Nepal – the country of the Buddha and the Mt. Everest

Peace comes from within. Do not seek it without – Buddha

Utilization focused evaluation of the nature and extent of use of Antenatal Services in Nepal

Posted by Ram Kumar Shrestha on August 2, 2011

By Prabha Shrestha

This project outlines a research proposal for the evaluation of a Nepali government program designed and implemented to improve the health status of women in general, and pregnant women in particular. This evaluation proposal has been developed based on Patton’s approach (Patton 1997) because he emphasizes the active participation of the primary stakeholders in the entire process of the evaluation to maximize the utilization of the findings in the program, thus making the program more effective and efficient. Moreover, it suggests that researchers analyze the views of stakeholders in order to determine findings and to form the research committee overseeing the evaluation. As a result, stakeholders may have greater ownership of the findings to make changes in the program since they understand the research process better; it is argued that without the active involvement of the primary stakeholders, the findings may not be utilized in the rural health facilities ofNepal.

This evaluation proposal has been designed with the involvement and/or agreement of the commissioner of DoHS to ensure the effective implementation of the evaluation plan and to maximize the utilization of evaluation findings.

 1.2     Country context

Nepalhas a multicultural, linguistically, ethnically, and religiously diverse population, derived from the large-scale migrations of Mongoloid groups fromTibet(northern part ofNepal) and Indo-Aryan people from northernIndia(southern part ofNepal) (Asiarecipe, 2003).  Indo-Aryan groups consist of the people of Tarai, Pahari, Newar, and Tharus, where as most of the Tibeto-Nepalese groups comprise the Tamang, Kirati (Rai/Limbu), Sherpa and Sunwar.  However, it seems difficult to identify who is indigenous and non-indigenous toNepal. Many customs are inherited from both sides and have been developed by the influences of the land, climate and available resources as well.  Nepali is the major official language and Hinduism is the major religion (Shrestha 2003) but there are no conflicts among other religions, including Buddhist, Muslim and Christian groups.

There are over 40 different races and tribes inNepal. The largest ethnic groups can be divided on the basis of three geographical regions: Himalayan, Mountain and Terai.  Sherpa, Dolpa, Manang, Larke and Satar, Lo Pas of Mustang and Olanchung people live in Himalayan region, Brahmin and Chetri, Kirati, Newars, Tamang, Magars, Gurungs and Thakalis habitats in Mountain Region and Rajput/Brahman, Tharus, Rajbansi, Satars and Masalmans are in the Terai Region. Certain ethnic groups inNepalare categorised according to their occupation. They are Kamis (smiths), Damais (tailors), Dhobis (launderers) Sarkis (cobblers), Gaines (professional singers) and Khumbharas (porters), which are called lower caste or untouchable (Shrestha 2003). Similarly, Brahmin and Chhetri are recognized upper caste and Newars, Tamang, Magars, Gurungs and Thakalis are known to be middle caste. However, no official criteria are set to distinguish the castes. This caste system ofNepalis so strong that it determines the religion, culture, custom and practice. Therefore, sampling of this population will be based on caste in the districts. A simple numerical representation will be used, relying on census data.

The majority of Nepali people live in villages or in small market centers. Outside of theKatmanduvalley, there are no major cities. The smaller urban centers: Biratnagar, Nepalganj, and Birganj are located in the Terai along the Indian border, and Pokhara is situated in a valley in the mid-mountain region. In addition, a few townships such as Hitauda, Butwal, and Dharan have begun to emerge in the foothills and hill areas where economic activity has developed. For the purpose of this evaluation the specialized hospitals, regional hospitals and zonal hospitals that are situated in the valleys and urban centers are also included, as the utilization would be higher in these areas compared to the district health offices. And so the utilization of AS, and its barriers can be compared between rural and urban areas’ health facilities, which help the health authorities to prioritize the problems and redesign the program accordingly.

Of the 23.74 million total populations, 86% of the population resides in villages, where 98% of area lies under the rural area (CBS 2001).  The division ofNepalinto the three geographic zones (Mountain, Hills, and Terai) has seen to facilitate planning development and management, and to ensure equitable distribution of development efforts to all parts of the country. This approach divides different areas of the country into groups with similar constraints and potentials (topographic/climatic/socio-economic) and has huge significance for macro level planning (APROSC, 1990). (Map ofNepalis in Appendix 1)

Regional differences in socio-economic status, education status, and in health status are large in the country (CBS, 2001).  Difficulty in transportation, the scarcity of cultivatable land, and the lack of accessible and reliable health services are major problems in rural areas especially in Hills and Mountain Regions (NPC, 1997). For example, the life expectancy in Capital District (Kathmandu) is 74.4 years, much higher than the 55 years life expectancy of the average Nepalese.  Life expectancy in the remote mountain districts in the Mid-Western region is just 37.4 years (Gartaula 1998). This situation is even worse with village women, where their health status, economic and education levels are low compared with men. The education rate for women is 42%, in contrast 65% for men (CBS 1993).  According to the SMH Policy (1998), the average age at first marriage of women is 17.9 years with 50% giving birth age by 20 (SMH policy 1998).

Furthermore, according to a government report, about 45% of the total population lives in complete poverty with earnings of less than one dollar a day (NPC, 1997) and more than 90% of the population depends in subsistence agriculture in the rural areas (NPC 2001).  It is suggested that income may also affect the utilization of the health services.

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One Response to “Utilization focused evaluation of the nature and extent of use of Antenatal Services in Nepal”

  1. Guna Raj said

    can u send me the main body of thesis pls? as it comes only covering pages.

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