6. DISABILITY, BASIC HEALTH AND WELFARE (ARTICLES. 6, 18 (PARA. 3), 23, 24, 26, 27 (PARAS. 1-3) AND 33)
(A) Children with disabilities (article 23)
Legislative provisions with regard to children with disabilities are described in paragraph 230 of the initial report and paragraph 187 of the second periodic report.
The Constitution under Article 22 clause (4) provides special facilities to helpless, orphan, mentally retarded, conflict victim, displaced, vulnerable and street children for their well-ascertained future.
Nepal is a party to the Convention on the Rights of Persons with Disabilities and its Optional Protocol.
The percentage of people in the total population, with diverse categories of disabilities is estimated to be 1 to 8 (TYIP). Disability Service National Coordination Committee has been formed with the adoption of the National Policy and Action Plan 2006. The GoN is implementing programs like special education classes and disabled rehabilitation skills orientation, targeting children and adults with disabilities. Monthly social security allowance provided during TYIP is continued under the TYP as well. Scholarship quota for students with disabilities is being provided. The GoN has also framed building codes requiring public buildings to be persons with disabilities friendly.
The GoN formulated a National Policy and Work Plan, 2006 in consultation with development partners, organizations of persons with disabilities, NGOs and institutions working on disability in the country. The rights concept and international standards guide the definitions and classification of persons with disabilities contained in this policy and plan. This plan is being implemented by the GoN in cooperation with development partners, NGOs and organizations of persons with disabilities under the TYP. In addition, the GoN has adopted an inclusive approach as a guiding principle in formulating policies, programs and institutions on disability. Accordingly, inclusion of children with disabilities is being made in education, health, social protection and society in general. The Eradication and Prevention of Disabilities Program is being implemented from 2007 by the MoHP. This program addresses the issues of prevention, early detection, interventions and referral of cases at local level.
With the adoption of an inclusive approach, the overall enrolment of students with disabilities at primary, lower secondary and basic levels have increased significantly. Out of the total enrolment at primary, lower secondary and basic levels, the per cent share of students with disabilities are 1.1 per cent, 0.9 per cent and 1.1 per cent respectively24, which is very low in terms of coverage. Hence, the GoN is in the process of bringing remaining children with disabilities in school and mainstreaming them to respective levels under the SSRP.
Under the TYIP, the GoN had allocated NRs. 500 million for the programs related to the empowerment, livelihood income, enhancement of accessibility, and physical aids for the persons with disabilities. Out of which about 55 per cent was allocated under the MoWCSW and the rest of the allocations were made to the sectoral ministries.
The GoN has classified disabilities into eight main categories and has distributed identity cards to the persons with disabilities, which allow concessions in services. Disability rehabilitation has been included in the essential health services too.
The TYIP sets an objective to create persons with disabilities friendly environment, free of obstacles, and enabling them to access to all possible facilities for a just, dignified and independent livelihood. Accordingly, the GoN has adopted strategies such as building legal, institutional, physical and economic infrastructure; empowering persons with disabilities; promoting coordination and collaboration among government, non-government and development partners; and implementing programs focused to the rights and needs of persons with disabilities.
The GoN in coordination and collaboration with National Federation of Disabled Nepal (NFDN) and other civil society organizations is providing services to persons with disabilities.
The GoN has expanded Community Based Rehabilitation (CBR) to 65 districts in cooperation with development partners and NGOs and significantly increased budget allocation in recent years. The MoWCSW, in cooperation with development partners, has developed software on situation of children with disabilities that would provide data on situation of children with disabilities in coming years.
(B) Health and health services, in particular primary health care (article 24)
The Constitution in Article 16 (2), under the Rights regarding Environment and Health, provides that every citizen shall have the right to basic health services free of cost from the State as provided for in the law.
The GoN has increased funding for the health sector over the last couple of years. Funding for nutrition has increased up to 2 per cent of the national health sector budget25.
The TYIP targeted to extend the CB-IMCI program to all the 75 districts within three years. The CB-NCP has been implemented from 2009 in different phases. National Infant and Young Child Feeding and Care Strategy have been formulated, and in consultation with the development partners, national nutrition priorities for 2008-2011 have been developed. National nutrition policy and strategy was formulated in 2006.
In accordance with the policy of decentralization and devolution, management of a total of 1433 health institutions (sub-health posts, health posts and primary health care centres) of 28 districts have been handed over to local bodies. Decentralized allocation of resources has also been followed with the Ministry of Finance disbursing resources directly to the district line agencies for the implementation of the concerned programs associated with child health. More than three-quarters of the population (78 per cent) now has access to a health facility within half an hour of travel time. The network of institutions involved in the delivery of basic health services include 93 government, non-government and private teaching Hospitals; 210 Primary Health Care Centres (PHCCs); 676 Health Posts (HPs); 3,134 Sub Health Posts (SHPs); and 14,292 Primary Health Care Outreach Clinics (PHCORCs)- supported by 48,514 FCHVs26.
The immunization services have been provided mainly through government facilities. The private sectors and NGOs clinics are also providing the services. Private sector has also provided immunization services mainly in urban areas through hospitals, nursing homes and NGOs.
The GoN has the aim to make 1,000 adolescent friendly health facilities by 2015. The GoN has felt a need for a comprehensive adolescent policy to guide service provisions for adolescents specifically for Sexual Reproductive Health (SRH), ANC and Prevention from Mother-to-Child Transmission (PMTCT) services.
The investment of the GoN in water supply and sanitation is primarily guided by the Twenty Year Vision (1997-2017), which seeks universal coverage by 2017.
The National Policy on Rural Drinking Water Supply and Sanitation, 2004 provides guidance on water and sanitation service provision in rural areas using community led participatory approaches. The National Drinking Water Quality Standards, 2006 provides details of water quality standard to be applied for all water resources; and this complements the Environment Protection Act, 1997. The GoN adopted National Drinking Water Standards in 2006 and has plan to roll them out in a phased manner, starting with projects in urban areas, and proceeding to district headquarters and then water supply schemes at the VDC level. A Sanitation Master Plan was recently developed to guide institutional and financial systems in the sanitation sub-sector.
The National Urban Policy, 2007 provides that the urban poor requires urgent attention through improvements in poor sanitation, environmental degradation and lack of services, and emphasizes building the capacity of municipalities to plan and manage integrated local development activities. The Nepal Water Supply Corporation Act 2nd Amendment, 2007; Water Supply Management Board Act, 2006; and Water Supply Tariff Fixation Commission Act, 2006 establish the legal basis for private sector management of schemes and independent fee setting and regulation to facilitate the improved management of water and sanitation services.
The GoN has also introduced School Led Total Sanitation (SLTS) and Community Led Total Sanitation (CLTS) programs across the country. These programs seek to spread awareness of hygienic practices through communities and schoolchildren in particular. The Open Defecation Free (ODF) campaign has been initiated by local bodies in collaboration with UNICEF. So far, 185 VDCs of 32 districts have been declared as ODF areas. The GoN has been providing subsidies of up to Rs. 2,000 per household to build toilets. The SLTS and CLTS programs seek to spread awareness through communities and schoolchildren in particular, and across the country to change behaviour on health and hygiene.
It is estimated that only 26 per cent of mothers of children aged less than five years dispose of their youngest child’s stools safely. The practice of safely disposing of children’s stools increased from 18 per cent of mothers in 2001 to 26 per cent in 200627.
Awareness on hand-washing practices is increasing in Nepal. About 64 per cent of females between the ages of 15 and 49 years had washed their hands with soap at least once during the previous day28.
Several recent budgetary decisions reflect the GoN’s increasing commitment to improving access to safe water and sanitation. The MoFALD has committed 20 per cent of its total budget for rural water supply and sanitation. The GoN has also authorized VDCs to allocate up to 15 per cent of their capital grants for programs that directly support and empower children, women, and socially excluded groups when they are working toward ODF status and other criteria of CFLG. It is estimated that on an average, 58 municipalities in the country are spending 13 per cent of their total budget on waste management related activities29.
Large cities, in particular Kathmandu, as well as other metropolitan cities, are growing fast due to influx of population mainly in search of better opportunities. The high rate of continuing migration from the rural areas to the urban areas has been putting enormous pressure on the urban infrastructure. Since, urban water demand is increasing rapidly between 6 per cent and 9 per cent per annum; this has placed a challenge on existing urban water supply as well as sanitation services30. This has been causing serious problems in urban planning, management, and governance. An adverse impact in safe drinking water supply, hygienic sanitation, drainage facilities, solid waste management, and river pollution has been observed.
The National Water Plan (NWP) has been prepared to operationalize the Water Sector Strategy (WSS) for maximizing the sustainable benefits of water use in Nepal. An Integrated Water Resources Management (IWRM) has been adopted as one of the principal themes of the NWP.
There is disparity in toilet facilities between rural and urban areas. The distribution of toilet in rural areas was 41.8 per cent compared to 85.4 per cent in urban areas in 2008. Similarly, a comparatively large proportion of households in Tarai region (61.4%) do not have toilet compared to mountains (51.7%) and hills (39.3%)31.
As per the Rural Water Supply and Sanitation National Policy, Strategies and Strategic Action Plan, Nepal has set the national goal to achieve universal toilet coverage by 2017. To achieve this goal, the GoN has been implementing various focused programs like ‘School Sanitation and Hygiene Education Program, SLTS program, National Sanitation Actions Weeks, CLTS, Hand Washing with soap campaigns, among others. As a result, more than 92 VDCs with more than 550 school catchment areas are declared ODF and significant level of public awareness has been increased on the necessity to build toilets. In addition, formation of health institutions management committees and training for their members has contributed to supply of drinking water and toilet constructions in rural and urban areas.
HIV and AIDS
The MoHP adopted the five-year National HIV/AIDS Strategic Plan in 2006, designed in line with Universal Access target of 80 per cent coverage with prevention, treatment, care and support services to most-at-risk population and people living with HIV and AIDS. This Strategic Plan has adopted prevention and treatment; and care and support as the two main programmatic components. In addition, advocacy, policy and legal reform; leadership and management; strategic information and finance and resource mobilization have been identified as the four major cross cutting components. It has also defined basic service packages and specialised service packages for various population groups keeping in view their vulnerability and needs.
The five-year National HIV and AIDS Strategic Plan, aims at making the Basic Minimum Package available to all vulnerable groups. The Basic Minimum Package includes Behaviour Change Communication (BCC), interventions (life skills, peer-education, health promotion, and creation of mass awareness), distribution of condoms, Voluntary Counselling and Testing (VCT), Sexually Transmitted Infection (STI) referral, Post Exposure Prophylaxis (PEP) and blood safety.
The MoHP and MoWCSW established a task force on Children Affected by HIV and AIDS (CABA) in 2007 in order to ensure the prioritization of the issues of children affected by HIV and AIDS in the national agenda. The national strategy, guidelines and basic minimum package for CABA was adopted in 2009. The National Plan of Action on HIV and AIDS 2008-11 has prioritized CABA. The GoN has also included HIV and AIDS, and other adolescent health content in the curriculum of educational institutes.
The GoN has allocated resources for CABA program including cash transfer for next 2 year, under Global Fund round 10 in 2010. HIV and AIDS policy has been formulated to address care, support and protection of CABA.
Other services for people affected by AIDS include (a) ART services available in 39 places; (b) VCT services available in 158 centres; and (c) the program for the PMTCT services available in 21 places (22 hospital based sites and 27 CB PMTCT sites), out of which 20 sites offer Paediatric services, and (d) A Universal Access for Children Affected by AIDS in Nepal (UCAAN) partnership has also been developed with membership of 34 development partners. The National AIDS Coordination Committee (NACC) and District AIDS Coordination Committees (DACC) have been formed32.
Adolescent reproductive health program and adolescent girls’ empowerment program have been implemented under the Department of Women and Children (DWC) to raise awareness among targeted groups on HIV and AIDS.
The HIV prevalence in Nepal in 2009 among adults and children was estimated at 63,528. Prevalence among people aged 15-49 years (an MDG indicator) was 52,504. About three males were infected for every female in this age range. The estimated number of AIDS-related deaths in 2009 was 4,701. Among children aged 0-14 years, an estimated 3,544 were infected with HIV in 2009. Average number of new infections amongst children (0-14) per year was 468. Average number of AIDS deaths among children (0-4) per year was 106 and total number of AIDS orphans until 2009 was 21,947. Average number of AIDS orphans per year is 455. Sharing of needles and sexual transmission are the most common modes of transmission33.
Some reports and field visits indicate that the number of child-headed households where both parents have died and the eldest child has become the head of the household is increasing. The GoN is in the process of collecting data on CABA along with other information pertaining to children through CROs.
The NDHS 2006 has examined knowledge, attitudes, and practices regarding HIV and AIDS among females and males aged 15-49 years. The survey found that 73 per cent of females and 92 per cent of males had heard of AIDS. Knowledge of AIDS among ever-married people in the reproductive age groups (women aged 15-49 years and men aged 15-59 years) has increased over time; for example, the NDHS 1996 and 2006 show an increase from 27 per cent to 69 per cent in the proportion of ever-married females with this knowledge.
During the reporting period, the cumulative HIV infection by age group and sex is projected as - for age group (0 – 4 years) - 253 males and 152 females; for age group (5 - 9 years) - 279 males and 198 females; for age group (10 - 14 years) - 103 males and 67 females; and for age group (15 – 19 years) - 263 males, 274 females. 34
So far, 21 sites have been made available to provide services for PMTCT, of which 20 sites offer paediatric ART. About 798,174 women get pregnant every year in Nepal, and about half of them have access to antenatal care services. Total number of pregnant women tested for HIV (2006 - 2010) is 190,874. Total number of new HIV positive women delivered (2006 - 2010) is 432. Only an estimated 6 per cent of the HIV-positive children in Nepal are receiving antiretroviral treatment.
The National Council for AIDS and STD Control (NCASC) under the MoHP has been managing the country’s HIV and AIDS response since 1988. In 2007, the GoN constituted the HIV and STD Control Board with the mandate of overall, multi-sectoral coordination of the response.
(C) Social security and childcare services and facilities (articles 26 and 18)
The GoN has continued the social security allowances for the benefit and welfare of children, the aged and persons with disabilities. A sum of NRs. 8.95 billion had been allocated to give continuity to the social security allowances in the budget of fiscal year 2010-11. In the past, the distribution of social security allowance was made through the VDCs and Municipalities. However, the GoN has now initiated distributing social security allowances through the banking system.
The GoN has made special provision of scholarships to the students of public schools in Karnali Zone. The students from the Dalit communities, students with disabilities and girl students across the country represent the other categories receiving scholarship. Under the program, a scholarship ranging from NRs 350 to 1,000 per student per year has been provisioned.
In recent years, the GoN has given more attention to the necessity for a comprehensive social protection scheme. The GoN is collecting contribution of 01 per cent of the salary for social security and is preparing to expand social security schemes gradually for formal and informal sector employees as well.
The concerns expressed by the Committee on the Rights of the Child, in particular, about the high level of prevailing poverty in the country and its direct impacts on those living in rural areas, among the Dalit and ethnic minorities have been addressed through social protection scheme such as “Child Protection Grant”. In addition, the GoN has facilitated in increasing access to basic services, in particular, education, health, water and sanitation, and poverty alleviation programs for families having children. The GoN expenditures on social services have increased from 4.3 per cent in 2001/02 to 22.9 per cent in 2007/08, after the signing of the CPA and promulgation of the Interim Constitution in 2007.
With the ratification of ILO Convention No. 169, awareness level of indigenous nationalities, ethnic minorities and marginalized groups have increased significantly and their identity, protection of culture, access to basic services and participation in civil service including parliament have been strengthened.
A sum of Rs. 200 million has been allocated under the fiscal year 2010/11 budget, for the human development, and for the protection of culture and heritage of indigenous nationalities, ethnic groups, Dalit, Madhesi, Muslim, people in remote areas and marginalized groups. With the allocation of this resource, the GoN has initiated social protection of indigenous nationalities and ethnic minorities including communities living in remote rural areas.
(D) Standard of living (article 27, paras. 1-3)
The GoN is making progress in reducing overall poverty rate in recent years and is likely to achieve some of the MDGs, in particular, MDGs 2, 4 and 5 by 2015. The poverty level in the country was 31.4 per cent in 2005 that has decreased to 25.4 per cent in 2009.
The GoN has taken a lead in a global study on child poverty and disparities in collaboration with UNICEF. The commitment to the study was translated through an inter-ministerial committee that oversaw the study. The study was conducted with seven deprivation indicators that were identified as necessities. These indicators were related with sanitation, information, shelter, water, malnutrition/food, education and health/immunization. The finding of the study was shared in 2010. The study has highlighted that malnutrition and lack of sanitation are serious obstacles to the survival growth and development of children. Every second child under five in the country is stunted or has a low height for age; and over half of country’s children between the ages 0-17 years have no access to a toilet of any kind35.
Poverty alleviation has been a major priority of successive governments. The GoN has established the PAF36 as an independent institution to implement poverty reduction programs in 2004-05. The implementing agencies of PAF are NGOs and community based organizations. The PAF has continuously strived in reaching out the unreached. The PAF has spent a total of Rs. 7,960 million from its establishment to 2009/10. Out of which, 96.52 per cent is from the International Development Association grant, 2.80 per cent, from the International Fund for Agriculture Development grant, and the rest 0.69 per cent, from the GoN source. PAF has been able to mobilize 14,827 community-based organizations throughout the country targeting poorest of the poor households and organizing 543,263 poor so far. These organizations have implemented 13,810 income generating and 2,740 community infrastructure projects37.
As reported in the second periodic report, micro-credit schemes are extended in rural areas in enhancing credit facilities to the poorest of the poor. Many Micro Finance Institutes (MFIs) are operating in the country through the support of Rural Micro-Finance Development Corporation (RMDC).
The growth of cooperatives in rural as well as in urban areas is significant in recent years. About 10,000 cooperatives are functioning throughout the country, extending credit services to small entrepreneurs and poor households. These cooperatives have also played an important role in reducing poverty, and thereby contributing in improving standard of living of poor households.
The GoN effort in alleviating poverty through establishment of PAF and supporting micro-finance institutions are heading towards strengthening strategies to combat poverty. In addition, establishment of child poverty indicators in collaboration with UNICEF is a step forward in monitoring the impact on the rights of children.