A decade of qualitative research informs equity and access programming

for safer motherhood in Nepal

Mary Manandhar, Bindu Gautam, Hom Nath Subedi, Sumi Devkota, Hazel Simpson, Deborah Thomas,

Greg Whiteside, Ben Rolfe, Laxmi Raj Pathak and BK Subedi

“The link between social disadvantage and mortality is subtle and indirect but maternal and newborn survival and good health are ultimately the result of a society that values women and children irrespective of their race, social, economic, and political status and provides unimpeded access to information and health services from the household to the hospital.”

Rosato, M. The Lancet Vol 372 September 13, 2008

International context

• Growing attention to social conditions as part of strengthening more equitable and rights-based health systems

• Nepal can offer lessons and preliminary evidence of the impact of action on the social determinants of maternal health

Commission on the Social Determinants of Health WHO 2008

Safer motherhood programming in Nepal

Between 1996 and 2006, Nepal halved its MMR to 281Nepal Safe Motherhood Project (NSMP) 1996–2004Support to Safe Motherhood Programme (SSMP) 2005-10, with an

Equity and Access programme (EAP)

2 GoN health systems strengthening programmes focused on:• increasing attention to social determinants

and inclusion• emergence and intensification of

a rights-based approach

Qualitative research

• Articulates women's voices - part of RBA• Provides a lexicon of local maternal and neonatal health

terms for Behaviour Change Interventions• Details contextual barriers to access to health care for

different social groups (ethnicity / caste / gender / region)• Informs efforts to improve equity and access for socially

excluded groups• Strengthens accountability and demand

• Beliefs about the spiritual causes of sickness and crisis determine care-seeking in favour of traditional healers

• Fatalistic beliefs dull urgency

• Complex pattern of delays and detours, and recourse to a variety of care providers (often from different health systems) in most health crises

Contextual barriers

“every kind of wind, every kind of ghost”

• Women exist in a complex web of relationships

Contextual barriers

• Socio-cultural norms related to ritual blood pollution, shame (laj) and avoiding loss of family prestige (ijjat) greatly influence delay

• The woman in childbirth is not a key decision-maker and is expected to defer to her in-laws, husband and healer

NSMP qualitative research

Highlighted previously unexplored social determinants of maternal health:

• Regional, caste, ethnic- based social exclusion which influence quality of care at the provider-client interface

• Persisting strength of indigenous beliefs and practices about sickness causation which influence care-seeking and the plurality of the ‘health system’

• Persisting deep-rooted gender inequity operating at household and community levels influencing access to available services

Ethnic / caste inequities in access to health care

Bennett, Dahal and Govindsamy 2008 (Further analysis of Nepal DHS 2006)

Context is everything

• This is not principally a ‘lack of knowledge’ problem

• Need to understand the deeply hierarchical nature of Nepali society and gendered cultural traditions

• ‘Sensitisation’ solves none of these problems

• Nor does simply describing the complexity

• Challenge the ideology of male domination: question male-controlled customary laws, affect on health

• Reflect on the family as the core of a woman’s own concept of self-hood

• Enable women to be heard and to gain control

• Support communities to seek and reflect on alternative behaviours and participate in their own solutions

• Transform the institutions and structures

Contested debate and novel solutions

Bringing transformative change to scale

EAP’s Key Informant Monitoring (KIM)

Advocacy: local and nationalAccountability: local, district, regional, nationalMonitoring ethnicity in routine data collectionCommunity mobilisation approachesParticipatory Video

• Research to understand barriers to access and inclusion• Disaggregated data, including for maternal morality• Address capacity to use these data in programming• Forget ‘sensitization’• The Nepal experience demonstrates the potential of:– Scaling flexible participatory community mobilisation– Integrated BCC informed by well supported research– Intensive capacity building – Long horizons for success

Challenges and opportunities

• The safe motherhood policies, the national safe motherhood programmes and the Interim Constitution have reflected the historical shift to incorporate both public health and human rights concerns (e.g. right to freedom from discrimination)

• New Gender and Social Inclusion Unit at the heart of government to strengthen this trend

Influencing at national level