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A decade of qualitative research informs equity and access programming for safer motherhood in Nepal PowerPoint PPT Presentation


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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.

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A decade of qualitative research informs equity and access programming for safer motherhood in Nepal

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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


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“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


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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


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Safer motherhood programming in Nepal

Between 1996 and 2006, Nepal halved its MMR to 281

Nepal Safe Motherhood Project (NSMP) 1996–2004

Support 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


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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


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Contextual barriers

  • 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

“every kind of wind,

every kind of ghost”


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Contextual barriers

  • Women exist in a complex web

    of relationships

  • 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


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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


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Ethnic / caste inequities in access to health care

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


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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


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Contested debate and novel solutions

  • 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


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Bringing transformative change to scale

EAP’s Key Informant Monitoring (KIM)

Advocacy: local and national

Accountability: local, district, regional, national

Monitoring ethnicity in routine data collection

Community mobilisation approaches

Participatory Video


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Challenges and opportunities

  • 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


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Influencing at national level

  • 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


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