considerations for incorporating health equity in project design_roy_5.12.11

Nepal - BackgroundPrides itself in never having being colonized

Was the only declared Hindu State in the world

Nepal, a part of the subcontinent, follows the caste system

March 12th 2011CORE – Equity Session

CARE Nepal’s CRADLE ProjectSept 2007- Sept 2011

And two earlier CS projects

Nepal

Project Districts

• CB-NCP: In Doti• BPP: Kailali• CB-IMCI: In Kailali, and Doti• HIV AIDS: In Both, Doti and Kailali

Technical Interventions

Wealth and AssetsWealth and AssetsCaste/ethnicity

IndicatorsHill Brahman

Tarai Janajati

Hill Dalit National

Wealth quintile

Lowest 9.5 11.5 45.9 20.2

Second 11.3 30.7 19.5 19.9

Middle 12.0 31.3 15.4 20.0

Fourth 26.0 16.9 10.9 20.1

Highest 41.2 9.5 8.4 19.8

Household facilities

Electricity 75.8 38.3 32.7 51.6

Private latrine 66.3 18.6 23.2 38.6

Improved drinking water 81.1 91.0 70.3 82.1

Radio 83.7 54.6 53.3 62.7

Television 45.8 23.4 13.3 29.4

Any means of transportation

41.3 74.1 13.6 37.5

Source: Bennett, Lynn, Dilli Ram Dahal and Pav Govindasamy, 2008. Caste, Ethnic and Regional Identity in Nepal: Further Analysis of the 2006 Nepal Demographic and Health Survey. Calverton, Maryland, USA: Macro International Inc.

EducationEducationPercentage of population with no formal education by cast/ethnicity and gender, Nepal

Source: Bennett, Lynn, Dilli Ram Dahal and Pav Govindasamy, 2008. Caste, Ethnic and Regional Identity in Nepal: Further Analysis of the 2006 Nepal Demographic and Health Survey. Calverton, Maryland, USA: Macro International Inc.

Maternal HealthMaternal HealthAntenatal care Economic barriers in accessing health

care:• 54 % of Dalit and 28% of

Brahman women cited lack of money as a problem in accessing health care

• High cost of institutional delivery (Rs.49,000) vs. lesser but still significant cost of using SBA at home (Rs. 13,600).

* Source: Bennett, Lynn, Dilli Ram Dahal and Pav Govindasamy, 2008. Caste, Ethnic and Regional Identity in Nepal: Further Analysis of the 2006 Nepal Demographic and Health Survey. Calverton, Maryland, USA: Macro International Inc.

Child HealthChild Health

Brahman Janajati Dalit NationalNeonatal mortality 34 36 44 37

Post-neonatal mortality 25 24 25 19

Infant mortality 59 59 68 55

Child mortality 18 22 23 13

Under-five mortality 76 80 90 68

Early childhood mortality rates by caste/ethnicity, Nepal(for 10-year period preceding the survey)

Source: Bennett, Lynn, Dilli Ram Dahal and Pav Govindasamy, 2008. Caste, Ethnic and Regional Identity in Nepal: Further Analysis of the 2006 Nepal Demographic and Health Survey. Calverton, Maryland, USA: Macro International Inc.

Child HealthChild HealthStunting (percentage of children under 5 who are -3 SD below normal

height-for-age) by caste/ethnicity, Nepal

Source: Bennett, Lynn, Dilli Ram Dahal and Pav Govindasamy, 2008. Caste, Ethnic and Regional Identity in Nepal: Further Analysis of the 2006 Nepal Demographic and Health Survey. Calverton, Maryland, USA: Macro International Inc.

Women and men planning/plotting

Focus Population• Landless, Dalits, Janajatis, Kamaiyas,

Haliyas, • People Living With & Affected by

HIV/AIDs (PLWHAs), Sex Workers, Conflict- and Disaster-Affected People

Women, children and youth cut across all the categories.

Prioritized VDC/HF

On site coaching (FCHV, Mothers, MIL, FIL, PW, PNM Husbands, Peoples Org,) in MG meeting

Ward categorizationSocial mapping

HMIS data analysis

VDC/HF prioritization at district level

Ensure regular MG meeting and increase utilization of health

servicesFeedback/Reflection

Analysis of HMIS data,

interaction among HF staff, HFOMC

members, MG representative,

WRF, WAF and other community

members, stakeholders

Feedback/reflection

Documentation and dissemination of

processes, learning and changes

Capacity building of

FCHV & HWs

Include RBA, Advocacy and

Social Inclusion Issues

Key MNH messages based on

BCC strategy

Self assessment and evaluation

Healthy and prosperous family / community

Improvement in maternal and neonatal health by reducing morbidity and mortality

Self Applied Technique for quality Health (SATH) Framework

CRADLE’s SATH Approach - Outcomes• Where SATH is applied more women from marginalized

communities are participating in the mother groups and accessing health services

• Some of the HFOMC members are concerned and committed to upgrading their respective health facility to birthing center.

• There is a greater demand for quality health services• Re-organization of outreach clinics which has increased coverage

of key health indicators in the poor performing clusters• Greater participation of Dalits and other PVSE, they have utilized

services more than before• Inclusion of PLHA• Inclusion of MIL, Husbands and FIL – changed perception towards

women’s health, increase in supporting behavior for MNH care

Best laid plans of ….

Ethnicity 4 ANC 2 BPP Know SDI

Institutional delivery

PNC ( 1-3 Days)

Dalit 51 32 69 26 60Janajati 73 4 40 70 24Others( Brahmin/Chetri/Equivalent

48 36 77 25 65

Knowledge and practices on MH( %)

CB-IMCI( %)

EBF Measles ARI

• Dalit 70 81 64 • Janjati 75 98 74 • Upper Caste 73 87 76

Women Participation in at least one IGA(%)

Dalit 45

Janjati 93

Upper Caste 57