‘‘ANALYZE THE PROGRESS TOWARDS ACHIEVING MDGs IN NEPAL’’

A Term paper submitted to fulfill the partial requirement of BPH second semester [Public

Health PBH 111.3]

SUBMITTED TO:

DEPARTMENT OF PUBLIC HEALTH,

LA GRANDEE INTERNATIONAL COLLEGE,

SIMALCHAUR-8, POKHARA

2011

SUBMITTED BY:

SAMJHANA GURUNG ‘A’

SAMJHANA GURUNG ‘B’

SABITA TIMILSINA

SARALA KUMAL

SAGUN PAUDEL

ii

1. Acknowledgement

The students of Bachelor of Public Health 2nd semester of 2nd year like to express our humbly thanks to all those who have supported and helped us in accomplishing this term paper in the topic ‘‘ANALYZE THE PROGRESS TOWARDS ACHIEVING MDGs IN NEPAL’’.

We would like to convey our heartfelt thanks to all those who were directly or indirectly concerned with this and to all our well wishers.

First of all we would like to thank our respected subject teacher Mr. Diphendra Kumar yadav for

giving us opportunity to prepare this term paper. We are fully indebted to our coordinator Mr.

Dilip Yadav for expert guidance, regular supervision, untiring encouragement, inspiration and

valuable suggestion and full support during preparation of term paper.

This term paper is written in simple language, with every bit of necessary information related to

the topic so that studying independently also would not find any difficulties. We think that this

effort will help every individual to understand about the information of the related topic.

iii

2. ACRONYMS

ADB : Asian Development Bank AIDS : Acquired Immune Deficiency Syndrome BMI : Body Mass Index CBOs : Community Based Organizations CMR : Child Mortality Rate DALYs : Disability Adjusted Life Years DOHS : Department of Health Services DOTS : Directly Observed Treatment Short Course EHCS : Essential Health Care Services FAO : Food and Agriculture Organization FCHVs : Female Community Health Volunteers FY : Fiscal Year GDP : Gross Domestic Product GNP : Gross National Product HDR : Human Development Report/UNDP ILO : International Labour Organization IMCI : Integrated Management of Childhood Illness IMF : International Monetary Fund IMR : Infant Mortality Rate INGOs : International Non-Governmental Organizations MCHW : Maternal and Child Health Worker MDGs : Millennium Development Goals MMR : Maternal Mortality Rate MOHP : Ministry of Health and Population/Nepal MTEF : Medium Term Expenditure Framework NGOs : Non-Governmental Organizations NLSS : National Living Standard Survey/Nepal NMR : Neonatal Mortality Rate NPC : National Planning Commission/Nepal NRB : Nepal Rastra Bank PCE : Per Capita Expenditure PEM : Protein Energy Malnutration PGR : Poverty Gap Ratio PPP : Purchasing Power Parity PRGF : Poverty Reduction and Growth Facility/IMF PRSP : Poverty Reduction Strategy Paper Rs. : Rupees/Nepalese SLTHP : Second Long Term Health Plan STD : Sexually Transmitted Disease UN : United Nations UNAIDS : United Nations Program on HIV/AIDS UNDP : United Nations Development Program UNESCO : United Nations Education and Social Council UNFPA : United Nations Fund for Population Activities

iv

UNICEF : United Nations Children's Fund VDC : Village Development Committee/Nepal WB : World Bank WDR : World Development Report/WB WFP : World Food Program WHO : World Health Organization WTO : World Trade organization

v

3. Table of contents

1. Acknowledgement ...................................................................................................................................... ii

2. ACRONYMS ................................................................................................................................................. iii

3. Table of contents ........................................................................................................................................ v

4. Introduction ................................................................................................................................................. 1

5. Goals............................................................................................................................................................. 1

Goal 1: Eradicate extreme poverty and hunger ............................................................................................ 1

Goal 2: Achieve universal primary education................................................................................................ 2

Goal 3: Promote gender equality and empower women ............................................................................. 2

Goal 4: Reduce Child Mortality Rate .............................................................................................................. 2

Goal 5: Improve Maternal Health .................................................................................................................. 3

Goal 6: Combat HIV/ AIDS, malaria, and other diseases .............................................................................. 3

Goal 7: Ensure Environmental Sustainability ................................................................................................ 4

Goal 8: Develop a global partnership for development ............................................................................... 5

6. Objective: ..................................................................................................................................................... 5

6.1. General Objectives: .................................................................................................................................. 5

6.2. Specific Objectives: ............................................................................................................................. 5

7. The MDGs and Nepal .................................................................................................................................. 6

8. Key Strategies of Nepal ............................................................................................................................... 6

9. Findings ........................................................................................................................................................ 9

9.1. Progress toward the Millennium Development Goals and Targets ..................................................... 9

10. Discussion .............................................................................................................................................. 11

11. Conclusion ............................................................................................................................................. 11

12. References ............................................................................................................................................. 12

1

4. Introduction

The UN global conferences of the 1990s drew up a number of different key global Development goals and targets to focus equalize and harmonize the needs and status of the people all over the world. These goals and targets were known as the International Development targets. Again in 2000, the representatives of 189 nations, including 147 heads of state and Government adopted the Millennium Declaration during the Millennium Development Summit (September 6-8, 2000) of the United Nations. The Millennium Declaration focused on peace, security and development concerns comprising environment, human rights and good governance. In this connection, the Declaration tried to mainstream a set of interconnected and mutually reinforcing development goals into a global agenda. The international development targets and the development goals were merged together and renamed as the Millennium Development Goals (MDGs). 1. Eradicate extreme poverty and hunger 2. Achieve universal primary education 3. Promote gender equality and empower women 4. Reduce child mortality 5. Improve maternal health 6. Combat HIV/AIDS, malaria and other diseases 7. Ensure environmental sustainability 8. Develop a global partnership for development. These goals had been decided and fixed earlier in many international forums and conventions. What is new about the MDGs is setting of targets under each goal, a joint meeting of UN Secretariat, and specialized UN agencies, the World Bank, IMF and OECD. The Millennium Development Goals were developed out of the eight chapters of the United Nations Millennium Declaration, signed in September 2000.There are eight goals with 21 targets, and a series of measurable indicators for each target.

5. Goals

Goal 1: Eradicate extreme poverty and hunger

Target 1:

Halve between 1990 and 2015, the proportion of people whose income is less than $1 per day.

Indicator:

Proportion of population below $1 (1993 PPP) per day (World Bank) Poverty gap ratio (incidence * depth of poverty) (World Bank)

2

Target 2:

Halve, between 1990 and 2015, the proportion of people who suffer from hunger. Indicator:

Prevalence of underweight children under five years of age (UNICEF-WHO) Proportion of population below minimum level of dietary energy consumption

Goal 2: Achieve universal primary education Target 3:

Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling.

Indicator:

Net enrollment ratio in primary education (UNICEF-WHO) Proportion of population starting grade 1 who reach grade 5(UNESCO) Literacy rate of 15-24 years old (UNESCO)

Goal 3: Promote gender equality and empower women Target 4:

Eliminate gender disparity in primary and secondary education preferably by 2005, and at all levels by 2015.

Indicator:

Ratio of girls to boys in primary, secondary and tertiary education (UNESCO) Ratio of literate women to men, 15-24 years old (UNESCO)

Goal 4: Reduce Child Mortality Rate Target 5:

Reduce by two thirds, between 1990 and 2015, the Under five mortality rate.

3

Indicator:

Under-five mortality rate (UNICEF-WHO) Infant mortality rate (UNICEF-WHO) Proportion of eye year children immunized against measles.

Goal 5: Improve Maternal Health Target 6:

Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio. Indicator:

Maternal mortality ratio (UNICEF-WHO) Proportion of births attended by skilled health personnel (UNICEF-WHO)

Goal 6: Combat HIV/ AIDS, malaria, and other diseases Target 7:

Have halted by 2015 and begun to reverse the spread of HIV / AIDS. Indicator:

HIV prevalence among pregnant women aged 15-24 years (UNAIDS-WHI-UNICEF) Condom use rate of contraceptive prevalence rate (UN Population Division) Condom use at last high- risk sex (UNICEF –WHO) Percentage of population aged 15-24 years with comprehensive correct knowledge of

HIV / AIDS (UNICEF-WHO) Contraceptive prevalence rate (UN Population Division) Ratio of school attendance of orphans to school attendance of non orphans aged 10-

14 years (UNICEF-UNAIDS-WHO) Target 8:

Have halted by 2015 and began to reverse the incidence of malaria and other major

diseases. Indicator:

4

Prevalence and death rates associated with malaria (WHO) Proportion of population in malaria-risk areas using effective malaria prevention and

treatment measures (UNICEF-WHO) Prevalence and death rate associated with tuberculosis (WHO) Proportion of tuberculosis cases detected and cured under DOTS (internationally

recommended TB control strategy)

Goal 7: Ensure Environmental Sustainability Target 9:

Integrate the principles of sustainable development into country policies and programme; reverse loss of environmental resources

Indicator:

Proportion of land area covered by forest (FAO) Ratio of area protected to maintain biological diversity to surface area (UNEP-

WCMC) Energy use (kg oil equivalent) per $1 GDP (PPP) (IEA, WORLD BANK) Carbon dioxide emission per capita (UNFCCC, UNSD) and consumption of ozone-

depleting CFCs (ODP tons) (UNEP-Ozone secretariat) Proportion of population using solid fuels (WHO)

Target 10:

Halve, by 2015,the proportion of people without sustainable access to safe drinking water and basic sanitation( for more information see the entry on water supply)

Indicator:

Proportion of population with sustainable access to an improved water source, urban and rural (UNICEF-WHO)

Proportion of population with access to improved sanitation, urban and rural

(UNICEF-WHO) Target 11:

By 2020, to have achieved a significance improvement in the lives of at least 100 million slum-dwellers.

Indicator:

5

Proportion of households with access to secure tenure (UN-HABITAT)

Goal 8: Develop a global partnership for development Target 12-18:

Develop further an open, rule –based, predictable, non-discriminatory trading and financial system. Address the Special Needs of the Least Developed Countries (LDC). Address the special needs of landlocked developing countries and Small Island developing States.

Deal comprehensively with the debt problems of developing countries through

national and international measures in order to make debt sustainable in the long term. In co-operation with pharmaceutical companies, provide access to affordable, drugs in developing countries.

In co-operation with the private sector, make available the benefits of new

technologies, especially information and communications. Indicator:

Net ODA as percentage of Development Assistance Committee (DAC) donor’s Gross National Income (GNI)

Unemployment rate of young people aged 15-24 years, each sex and total (ILO) Proportion of population with access to affordable essential drugs on a sustainable

basis (WHO)

6. Objective:

6.1. General Objectives: To analyze the progress towards achieving MDGS in Nepal.

6.2. Specific Objectives: To compare the various indicators such as;

% of population below $1 per day (PPP value) Employment-to-population ratio % of the population below the minimum level of dietary energy consumption % of underweight children under 5

6

Share of women in wage employment in the Non agricultural sector (%) Net enrollment rate in primary education (%) Proportion of pupils starting grade 1 and reaching grade 5 (%) Ratio of women to men at tertiary level Literacy rate of people 15–24 years old (%) Infant mortality rate (per 1,000 live births) Under-5 mortality rate (per 1,000 live births) % of 1 year-old children immunized against measles Maternal mortality ratio (per 100,000 live births) Proportion of births attended by skilled birth attendant Contraceptive prevalence rate (%) HIV prevalence among people 15–49 years old (number of cases per 1000 of the population) Proportion of the population with sustainable access to improved sanitation (%) etc.

7. The MDGs and Nepal

Nepal has set up its long-term development targets in line with the MDGs. The MDG programs are linked with the programs of the ongoing 10th Plan (2002-2007). The achievements attained by the end of the final year of the 12th Plan (2016/17) will be assessed with the achievements of the MDGs (NPC, 2002). If the objectives and targets of the 12th Plan are not fulfilled, the targets of MDGs will also become futile and incomplete. Global Monitoring Report of 2004 lays emphasis on high and broad based economic growth, empowerment and investment increment for the achievement of the MDGs. In order to empower the people, services designed for the targeted people should be rendered timely with quality, quantity and participatory approach. Nepal faces problems pertaining to project design, implementation and attainment of the targeted results. At times, policy ambiguity becomes an acute barrier. Still, the implementing pitfalls and rampant corruption have been primarily responsible for the failure of the projects. This reality calls for an awareness right from the designing phase of the project to the end of implementation.

8. Key Strategies of Nepal

While the Nepal Government is committed to achieving the MDGs by putting the right policies in place, improving efficiency and effectiveness of the interventions that contribute to reaching the goals, and pursuing the required policy and institutional reforms, Poverty Reduction Strategy Paper (PRSP) should serve as a medium-term roadmap to get to the longer-term goals set out by the MDGs, and thus needs to be fully aligned with the MDGs and backed up by resources. All development activities must be strategically geared towards attainment of the Goals, which calls

7

for enhanced coordination and harmonization among development actors. This, in turn, requires a comprehensive development framework which (i) prioritizes MDG based programs, and sufficient resources allocated to such programs and (ii) Addresses the gender, caste, ethnicity, and spatial dimensions of poverty. The next cycle of PRSP/ 11th Plan is the crucial instrument for the operationalization of MDGs through the PRSP process. The followings would be the milestones for the government fully integrate MDGs in the PRSP process:

(i) preparing the national planners to devising approach paper of the Plan towards attaining MDGs,

(ii) revising MDG Needs Assessment (MDG NA) and making it as the entry point for building the PRSP so that each activity in each sector of the PRSP/ 11th Plan is tied up with the goals, targets and indicators of MDGs,

(iii) initiating the consultation process at the central and local level, supporting key Ministries to develop MDG based sectoral business plans and programs in the process of PRSP preparation,

(iv) engaging in dialogue with other stakeholders, and (v) Streamlining all donor programs towards the attainment of MDGs and coordinating

aid programs to focus them towards this direction.

The current MDG NA covers only agriculture, education, gender, health and rural infrastructure sector. In order to achieve all the Goals, the needs assessment needs to incorporate other remaining MDGs related sectors such as energy, forestry, slum and global partnership. Based on the findings of MDG NA and MDG Progress Report 2005 and the review of PRSP, the existing institutional arrangements need to be assessed, and recommendations and findings thereof need to be implemented. Capacity building for achieving MDGs requires covering; (i) Government and local bodies, (ii) Community workers and other volunteers. (iii) Civil Society Organizations (CSOs) including national non-governmental organizations

and CBOs, (iv) private sector, (v) political activists, and (vi) Media. This need to be done by the preparation of CSO strategies, capacity building for utilizing CSO strategies for moving towards MDGs, awareness creation to the private sector, and mobilization of teachers, students, political activists, health workers and social volunteers. The government has introduced MTEF since 2002/03 for linking annual budget with PRSP, prioritizing the programs and projects, ensuring full budget release for the priority one projects even in a situation of resource shortfalls, and linking resource allocation with intended output/ outcome. This is critical step in translating MDG based development strategy into annual budget programs. Internalization of MDGs in the relevant Ministries through the business plan and

8

MTEF requires training to the officials involved in planning and monitoring, MTEF, and MDG operationalization. The existing MTEF Working Committees in all the line ministries have to be involved in the preparation of MDG based annual program/budget, business plan, and monitoring and evaluation of sectoral programs. The committees should include planning and accounting officials in addition to technical staff of the concerned ministries/departments and be trained in MDG based PRSP, business plan and MTEF preparation, poverty monitoring and evaluation, and human development oriented approach to policy formulation and implementation. A Trainers’ Training MDG, PRSP and MTEF preparation should be provided to a wide range of staff of line ministries and their local agencies. Business Plans for major sectors like education, health, drinking water, agriculture and irrigation, and rural infrastructure (road and electricity) have been prepared. Making these business plans MDG based or at least MDG friendly is extremely necessary; as future PRSP and MTEF process will build on these business plans. District Periodic Plans (DPPs) are instrumental in linking MDGs to annual development programs of the districts. Currently, 52 districts have periodic plans prepared under the guideline provided by NPC. These Plans suffer from various shortcomings. First, plans are ambitious and programs are not prioritized. Second, resource estimation is ad hoc and financing of the programs is not sufficient. Third, they are developed with limited participation and focus disproportionately on infrastructure (mostly road), often at the cost of pro-poor social, and MDG related programs. Localizing MDGs would require that DPP are MDG driven and sufficiently backed with resources, which is not the case so far. Now, as midterm review of the DPPs is on unveiled, and as the remaining districts also need to prepare their DPPs if they are to be linked with the national PRSP, support in DPP strengthening and up-scaling exercise is necessary. For localization of MDGs, there is huge area for mobilizing the local bodies including the Village Development Committees and Municipalities. The current MDG Project has started to prepare the District MDG Progress report in some districts. But, given the remaining time for the deadline, this process needs to be substantially expanded to other districts. The importance of this program would be: (i) awareness generation to general public at the district level; (ii) getting commitment and ownership on the MDGs by local government bodies –

particularly from the district level policy makers, planners and bureaucrats, external development partners, non-governmental sectors including the private sectors; and

(iii) Mobilization of all these stakeholders for preparing their MDG based time bound action plan.

The process of devolution should not end at the district level. VDCs and municipalities are to be taken as the next stage of devolution. For MDG based resource allocation, VDCs need a vision and capacity to formulate plans and programs with priority on MDG and pro-poor areas. So far, the resource allocation pattern is ad hoc, based on who can garner pressure on the decision

9

makers, resources are thinly distributed and in the absence of prioritization criterion, judgment of the key officials prevails in programming activities and financing them. For MDG based programming at the village and municipal level, these bodies also need to have their perspective plans, prioritize them in line with the MDGs based PRSP, and sequencing activities as per the priority so that resource could be optimally allocated to prioritized projects. There is a need that NPC, DDCs, and donors pilot VDC plan preparation in selected villages and municipalities in some districts (preferably with the fully devolved districts).

9. Findings

9.1. Progress toward the Millennium Development Goals and Targets Goals and Targets Current Status, against 2015 Target Goal 1: Eradicate Extreme Poverty and Hunger Target 1.A: Halve, between 1990 and 2015, the proportion of people whose income is less than $1 a day. Target 1.B: Achieve full and productive Employment and decent work for all, including women and young people. Target 1.C: Halve, between 1990 and 2015, the proportion of people who suffer from hunger.

Item 1990 Latest 2015 % of population below $1 per day (PPP value)

33.5 24.1 (2005) 17

Poverty gap ratio at $1.25 a day (PPP) (%)

- 6.1 (2008) -

Item 1990 Latest 2015 Employment-to-population ratio - 81.7 (2008) - Proportion of own-account and contributing family workers in total employment

- 81.9 (2010) -

Item 1990 Latest 2015 % of the population below the minimum level of dietary energy consumption

49 22.5 (2006) 25

% of underweight children under 5 57 38.6 (2006) 29

Goal 2: Achieve Universal Primary Education Target 2.A: Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling.

Item 1990 Latest 2015 Net enrollment rate in primary education (%)

64 93.7 (2009) 100

Proportion of pupils starting grade 1 and reaching grade 5 (%)

38 77.9 (2009) 100

Literacy rate of people 15–24 years old (%)

49.6 86.5 (2008) 100

10

Goal 3: Promote Gender Equality and Empower Women Target 3.A: Eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015.

Item 1990 Latest 2015 Ratio of girls to boys at primary level 0.56 1.0 (2009) 1.0 Ratio of girls to boys at secondary level

0.43 0.93 (2009) 1.0

Ratio of women to men at tertiary level

0.32 0.63 (2007) 1.0

Share of women in wage employment in the Non agricultural sector (%)

18.9 19.9 (2009) -

Proportion of seats held by women in Parliament (%)

3.4 32.8 (2010) -

Goal 4: Reduce Child Mortality Target 4.A: Reduce by two thirds, between 1990 and 2015, the under-5 mortality rate.

Item 1990 Latest 2015 Infant mortality rate (per 1,000 live births)

108 41 (2010) 34

Under-5 mortality rate (per 1,000 live births)

162 50 (2010) 54

% of 1 year-old children immunized against measles

42 85.6 (2009) >90

Goal 5: Improve Maternal Health Target 5.A: Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio. Target 5.B: Achieve, 2015, universal access to reproductive health.

Item 1990 Latest 2015 Maternal mortality ratio (per 100,000 live births)

850 229 (2009) 213

Proportion of births attended by skilled birth attendant

7 28.8 (2009) 60

Item 1990 Latest 2015 Contraceptive prevalence rate (%) 24 45 (2010) 67 Unmet need for family planning - 26.3 (2010) - Contraceptive prevalence rate (%) 24 45 (2010) -

Goal 6: Combat HIV/AIDS, Malaria, and Other Diseases Target 6.A: Have halted by 2015, and begun to reverse, the spread of HIV/AIDS. Target 6.C: Have halted by 2015, and begun to reverse, the incidence of malaria and other major diseases.

Item 1990 Latest 2015 HIV prevalence among people 15–49 years old (%)

NA 0.5 (2009) -

Item 1990 Latest 2015 Prevalence rate associated with malaria (number of cases per 1000 of the population)

1.96 0.16 (2009) -

Prevalence associated with tuberculosis 460 280 (2005) -

11

Goal 7: Ensure Environmental Sustainability Target 7.A: Integrate the principles of sustainable development into country policies and programs and reverse the loss of environmental resources. Target 7.B: Reduce biodiversity loss, achieving, by 2010, a significant reduction in the rate of loss. Target 7.C: Halve, by 2015, the proportion of people without sustainable access to safe drinking water.

Item 1990 Latest 2015 CO2 emission (tons per capita) - 0.2 (2005) -

Item 1990 Latest 2015 Proportion of land area covered by forest (%)

37 29 (2009) -

Proportion of terrestrial areas protected (%)

- 19.7 (2009) -

CO2 emissions, total (million tons) - 3 (2004) -

Item 1990 Latest 2015 Proportion of the population with sustainable access to improved water sources (%)

46 80 (2010) 73

Rural 43 78 (2010) 72 Urban 90 94 (2010 95 Proportion of the population with sustainable access to improved sanitation (%)

6 43 (2010) 53

Rural 3 37 (2010) 52 Urban 34 78 (2010) 67

10. Discussion

11. Conclusion

The development area covers all aspects of changes needed to make human life easier. Many international forums tried to bring all human needs & challenges focusing, synchronizing and bringing into a common plate form to resolve. But, there is still feeble consolidation and integration to each other regardless the developed or developing. However, a global concern has been started.

12

12. References

A report on ‘‘Achieving the Health Millennium Development Goals in Asia and the

Pacific Policies and Actions within Health Systems and Beyond’’ by Asia-Pacific MDG Study Series.

A statistical data published by ‘‘The World Bank Group’’ ‘‘Achieving Millennium Development Goals: Challenges For Nepal’’ by Research

Department, International Finance Division, Nepal Rastra Bank http://www.undp.org Nepal MDGs Progress Reports 2010. ‘‘Nepal’s progress towards Millennium Development Goals’’ by Asian Development

Bank.

THANKYOU

www.facebook.com/sagun.paudel

http://www.upload-slides.blogspot.com/

mail4sagun@gmail.com