Building capacities on evidence-based SRHR advocacy in Nepal
Nepal, a country with 83% of the population living in rural areas (1) and with 40% living in poverty, is also a country with stark gender inequality. This is reflected in the gender gap in socioeconomic and health indicators, particularly on women’s sexual and reproductive health and rights (SRHR). Until recent data came out, Nepal had one of the highest mortality rates in South Asia. (2) Majority of these deaths are attributed to unsafe abortions. Although there is no systematic collection of abortion data, some studies, such as a hospital-based study, revealed that more than a half of the total maternal deaths in hospitals in Nepal were due to unsafe abortions. (3) The 1998 Maternal Mortality and Morbidity Study of the Ministry of Health, on the other hand, found that abortion accounted for 10% of maternal mortality. As abortion was illegal in the country until recently, the rate of covert abortions was estimated by a community-based study to be 117 per 1,000 women between 15-49 years. (4)
Through nearly three decades of efforts by different organisations and individuals, abortion was legalised in Nepal in 2002. However, daunting challenges remain in effectively implementing the law, such as: a) socio-cultural and religious challenges of overcoming social stigma and religious restrictions; b) health system challenges (e.g., uneven quality of care and service in Comprehensive Abortion Care or CAC centers, inadequate number of doctors, no separate budget allocation to the safe abortion programme); and c) legal challenges (e.g., no clear legal definition of abortion in law, abortion still dealt under the Homicide Chapter).
It is within this scenario that Beyond Beijing Committee (BBC) began implementing the Women’s Health Rights Advocacy Partnership (WHRAP) project in Nepal in 2003. BBC works at local, national and regional levels, ensuring participation of marginalised rural women and focusing on holding duty bearers accountable for fulfilling women’s health and wellbeing. At the community level, BBC works with eight local non-government organisations (NGOs) and community-based organisations (CBO) in two districts: Bardiya and Makwanpur. Key WHRAP strategies include: a) conducting baseline research on the SRH situation in project sites and collecting case studies related to abortion and maternal mortality; b) capacity building workshops on research, strategic evidence-based advocacy, media advocacy and health systems monitoring, for local NGOs and CBOs; and c) production of references such as a pictorial Advocacy Tool in Nepali, which uses a rights-based approach and contains key messages on health service provision, safe abortion and safe motherhood.
Local evidence is then used to inform strategic planning, as well as local and district-level advocacy and monitoring interventions to key stakeholders, such as health providers, community health workers, community leaders, local media and Village Development Committees. These same rural women’s concerns are then brought up to the national level by rural women and CBOs themselves in policy dialogues and other interactions with national SRHR focal points, including representatives from the Ministry of Health, Ministry of Women, National Planning Commission, and others.
Concrete results from advocacy efforts are often difficult to see in a short time. Still, BBC/WHRAP, through its interventions with partner CBOs, has been successful in bringing about some changes. Having gained advocacy skills and knowledge of SRHR issues and government commitments, rural women and CBOs have been empowered. They have spoken up in public meetings and policy dialogues, demanding accessible and free abortion services in primary health posts; they have challenged political parties to commit to including SRHR as a priority area for action in their parties’ manifestos in upcoming elections. On the SRH services delivery side, concrete changes include successfully lobbying for the increase in the number of government doctors in the Makwanpur district hospital from one to two, while in Bardiya there are now two doctors whereas before there was none. In addition, the Makwanpur district hospital has increased the number of days wherein they provide safe abortion services from two to six days a week, and has reduced the abortion fee from Nrs. 1200 to Nrs. 1000 (about US$18.90 to US$15.75).
BBC/WHRAP Team, BBC, Nepal.
(1) UNFPA. 2007. State of the World Population: Unleashing the Potential of Urban Growth. New York.
(2) The 2006 Nepal Demographic and Health Survey reports that the MMR has been reduced to 281 out of 100,000 (from 539 out of 100,000 in 1996). The various contributing factors for the decrease, such as conflict and the legalisation of abortion, still needs to be fully understood.
(3) Thapa, P.J.; Thapa, S.; Shrestha, N. 1992. “A hospital based study of abortion in Nepal.” Studies in Family Planning. Vol.23, No.5, pp.311-318.
(4) Thapa, S.; Thapa, P.J.; Shrestha, N. 1994. “Abortion in Nepal: Emerging insights.” Journal of Nepal Medical Association. Vol.32, pp.175-190.
(5) WHRAP is a regional project to increase the capacity and effectiveness of civil society to advocate for SRHR at the local, national and regional levels. It is being implemented by ARROW and national partners in four countries in South Asia: Bangladesh (BWHC and Naripokkho), India (CHETNA and SAHAYOG), Nepal (BBC) and Pakistan (Shirkat Gah), with support from the Danish Family Planning Association.
(6) BC’s partners at the grassroots level are Asmita, Nari Sip Srijana Kendra, Youth Welfare Society and HimRights/Hetauda in Makwanpur, and Nepal Red Cross Society/Gulariya, Social Campaign for Integrated Development, Nepal National Depressed Social Welfare Organization, and Bardiya Handicapped Rehabilitation Centre in Bardiya.