[PHP Nepal Vol 5 Issue 2 Feb 2015] | Green Tara Nepal, a leading NGO working on Health Promotion, recently disseminated the findings of the evaluation of key health promotion initiatives in the country. The evaluation was conducted in collaboration with the Government of Nepal, Green Tara Trust, a UK-based charity, several NGOs and INGOs and three UK universities, namely Liverpool John Moores University, Bournemouth University and the University of Sheffield. The evaluation identified key government, bilateral, UN agencies and I/NGOs working in health promotion in Nepal.
Their health promotion activities and approaches were documented and gaps were identified. This editorial focuses on the position of health promotion in the different health policies in Nepal.
What is health promotion?
Health promotion is most commonly defined as ‘the process of enabling people to increase control over the determinants of health and thereby improve their health’. Health promotion today has globally emerged as a separate identifiable stream of public health. However, in Nepal, health promotion is still a relatively new concept. No studies have been conducted so far to explore the kind of health promotion initiatives and approaches being undertaken in Nepal. Hence the aim of this study was to identify key players in health promotion in Nepal, identify the different activities and approaches carried out by them and then identify and analyse the gaps in health promotion if any.
This evaluation was carried out by first defining health promotion and its approaches in order to determine what constitutes health promotion. Health promotion activities were themed in terms of the health promotion approaches based on Naidoo and Wills’ (2005) theoretical framework. They outline three approaches: the medical approach, behavioural change approach, educational approach, empowerment approach and the social approach. A special data collection tool was prepared for this study. The tool was used to seek relevant and key information from our sources such as the project name, geographic coverage, implementing organization, target population, objectives, health focus area, health promotion approach, activities, methodology and incentives.
This study also included a review of national health policies to understand the status of health promotion in policy and planning. The policies included are the National Health Policy 1991, The Second Long Term Health Plan (1997-2017), National Safe Abortion Policy 2002, National Nutrition Policy 2004, Three Year Interim Plan (2007/08-2009/10), Three Year plan Approach Paper (2010/11-2012-13), The Ninth Plan (1997-2002), the Tenth Plan (2002-2007), Nepal Health Sector Programme-Implementation Plan (2004-2009), Nepal Health Sector Programme-Implementation Plan II (2010-2015), and Nepal Health Sector Strategy 2004.
The National Health Policy 1991 first acknowledged health promotion at the policy level in Nepal. The policy document vaguely mentioned health promotion in the context of awareness-raising through information and education. Later policies dedicated small sections to information, education, communication, and behaviour change communication, only indirectly touching upon health promotion. Health promotion in the Nepali policy documents are still under-addressed, and still focus almost exclusively on awareness generating and education. This study also found that although there were strategies in place in some government agencies, there were no health promotion activities recognised.
This study also includes health promotion initiatives from sectors other than health. Nepal Traffic Police formally banned driving under the influence of alcohol under its “zero alcohol tolerance programme” (MaPaSe) campaign since December 2011. This new “zero alcohol tolerance programme” for drivers of motor vehicles has not only led to decreased road traffic accidents but also decreased intake of alcohol, which has the potential to eventually lead to fewer people suffering alcohol-related illnesses. Traffic Police data for a duration of 30 months shows the campaign promising results. Despite of exponential growth of vehicles in Kathmandu, there was a reduction of fatal accidents by 6% and severe injuries by 68% (Kantipur 2014). Similarly, 1.3 million drunk drivers were fined during the same period yielding in over 13 million Rupees as revenue (Kantipur 2014). Learning by the experience, Nepal Traffic Police is improving the campaign and services.
The National Strategy on School Health and Nutrition initiated by Ministry of Education is in effect since 2006 and focuses on areas: 1) school-based health and nutrition services, 2) a healthy, safe and secure learning environment, 3) skills-based health education and 4) health-related school policies. In 2010, the Ministry of Education endorsed the Child-Friendly School Initiative Framework that outlines nine aspects of quality education and a child-friendly school.
Lastly, this study has identified and analysed enduring gaps in health promotion in Nepal. The first major gap identified is the understanding of the term ‘health promotion’ itself, which is often used interchangeably to signify prevention, health education or awareness-raising. Whilst some health focus areas, include health promotion, at least as defined here, mental health and geriatric health were highly neglected issues overall. The main contextual challenge for mental health in Nepal is the lack of awareness and adequate policy regarding promoting good mental health. The elderly account for 7% of the total population in Nepal, yet there are no specific health promotion initiatives undertaken to promote their health and wellbeing. In terms of health promotion approaches, the most commonly used were the medical and educational approaches. The behavioural change approach is used by a handful of bilateral agencies and I/NGOs. Interestingly the empowerment and social approaches have been neglected by almost all organisations. Whilst analysing the health promotion gaps in geographic coverage, this study found that Kathmandu and Doti were the two districts with the highest number of health promotion programmes which could be perhaps attributed to the larger number of NGOs working in those areas. The districts that were completely lacking any obvious health promotion interventions were Jajarkot, Dolpa, Mustang, Solukhumbu, Khotang and Taplejung.
In conclusion, this study found that there were huge gap in coordination and collaboration of health promotion efforts in Nepal. Many organisations were focusing on the same health focus area as well as the same geographic region, which has led to a duplication of health promotion activities in some areas, and a scarcity in most.
Research-based policies and research impact
This editorial is on the one had a call for more evidence-based policy making. We would like to see a new Nepal in which public health research helps politicians and policy-makers to make better decisions. This does not mean that research or researcher drive the policy agenda. Epidemiological research may help politicians to decide which diseases, problems of patients groups are most prevalent, but the decision to do something about it is still the politicians. Thus political decisions will still be made by politicians in a democratic way, but once the politician have decided to improve child health, or focus on the growing problem of obesity or address the threat of bird flu then research will hopefully be able to provide the evidence what works for whom and under what circumstances.
The second issue we would like to highlight is the notion of research impact. As individual applied researchers we would like to ensure that the findings of our research are relevant to society and make a difference in the real world. Moreover, universities also want their research to have societal impact. In the UK this notion of impact become formalised in the 2014 Research Excellence Framework (REF). The REF is a nation-wide system to assess the quality academic research in all academic disciplines (Parker & van Teijlingen 2012; van Teijlingen et al. 2011; Hartwell et al. 2013). One key part is measuring ‘impact’ that a UK university has on society and the economy. This REF requires UK universities to write a number of case studies that show societal impact. Thus there is an additional motivating factor for UK academics to ensure that their research gets applied in the real world.
Thus our field of health promotion research in Nepal is a clear example of ensuring research findings are applied in real live through this collaboration between the UK universities Liverpool John Moores University and Bournemouth University, Green Tara Nepal, Green Tara Trust (UK) and many other NGOs, INGOs and most importantly, the Government of Nepal.
1.Green Tara Nepal, Kathmandu, Nepal 2. Member of The Constituent Assembly of Nepal and Former Minister for Education, Nepal 3. Visiting Research Fellow, Ehime University (Japan) 4. Honorary Research Fellow, the University of Sheffield (UK) 5. Green Tara Trust, London, UK 6. Bournemouth University, Bournemouth, UK 7. Manmohan Memorial Institute of Health Sciences University, affiliated with Tribhuvan University, Nepal 8. Nobel College, affiliated with Pokhara University, Nepal 9. Liverpool John Moores University, Liverpool, UK