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Keywords:

  • Nepal;
  • non-governmental organisation;
  • reproductive health;
  • Millennium Development Goals

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Tropical Health and Education Trust: partnerships for global health
  5. Royal College of Obstetricians and Gynaecologists
  6. PHASE Worldwide: practical help achieving self-empowerment
  7. International Nepal Fellowship
  8. Conclusions
  9. Disclosure of interests
  10. Contribution to authorship
  11. Details of ethics approval
  12. Funding
  13. Acknowledgement
  14. References

Please cite this paper as: Nunns D. Working with UK-based non-governmental organisations for better reproductive health in Nepal. BJOG 2011;118 (Suppl. 2):93–95.

Over the years, strong health links have developed between Nepal and the UK with the overall aim of helping to achieve Millennium Development Goals 4 and 5. The nature of such health links is varied and ranges from education and training projects to service work, with a focus on direct medical care. The role of non-governmental organisations (NGOs) in Nepal cannot be underestimated: there are over 5000 NGOs, working in all aspects of Nepali life. Most are not specifically dedicated to maternal, neonatal and reproductive health care, but have developed this area of interest in response to the identified needs in the local communities. The benefits from such health links are immense but, in times of limited funding of projects, it is increasingly important that different agencies work together to maximise the impact of projects.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Tropical Health and Education Trust: partnerships for global health
  5. Royal College of Obstetricians and Gynaecologists
  6. PHASE Worldwide: practical help achieving self-empowerment
  7. International Nepal Fellowship
  8. Conclusions
  9. Disclosure of interests
  10. Contribution to authorship
  11. Details of ethics approval
  12. Funding
  13. Acknowledgement
  14. References

Despite high levels of maternal mortality in Nepal, the situation has improved dramatically over the last 10 years with the current maternal mortality ratio estimated to be 380/100 000 live births.1 There has been considerable investment and effort put into meeting Millennium Development Goal 5 (MDG 5), with a 46% reduction in the number of women dying in or around childbirth.2 Examples of improvements include: access to free health care; an increased number of women giving birth in a government health facility; new birthing centres and emergency obstetric care facilities; nearly 1700 skilled birth attendants trained; and promotional campaigns that have helped raise awareness of reproductive health care.2

The three-delays model (delay in the decision to get help; delay in getting to a healthcare post, usually as a result of transport problems; and delay in getting adequate health care at a health post, usually because of problems with capacity) provides a fitting explanation for maternal mortality levels in a country that is diverse in its geography, status of women, education levels and access to, and availability of, strengthened maternal healthcare systems. Geographical issues are a significant barrier to accessing health care: although the terrain in the south is flat with good transport links, the hilly and mountainous regions have a fragile network of roads, and some very mountainous areas in the north have no transport at all.

Emergency care in pregnancy and childbirth is crucial to save lives. However, the capacity for training healthcare providers and delivery of health care remains a problem in rural areas. A failure to address health systems as a whole, with a tendency to deal with only certain aspects of the overall process (which includes both community and facility factors), has hampered progress towards meeting MDG 5. For example, there has been a push to train skilled birth attendants in the country but access to functional emergency obstetric care services in rural areas remains a problem. The role of non-governmental organisations (NGOs) over the years in addressing poor maternal health has been vitally important to fill essential gaps in care that are not filled by the existing healthcare system. Sadly, many gaps are currently left unfilled and often projects do not address all of the ‘three delays’ of maternal mortality as a package. Some examples of collaborative links between the UK and Nepal are given below.

Tropical Health and Education Trust: partnerships for global health

  1. Top of page
  2. Abstract
  3. Introduction
  4. Tropical Health and Education Trust: partnerships for global health
  5. Royal College of Obstetricians and Gynaecologists
  6. PHASE Worldwide: practical help achieving self-empowerment
  7. International Nepal Fellowship
  8. Conclusions
  9. Disclosure of interests
  10. Contribution to authorship
  11. Details of ethics approval
  12. Funding
  13. Acknowledgement
  14. References

The development of health links between the UK and overseas countries should be encouraged. The ‘health links’ programme run by the Tropical Health and Education Trust (THET)3 provides an example of how such links can be organised. ‘Health links’ are long-term partnerships between UK health institutions and their counterparts in developing countries. The aim of such links is to improve health services in developing countries through the reciprocal exchange of skills, knowledge and experience between partners in the UK and those overseas. Links can operate between a diverse range of formal health institutions (including colleges/universities, teaching hospitals or training centres, hospitals, NHS foundation trusts, NGO-run clinics, not-for-profit health practices and health ministries), and cover numerous disciplines. Such collaboration between countries like Nepal and the UK play a small but important role in helping meet the aims and target date of 2015 specified in MDG 5.

Royal College of Obstetricians and Gynaecologists

  1. Top of page
  2. Abstract
  3. Introduction
  4. Tropical Health and Education Trust: partnerships for global health
  5. Royal College of Obstetricians and Gynaecologists
  6. PHASE Worldwide: practical help achieving self-empowerment
  7. International Nepal Fellowship
  8. Conclusions
  9. Disclosure of interests
  10. Contribution to authorship
  11. Details of ethics approval
  12. Funding
  13. Acknowledgement
  14. References

The Royal College of Obstetricians and Gynaecologists (RCOG)4 strives for excellence in reproductive health care, and plays a leading role in education and the training of obstetricians and gynaecologists worldwide. Nepal has been a former host country for the MRCOG examination, but this was withdrawn when the exam became available in northern India. An international representative committee of the RCOG is based in Nepal, and it focuses on matters relating to training, education, standards and advocacy in academic institutions. In addition, a Nepal liaison group was recently set up and aims to foster links between the two countries. The group currently focuses on postgraduate training, specifically organising courses such as the basic practical surgical skills course. The international membership of the RCOG, its track record of working globally through such liaison groups and the international office of the RCOG provide considerable scope for future collaboration in Nepal. Areas that could be explored include structured training of junior medical staff, subspecialisation, and exchange visits between Nepal and the UK. For the RCOG liaison groups the health needs assessment is decided by the host country. In some instances, this health need may focus on subspecialist reproductive health separately from tackling maternal mortality: for example urogynaecology.

PHASE Worldwide: practical help achieving self-empowerment

  1. Top of page
  2. Abstract
  3. Introduction
  4. Tropical Health and Education Trust: partnerships for global health
  5. Royal College of Obstetricians and Gynaecologists
  6. PHASE Worldwide: practical help achieving self-empowerment
  7. International Nepal Fellowship
  8. Conclusions
  9. Disclosure of interests
  10. Contribution to authorship
  11. Details of ethics approval
  12. Funding
  13. Acknowledgement
  14. References

PHASE Worldwide is a UK-based charity that supports qualified Nepalese professionals to deliver integrated community development programmes addressing the interlinked sectors of health, education and poverty reduction.5 PHASE choose the target communities on the basis of need and feasibility of the programme of work, and work in close cooperation with the communities, thereby increasing local capacity. PHASE particularly specialises in delivering high-quality primary health care in very hard to reach communities, where government service provision is non-existent, and where there are very few other NGO projects. In reproductive health care the focus is on the provision of family planning and training of skilled birth attendants in primary healthcare settings. The strengths of the programme include high staff retention, mentoring, training and the support of rural workers.

International Nepal Fellowship

  1. Top of page
  2. Abstract
  3. Introduction
  4. Tropical Health and Education Trust: partnerships for global health
  5. Royal College of Obstetricians and Gynaecologists
  6. PHASE Worldwide: practical help achieving self-empowerment
  7. International Nepal Fellowship
  8. Conclusions
  9. Disclosure of interests
  10. Contribution to authorship
  11. Details of ethics approval
  12. Funding
  13. Acknowledgement
  14. References

The International Nepal Fellowship (INF)6 is a faith-based organisation that has been based in Nepal for over 50 years. This NGO runs six programmes largely based in the west of the country (Banke, Dang, Jumia, Kaski and Surkhey districts), where there is considerable poverty and communities are poorly served by health care. Much of the INF’s work has involved the treatment and rehabilitation of patients with long-term disabilities resulting from leprosy, strokes and injury. The INF employs one obstetrician/gynaecologist who provides an emergency obstetric service (EOS) to the far-western region of the country. She also mentors trainee obstetricians and gynaecologists in rural areas with the aim of providing high-quality EOS. The rural health posts she works in provide obstetric care to a community of up to 50 000 people. Junior obstetricians as a part of postgraduate training are posted to rural health posts to provide an obstetrics service to local communities, but are frequently too junior and inexperienced to deal with obstetric complications. One of the strengths of this work is that it provides a sustainable solution by the one-to-one, hands-on training of junior obstetricians posted to this region. In the absence of such mentoring, it is not uncommon for patients to have to travel to larger cities for care, if they can afford to do so.

In addition, INF carries out a medical camps programme that includes training in gynaecological surgery, thereby addressing reproductive health care capacity. The camps are effective at tackling the endemic problem of uterovaginal prolapses, which are considered to be a consequence of high parity and a lifetime of carrying heavy loads. The individual benefits are considerable: the women who undergo surgery (usually performed by UK/Australian volunteer gynaecologists) receive high-quality care without the need to travel to large cities/towns. Many of the rural poor are not able to travel for such health care because of a lack of money. The INF also provides a fistula repair camp twice a year to women in the rural west of the country. One criticism of the project is its lack of sustainability, as it does not provide training for local doctors.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Tropical Health and Education Trust: partnerships for global health
  5. Royal College of Obstetricians and Gynaecologists
  6. PHASE Worldwide: practical help achieving self-empowerment
  7. International Nepal Fellowship
  8. Conclusions
  9. Disclosure of interests
  10. Contribution to authorship
  11. Details of ethics approval
  12. Funding
  13. Acknowledgement
  14. References

Maternal health in Nepal is improving, but there is much to do. UK NGOs and donors have played a crucial role in reproductive health care in Nepal over many decades, and continue to offer high-quality care in the rural poor regions. However, there is a need to ensure better coordination between both NGOs and governmental organisations to focus on strengthening the existing healthcare systems, which are still weak.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Tropical Health and Education Trust: partnerships for global health
  5. Royal College of Obstetricians and Gynaecologists
  6. PHASE Worldwide: practical help achieving self-empowerment
  7. International Nepal Fellowship
  8. Conclusions
  9. Disclosure of interests
  10. Contribution to authorship
  11. Details of ethics approval
  12. Funding
  13. Acknowledgement
  14. References