In 2010, the World Bank’s Gender and Development group stated, “Investing in women and girls is the right thing to do; it is not only fair for gender equality but it is smart economics.” On the contrary, in Nepal, despite huge funding for healthcare, particularly in maternal and child health by the government and external development partners, the current maternal mortality ratio published in the 2014 Population Monograph by the Central Bureau of Statistics (CBS) indicates that there has been a shockingly poor return on investment.

The appalling disparities in maternal mortality between mountainous regions and other areas indicate the failure to ensure equitable access to quality healthcare services. Given that the majority of maternal deaths are preventable, this state is a reflection not only of the failure of our health system but also of implementing the Universal Declaration of Human Rights in providing basic essential medical services. Therefore, the current adjusted Maternal Mortality Rate (MMR) in the Far-Western mountains (1,005) and Mid-Western mountains (1,288), which is three times higher than the national average (663), should be the final eye opener for development partners and the government since the situation has remained stagnant for over a decade now.

The 2014 Population Monograph shows that the average MMR for the whole country overshadows extreme inequalities by regions and how such information can be misleading, since the population who are at greatest risk are hidden in the statistics. The Further Analysis of NDHS data published its report in 2013, but by grouping indigenous groups under one category, confounding factors relevant to certain ethnic groups have been overshadowed. Hence, debates over the quality of maternal care should not ignore these subtle but very important differences.

Barriers and problems

Most maternal deaths occur due to untimely identification of risk and untimely referrals. So birthing centres were established to change this situation. Unfortunately, existing centres are not well-resourced and equipped. According to the government’s policy, all 240 electoral constituencies in Nepal should have at least one well-functioning primary healthcare centre (PHC) with quality equipment, essential medicines, and health workers, including a doctor. However, most PHCs at the constituency level and also health/sub-health posts at the VDC level either lack supplies, the health workers assigned are absent, or both. The Comprehensive Emergency Obstetric Care centres for back up services in most districts are also non-functional.

In order to improve safe delivery practices, the government took various initiatives, like the promotion of Maternal and Child Health Workers to Auxiliary Nurse Midwives, Skilled Birth Attendant trainings, and the introduction of midwifery education. However, in spite of all these efforts and funding, the basic health needs of many in remote areas are still not being met.

Furthermore, the Public Service Commission (PSC) examination in Nepal is conducted only in the hills and plains areas. Anecdotal evidence shows that residents of the district where the PSC examinations are held are more likely to pass than those coming from other districts. This again provides less opportunity for service providers from mountain regions who are determined to serve in their respective districts. In the wake of the high-profile leaking of MBBS examination questions, strict measures should be taken to oversee any irregularities in the PSC examination. As one of the major barriers to strengthening the health system is the retention of qualified health workers, additional points could be given to local health workers from remote mountain districts determined to serve in their own areas.

Failed initiatives

Health workers also face problems as the Health Management Information System form developed to monitor progress are not available in many VDCs. In case they are available, in many instances, they are not filled in accurately, which could act as a barrier to providing useful information.

Most Health Facility Operation Management Committees (HFoMC) have been seriously influenced by conflicts of interest, affecting their performance. In the current structure, there is a provision for the health in-charges to be member secretaries of HFoMC and VDC secretaries as Chairpersons. Both are already overburdened with the responsibility of overseeing various issues of several other VDCs, making the HFoMC non-functional. Only the health in-charges in the VDCs are responsible for maintaining both accountability and health performance, which is a paradox in the current health system structure.

Resource allocation to districts for their development is often based on political affiliation of the receiving group. Politicians spend more in areas where swing voters are likely to switch votes to their benefit or where their support is concentrated in order to have an assured return. Such criteria for resource allocation do not justify equity considerations. These are examples of only some issues easily identifiable and verifiable at the local level. However, there are many other serious issues at the district, regional, and central level.

Unacceptable statistics

The ‘one-size-fits-all’ approach of the state does not take into account specific geographical, social, economic, and cultural contexts that differentiate the many rural mountain and other communities scattered across large areas. In most districts, the proportion of marginalised people increases with increasing remoteness. Therefore, until this issue becomes ubiquitous in national dialogue and until the gravity of these unacceptable statistics becomes a household conversation, the misconception of Nepal’s ‘superior’ maternity care system will prevail.

The gap in maternal mortality, as seen in the CBS data, is not just an isolated medical event; it has many inter-related factors that cannot be solved in the way the current societal and healthcare systems are structured. Exclusionist policies still exist, which results in unobserved consequences that are difficult to measure and one that permanently affects an ever-enlarging circle of the society. Therefore, it would be unwise to keep pouring resources into the same unyielding structures. As the country is moving towards a federal system, productive discussion to restructure the health system would be the best way forward.

Yangchen Sherpa is a researcher at the University of Oslo, Norway