Halfway up the highway : Can Nepal meet its Health Millennium Development Goals ?

The Millennium Development Goals (MDGs) are international objectives on poverty reduction adopted by the world community and provide the broad context for this revolution in thinking and practice. The MDGs place a central focus on public health, in recognition of the fact that improvements in public health are vital not only in their own right but also to break the poverty trap of the world’s poorest economies. Nepal has been committed to achieving the MDGs since it endorsed the Millennium Declaration. As we have at present just passed the midway through the 15 years to MDGs deadline of 2015, this article reviews the status of Nepal in achieving the MDGs, the challenges it faces and whether it can achieve the MDGs by 2015.


IntRODUctIOn
Health for All by the year 2000 has been in existence for more than 25 years since the Alma Ata declaration when it was stated that 'inequality in the health status of people, particularly between developed and developing countries as well as within countries, is politically, socially and economically unacceptable'. 1 Yet, Health for All remains an elusive goal and large and growing disparities in health persist both within and between the countries. 2With the failing Health for All by 2000, the stakeholders around the globe realized the need to readdress the problems of health, poverty and overall human development in a more holistic manner.Many targets were set and compiled in the 1990s in to what was known as the International development Goals.But it was only at the turn of the millennium that the Member States of the United Nations adopted the Millennium Declaration from which the Millennium Development Goals (MDGs) were drawn. 3The MDGs are a groundbreaking international development agenda for the 21 st century and outline the major developmental activities and priorities to be achieved by the year 2015. 4e MDGs place a central focus on public health, in recognition of the fact that improvements in public health are vital not only in their own right but also to break the poverty trap of the world's poorest economies.Three out of the total 8 goals, eight out of the total 18 targets and 18 out of the 48 indicators are explicitly about health. 5Other goals are also indirectly but intimately associated with health.The overall MDGs, with emphasis on health-related goals with their targets and indicators, are given in the table 1. Goals 4-6 are directly related to health.Other goals involve the other vital aspects of human development such as poverty reduction, education, environment sustainability, women empowerment and gender equality.Goal 8 identifies actions that donor countries must take to support developing countries to achieve the first seven goals.

MDGs AnD nePAL
Nepal has been committed to achieving the MDGs since it endorsed the Millennium Declaration.A number of steps have been taken since then to align the MDGs with the national planning process.

challenges for nepal in achieving the MDGs
The major challenges that lie ahead for achieving the MDGs in Nepal are briefly outlined (Table 2).The foremost challenges in health include the strengthening of the health systems, prioritization of health within overall development and economic policies, mobilization of more resources for health in remote areas, improvement of the quality of health data and development of health strategies that respond to the diverse and evolving needs of the country. 13,14In the overall development, the crucial obstacle to overcome would be the ongoing insurgency and conflict in the country because they will have their ill-effect on all developmental activities.
The financial crunch to achieve the goals including the health goals shall be another major uphill task for Nepal.In Nepal's health sector, seventy percent of the total health expenditures come from private out-of-pocket contributions whereas the shares of the government, external development partners and other public sector are 14%, 13% and 3% respectively.

Likelihood of nepal attaining the Health-related MDGs
On basis of the current trends, the goals on child health, tuberculosis, safe-drinking water and poverty will probably be met whereas it is very unlikely that goals on education and HIV/AIDS will be achieved.On the contrary, the targets on huger, education, gender equality, maternal health, malaria and environmental sustainability can be accomplished if the efforts to achieve them can be accelerated.For poverty reduction, investments in pro-poor labour-intensive activities must be encouraged.Hunger minimization can be accomplished only by addressing the root causes of food security.Emphasis on more gender-responsive policies and programmes and implementation of  Accomplishing the health-related MDGs thus requires more than escalating public health investment and a makeover in underlying values and societal structures.Progress towards health for all calls for a strong commitment and assurances by the stakeholders to protect all individuals especially the most deprived and excluded.In addition, the financial resources provided by the international community to support health spending must be sustainable such that it encourages and provides support and not dependency.Last but not the least, achieving the MDGs for health also demands a democratic system that are inclusive and publicly accountable and that ensures free and independent media and civil society and transparent policy making.

7
It has been estimated US dollars 16.1 billion will be required to achieve the goals in Nepal, almost half of which (US dollars 7.6 billion) will have to come from External Development Partners and this requires almost doubling of the present level of external financial support.6 cOncLUsIOn

table 1 . Millennium Development Goals highlighting the health-related goals 3 GOAL 1: eRADIcAte eXtReMe POVeRtY AnD HUnGeR Target
Vaidya et al.Halfway up the highway: Can Nepal meet its Health Millennium Development Goals? 1: Halve, between 1990 and 2015, the proportion of people whose income is less than one dollar a day Target 2: Halve, between 1990 and 2015, the proportion of people who suffer from hunger

Progress of nepal in achieving the Health MDGs
6For example, as the primary medium-term strategy and implementation plan for reaching the MDGs, the country's Tenth Plan/ Poverty Reduction Strategy Paper (PRSP) (2002/03 -2006/07) has incorporated the MDGs into its strategic framework.7Similarly,it has already begun to implement three-hear rolling Medium Term Expenditure Framework (MTEF) which helps to link programs and projects more closely with PRSP priorities.Though Nepal has made a notable progress in human development, as reflected in its ascent to 136 th place in 2005 from 140 th place in 2004 in the Human Development Index 8 its development has been restricted by a number of constraints including its rugged terrain with insufficient infrastructure, high transport and investment costs, high population growth, weak governance, political instability and insurgency.In the international arena, Nepal draws particular interest for being one of the Least Developed Countries (LDC), a landlocked developing country and a country with environmental vulnerability, and recently for its political upheavals.(SNL) succeed, it is likely that the target on child mortality is met.Similarly, Nepal's significant success in tuberculosis control can be observed from its

table 2 . nepal's indicators in health and health-related MDGs, challenges and likelihood of achieving them 6
NDHS 2006 12 , b Data not available for the recommended indicator (HIV prevalence among pregnant women aged 15-24 years), c No separate data available for the recommended indicator (Condom use rate of the contraceptive prevalence rate), d Data on this indicator currently unavailable, e Data for people using wood as their main fuel, NA Data not available