rural areas. However, even if fertility declines to an appreciable level, Nepal's population size will continue to grow because of in-built momentum in its age-sex distribution. Of the total population of Nepal, about 38 percent is below 15 years of age and this is the age group which will be entering parenthood and labour force in near future. Even if they bear only two children per couple, Nepal's population will continue to grow for some time. If Nepal does not focus on accelerating fertility decline and designing specific policies and programmes to reap the benefits of ‘demographic window’, a period when people entering the labour force, is larger than the mouths to feed. Nepal will miss the opportunity of 'demographic bonus'. It is high time Nepal designs its policies and programmes to address these issues. Countries such as Taiwan, South Korea and Thailand concentrated and made huge investment on human resource development such as education, women's empowerment, skill and profession-based training and benefited from the demographic transition. UNFPA is assisting Nepal in fulfilling its development goals of population stabilization and poverty reduction by improving access to quality reproductive health services and strengthening Nepal's capacity to formulate and implement gender-sensitive development policies and programmes at all levels. Nepal was heading in the right direction but the conflict has stalled that process and we are worried that Nepal's sustainable development goal may not be realized if this prolongs for some more time.

What are the state of HIV/AIDS and the level of poor people affected by it?