Overview
The Second Health, Nutrition and Population (HNP) and HIV/AIDS Project builds upon the success of the first HNP and HIV/AIDS Project (2004-2010) to enable the Government of Nepal to increase access to essential health care services and their utilization by the underserved and the poor. Nepal is globally recognized for its achievement in reducing maternal mortality from 530 per 100,000 live births in 1996 to 281 in 2006 and a decline in under-five mortality by 48 percent from 118 to 61 deaths per 1,000 live births during 2001-2005.
Challenge
Even though the country has made significant progress in the health sector, not all segments of the society equally benefit from the progress. Inequality in health outcomes, access and service utilization remains high. The poor have the largest unmet demand for family planning, make the lowest use of maternal care, have the lowest vaccination coverage, and are least likely to seek care when ill. The poor also have the lowest physical access to health care. In geographical terms, the mid and far west regions have the worst access to health services. Earlier surveys have shown that Dalits and ethnic and religious minorities have lower utilization of health services.
Furthermore, the Millennium Development Goal (MDG) targets for nutrition and HIV/AIDS are not on track. Working multi-sectorally across ministries also poses significant coordination challenges: the most significant gains in health status are likely to be dependent on more complex multi-sectoral activities and community participation, particularly in the areas of water, sanitation and hygiene, nutrition, and road safety.
Approach
The Second HNP and HIV/AIDS Project is supporting the Nepal Health Sector Program II, the government’s five-year program (2010-2015) and is building upon IDA’s on-going support to Nepal’s health sector since 1994. The Sector-Wide Approach (SWAp) modality of the project helps the government coordinate development assistance to the health sector. The Bank’s financial inputs will supplement those from government and other partners, while its technical expertise in nutrition, health care financing, governance, pro-poor health strategies, multi-sectoral action for AIDS, and monitoring and evaluation will complement that of other partners.
The project supports the government’s sector program under two broad components: (i) Health Service Delivery and (ii) Health Systems Strengthening.
(i) Health Service Delivery to increase access to and utilization of an affordable package of health services by the underserved and poor and
(ii) Health Systems Strengthening to improve governance and accountability in the health sector.
Results
Since 1994, IDA has been helping Nepal meet its fundamental health needs, with special attention to the poor and more disadvantaged populations. Nepal’s health sector has seen impressive progress in the past few years and is expected to improve in the future. Nepal is globally recognized for its achievement in reducing maternal mortality and under-five mortality.
• Infant mortality declined by 39 percent over the last fifteen years from 79 deaths per 1,000 live births in 1991-94 to 48 deaths in 2001-2005.
• Under-five mortality, declined by 48 percent from 118 to 61 deaths per 1,000 live births over the same period.
• Neonatal and postnatal mortality also decreased by 34 percent and 48 percent, respectively.
• Both infant and under-five mortality have further declined to 41 and 50 per 1000 live births respectively between 2004 and 2008.
• Maternal mortality declined significantly from 530 per 100,000 live births in 1996 to 281 in 2006.
• At the service delivery level: skilled antenatal care has increased from 34.1 percent in 2001 to 43.7 percent in 2006. During the same period, skilled birth attendance has increased from 10.9 percent to 18.7 percent; immunization from 72 percent to 89 percent; and Vitamin A supplementation stands at 90 percent.
Bank Contribution
The IDA financed Second Health, Nutrition and Population (HNP) and HIV/AIDS Project (US$129.2 million), approved on April 20, 2010, is supporting the expansion and strengthening of these services with a focus on reaching the poor and excluded segments of the society more effectively. This project builds upon the success of the first HNP and HIV/AIDS Project, which was effect during 2004-2010, and is in the context of a total program cost of US$1.527 billion.
Partners
Partnerships have been crucial in the successful implementation of the project. With the large number of donors active in Nepal, program coordination is important. Since 2004, the UK Department for International Development (DFID), the Australian Government’s overseas aid program (AusAID), and the World Bank have pooled finances to meet a slice of Nepal’s health sector expenditures and other partners have expressed interest in joining this mechanism in the near future. This coordination has helped harmonization among the development partners in the health sector and has reduced transaction costs for the government.
Toward the Future
The government’s program for the Health Sector 2011-2015 has broad and sustained support from all major stakeholders. Stakeholder consultations have been extensive and will be an ongoing process during implementation to sustain the support from government entities, external development partners and non-state actors. The community scorecard generation process (residents giving their feedback) will ensure regular participation of communities.
The Bank seeks to strengthen government structures at all levels by using the existing institutional structure and providing technical assistance. The project will further strengthen the inter-sectoral collaboration to address nutritional problems and provide technical assistance for the strategic planning and monitoring of nutrition interventions across the wide variety of stakeholders and actors. The project will provide support to the MOHP in the planning of a transition to a federal structure of government.