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Sustainable Livelihood Systems in Nepal
Sustainable Livelihood Systems in Nepal
Principles, Practices and Prospects
Editors: Ambika P. Adhikari and Govinda P. Dahal
Associate editors: Ishara Mahat, Bishwa Regmi and Kalidas Subedi
SUSTAINABLE LIVELIHOOD SYSTEMS IN NEPAL
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14 Social Determinants of
Health in Nepal:
A Neglected Paradigm
Govinda P. Dahal and Madhusudan Subedi
Abstract
While health equity issues related to universal access to health care services remain
crucial, social determinants of health (SDH) and their distribution have emerged to
the forefront of the policy agenda for reducing health inequalities, especially after
the reinforcement given by the World Health Organization’s Commission on Social
Determinants of Health in 2008. In this paper, the theoretical background of SDH,
current health issues in Nepal and transitional policy development are discussed.
The review of Nepal’s policy development over the last half a century still suggests
a gloomy scenario when we consider the current status of population health in
Nepal. For the first time, the key SDH applicable to Nepal are identified, and their
links to current disease burdens are explored and synthesised. The synthesis of
facts shows that the origin of the burden of diseases, disabilities and premature
deaths are primarily due to living conditions. Despite this fact, the majority of
people in Nepal are not aware of this evidence or workable solutions to reduce
the burden of diseases. The key recommendations to address the SDH include:
raising public awareness of this issue; developing political will; and effectively
implementing health policies and programmes through coordination and actions
between relevant Ministries and local communities.
1. Introduction
Healthy life is an outcome of sustainable development, as well
as a powerful and undervalued means of achieving it. We need
to see health both as a precious asset in itself, and as a means
of stimulating economic growth and reducing poverty - Dr. Gro
Harlem Brundtland (http://www.who.int/wssd/en/).
The above statement by Gro Harlem Brundtland, Director-General Emeritus of the
World Health Organization (WHO) indicates that health – “as a state of complete
physical, mental and social wellbeing and not merely an absence of disease
or infirmity” (WHO, 1946) – is both a resource for, as well as an outcome of,
sustainable development. As good health is a major resource for social, economic
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and personal development, it is an important dimension to the quality of life.
Health as an ingredient of human capital is a vital element in achieving sustainable
livelihoods; hence good health and sustainable livelihoods are interconnected as
they are mutually reinforcing elements. Our everyday interactions with political,
economic, social, cultural, ecological, behavioural and biological environments help
to determine our health (Dahal, 2000). Lack of proper optimisation of these factors
means that ill-health is more or less inevitable (WHO/HWC & CPHA, 1986).
Until recently, it was believed that access to quality healthcare services and life
style choices were the primary factors that shape health outcomes (Mikkonen, et
al., 2010). However, we have come to learn now that medical treatment or life style
choices are only valuable components, but are not the primary factors. According
to WHO’s Commission on Social Determinants of Health, the prime factors that
really shape our health are the living conditions into which we are born, grow,
live, work and age (WHO, 2008). These conditions have come to be known as the
'social determinants of health' (SDH):
“Our health is shaped by how income and wealth is distributed,
whether or not we are employed, and if so, the working
conditions we experience. Furthermore, our well-being is also
determined by the health and social services we receive, and
our ability to obtain quality education, food and housing, among
other factors. And contrary to the assumption that citizens
have personal control over these factors, in most cases these
living conditions are (for better or worse) imposed upon us by
the quality of the communities, housing situations, our work
settings, health and social service agencies, and educational
institutions with which we interact” (adapted from Mikkonen &
Raphael, 2010:p7-8).
It is clear from the above excerpt that SDH are those factors that directly influence
our health and well-being. The indisputable evidence based on hundreds of studies
and decades of research findings from all over the world has proven that, more
than any other factors, it is the social injustice resultant from social structures and
power relationships that is detrimental on a grand scale (Mikkonen et al., 2010;
WHO, 2008). New studies also claim that during the last 20 years, health equity
gaps (differences in health that are unnecessary, avoidable, unfair and unjust)
within and between countries appear to be widening more than ever before, no
matter whether the country is developed or developing (Dahlgren & Whitehead,
1992; Marmot & Wilkinson, 1999; Tarlov 1999; Braveman & Gruskin, 2002;
Mackenbach, 2005; Wilkinson, 2005; Marmot, 2005; WHO, 2008). For instance,
the majority of people in low and middle-income countries and one-in-five in high
income countries face rampant health inequality (Yazbeck, 2009; Labonte et al.,
2005; Wade, 2004; Cornia, 2001).
Considering the extent to which health inequalities are occurring even in Europe’s
most affluent countries where substantial improvements in health care systems
have taken place for decades, one can easily imagine the degree of severity in the
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situation of health equity in low income countries where health care systems are
still fragile and national economies and development budgets are solely relying on
external sources and donors. The poorest of the poor and/or socially marginalised
groups, especially from remote rural areas of third world countries are suffering the
most (Yazbeck, 2009; WHO, 2008).
Despite huge efforts and investments to improve population health over many
decades and having remarkable development in biomedicine, the stunning picture
of health inequity demonstrates systemic problems in health policies within and
between countries. Given the earlier failures resulting in differentiated health
outcomes, addressing SDH is becoming a global and national agenda as a means
to reduce health equity gaps, presumably in a generation (Schrecker & Taler, 2013;
WHO, 2008). However, in many low and middle income countries (e.g. Nepal),
where health problems are enormous, there is still little understanding of SDH and
a lack of prioritisation of issues to reduce the associated structural barriers. This
article attempts to explore and discuss SDH in Nepal linking it to the context of
disease burden, health policies and practices.
This paper aims to describe the existing scenarios and theoretical concepts of
SDH in association with Nepal’s current health related issues, policy development
and their changing patterns over time. This paper also aims to identify SDH that
can be applicable to Nepal’s context, which in turn, will be helpful in narrowing
down the health equity gaps across the country. Understanding the gaps and
associated factors are crucial pre-requisites in promoting sustainable livelihoods.
In analysing social determinants of health, it should be clear whether the author
is focusing on only social determinants of health such as how these factors shape
health outcomes in general; or the distribution of social determinants of health
such as how the inequitable distribution of these determinants comes to cause
health inequalities. This paper focuses more on the former case.
The paper begins with some of the international commitments to take action on
SDH, followed by presentation on Nepal’s position on health status internationally,
and in South Asia. The paper also discusses Nepal’s current health problems and
their changing scenarios, historical background, a logic model and some important
conceptualisations of SDH to layout the theoretical foundation, and identification of
SDH that are applicable to Nepal with their brief explanations.
2. Methodology
This article is based on review of literature from published peer reviewed journal
articles and web-based literature. In addition, grey literature - such as books, book
chapters, government reports, and conference proceedings relevant to this chapter
were reviewed. Many health experts and government officials were contacted for
relevant grey literature. Furthermore, a main database that was used for literature
search was ‘Google Scholar’, and the search was guided by a list of key words and
names of key health institutions, authors and some of the relevant references that
were identified from recently published articles and reports. All relevant literature which
were accessible online were downloaded and screened. Only articles deemed relevant
were reviewed. The results were synthesised mainly using a rapid review technique.
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To review the level and trend of relevant health outcomes, a number of indicators
highlighted by the WHO 2013 (Table 1) and the Institute for Health Metrics and
Evaluation (IHME), 2013 (Table 2) were considered. Among health indicators,
the life expectancy at birth is considered as a standard to measure overall health
status of people in a given country. For example, in 2010, people of Sierra Leone
and Japan had respectively, the lowest (45 years) and the highest (83 years)
average life expectancy at birth. The former indicates the poorest health while the
latter indicates the strongest health. In the given circumstances, some people can
live longer with an absolutely healthy life, while some survive for relatively long
periods but with illnesses and some die prematurely. The experiences of disease
burden, the number of years lost due to ill-health, and disability or early death
ultimately influence the overall longevity of people. To adjust such experiences
while estimating longevity the estimation of health-adjusted life expectancy has
been the most common approach used recently. To estimate health-adjusted life
expectancy at birth, as used in this paper, the estimation of disability-adjusted
life years (DALY) is needed and can be calculated by combining both mortality
(average years of life lost-YLL) and morbidity (years lived with disability-YLD)
experience into a single common metric. To estimate DALY, a standard statistics
of life expectancy is needed. In this paper DALYs are used to indicate the health
or premature death status of Nepalese, explaining the step-by-step calculation
and procedure used is beyond the scope of this paper but for more details of this
method see Horton (2012).
3. National and international commitments
On October 2011, the representatives of WHO member states came together in
Rio de Janeiro and every national authority reiterated their determination "to take
action on SDH through the three overarching recommendations: to improve daily
living conditions [of people]; to tackle the inequitable distribution of power, money
and resources; and to measure and understand the problem and assess the impact
of action" (WHO, 2011:p1).
The WHO (2011: p1) also reaffirmed that:
“Health inequities within and between countries are politically,
socially and economically unacceptable, as well as unfair and
largely avoidable, and that the promotion of health equity is
essential to sustainable development and to a better quality of
life and well-being for all, which in turn can contribute to peace
and security.”
In May 2013, the 66th Assembly of WHO was held in Geneva where delegates
and representatives from 188 out of 194 member states attended. They restated
the pressing need to take action on reducing health inequities across the member
states by implementing the 2011 Rio Political Declaration on Social Determinants
of Health to: identify social determinants which cause health inequalities; address
health inequalities and achieve good health; enjoy good health as a fundamental
right; adopt better governance for health and development; promote participation
in policy-making and implementation; further reorient the health sector towards
reducing health inequities; strengthen global governance and collaboration;
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monitor progress and increase accountability; and call for global action (WHO,
2013). Nepal has also vowed to commit to the implementation of these declarations
(WHO, 2013b).
4. An overview of population health situation in Nepal:
Positioning in the globe and in South Asia
Health inequalities in Nepal are widespread and manifested through numerous
health indicators such as life expectancy, infant mortality, adolescent fertility and
level of stunted children. Table 1 shows Nepal’s health status in the globe and in
South Asia based on these health indicators. Although Nepal has experienced
complex political turmoil along with relatively weak economic growth over the past
few decades, it has been progressing well in its population health outcomes (NPC/
UNCTN, 2013). For example, life expectancy at birth has increased from 38 years
in 1960 to 68 years in 2011. The infant mortality rate also declined steadily from
around 200 per 1,000 live births in 1960 to 39 per 1,000 live births in 2011 (WHO,
2013). The under-five mortality rate and maternal mortality ratio also followed a
similar trend. For example, the maternal mortality ratio of 770 per 100,000 live
births in 1990 decreased to be 360 and 170 respectively in 2000 and 2010 (Ministry
of Health (MoH), 2011).
Table 1: Nepal's ranking on selected health indicators in the world and in South Asia
Indicators Status Relative Ranking (1 is best) among
WHO member states and SAARC*
countries
Life expectancy at birth
(both sexes) 2011
68 years 128th of 194 WHO
member states
4th of 7 South
Asian nations
Infant mortality rate (per
1,000 live births) 2011
39.0 140th of 194 WHO
member states
4th of 7 South
Asian nations
Adolescent fertility rate
(per 1,000 girls ages 15-
19 years) (2005-2010)
81.0 118th of 147 WHO
member states
6th of 6** South
Asian nations
Stunted Children <5 (%)
(2005-2012)
40.5 92nd of 114 WHO
member states
4th of 7 South
Asian nations
(Source: WHO, 2013)
*SAARC (South Asian Association of Regional Cooperation) comprises Nepal, India, Bhutan,
Bangladesh, Pakistan, Maldives, Sri Lanka and Afghanistan. As Afghanistan was recently added to
this network, is not included in this ranking
** Bangladesh has no data reported for adolescent fertility rates of girls aged 15-19.
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Table 2: Ranking of general life expectancy and the health adjusted life expectancy
at birth in South Asia between 1990 and 2010
Countries Life expectancy at birth
(Years)
Health adjusted life
expectancy at birth (Years)
1990 Rank 2010 Rank 1990 Rank 2010 Rank
1. Sri Lanka 73.3 1 75.5 2 62.1 1 65.3 2
2. Maldives 65.1 2 78.8 1 55.7 2 68.0 1
3. Pakistan 62.3 3 65.7 6 53.3 3 56.5 5
4. Bangladesh 58.9 4 69.0 5 49.2 7 58.4 6
5. Bhutan 58.8 5 69.4 3 50.0 4 59.7 3
6. Nepal 58.8 6 69.2 4 49.8 5 58.8 4
7. India 58.3 7 65.2 7 49.8 6 56.2 7
Note: Although life expectancy at birth in Nepal in 2010 seems slightly higher
than in 2011 (Table 1), the two sources are inuenced by different calculation
techniques. Source: IHME, 2013.
As other South Asian neighbours, Nepal is improving its population health indicators
over time. For example, life expectancy at birth in Nepal in 1990 was ranked 6th,
which moved up to a rank of 4th in 2010 (Table 2). Similarly, the health adjusted life
expectancy at birth moved up to 4th in 2010 from its 5th rank in 1990. Despite these
improvements, Nepali people are dying 14.3 years earlier (IHME, 2013) than their
potential capacity of surviving, which may be due to the current burden of diseases
(Table 3).
5. The real health problems in Nepal that cause
premature deaths and disabilities
It is important to understand the diseases that cause ill health among Nepalese
and lead them to die prematurely. Robust scientific evidence shows that there are
168 causes of ill health, disability and premature deaths in Nepal (IHME, 2013)
including both communicable and noncommunicable diseases. Table 3 shows
some of the most common causes that contribute to ill-health and premature
deaths in Nepal.
Overall, in recent years, South Asia has made good progress in reducing
mortality and prolonging life (WHO, 2013). Although most South Asian countries
have succeeded in decreasing the intensity of communicable diseases, with the
exception of HIV/AIDS, communicable disease have still remained the top drivers
of premature deaths and disabilities (Table 2).
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Mean
rank
(a) Top 20 diseases in 1990 (b) Top 20 diseases in
2010
(c) Change
in rank
from 1990
to 2010
1 Lower respiratory infection
***
Lower respiratory
infection***
No change
2Diarrheal disease*** Diarrheal disease*** No change
3 Neo-natal encephalopathy*** Neo-natal
encephalopathy***
No change
4 Pre-term birth
complications***
Chronic Obstructive
Pulmonary Disease
(COPD)**
6 to 4
5 Tuberculosis*** Low back pain** 11 to 5
6 Chronic Obstructive
Pulmonary Disease
(COPD)**
Tuberculosis*** 5 to 6
7 Congenital anomalies** Pre-term birth
complications ***
4 to 7
8 Protein energy
malnutrition***
Ischemic heart disease** 19 to 8
9 Tetanus*** Iron deficiency
anaemia***
10 to 9
10 Iron deficiency anaemia*** Self-harm* 18 to 10
11 Low back pain** Road injury* 15 to 11
12 Neo-natal sepsis*** Neo-natal sepsis*** No change
13 Syphilis*** Stroke** Emerged
14 Mechanical Forces* HIV/AIDS*** Emerged
15 Road injury* Major depressive
disorder**
Emerged
16 Measles*** Asthma** 20 to 16
17 Maternal disorders*** Diabetes** Emerged
18 Self-harm* Migraine** Emerged
19 Ischemic heart disease** Anxiety disorder** Emerged
20 Asthma** Congenital anomalies** 7 to 20
Table 3: Top 20 causes of premature deaths and disabilities in 1990 and 2010 in
Nepal by types
Note: *** Communicable, maternal, neonatal, and nutritional disorder;
** Noncommunicable; *Injury
(Source: IHME, 2013) †Although evidences from IHME, 2013 cannot be free from limitations.
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In Nepal, respiratory disease is the number one cause of premature deaths and
disabilities, especially infecting the lower respiratory system in the human body
such as the trachea (windpipe), airways and lungs (Gostin et al., 2003). Similarly,
diarrheal disease is the second leading cause of death among children under
five years of age, which can be caused by a host of viral, bacterial or parasitic
organisms, most of which are spread by faeces-contaminated water (WHO, 2015).
Neonatal complication, the third leading cause of death in Nepal, is a clinically
defined syndrome of disturbed neurological function in infants which manifests by
difficulty with initiating and maintaining respiration, depression of tone and reflexes,
sub-normal level of consciousness, and often seizures (Nelson et al., 1991).
Similarly, as people age and tend exercise less, bone strength and muscle elasticity
and tone tend to decrease loosing fluid and flexibility that lead to nerve or muscle
irritation or bone lesions which cause musculoskeletal disorders (e.g. lower back
pain) (NIH, 2014). Tuberculosis, which typically affects the lungs and also other
parts of the body, is another cause of premature death. Similarly, as shown in the
Table 3, pre-term birth complications (before 37 completed weeks of gestation);
cardio-vascular disease (any abnormal condition characterised by dysfunction
of the heart and blood vessels); iron deficiency anaemia (low red blood cell or
haemoglobin levels); psychological disorder (a syndrome characterised by clinically
significant disturbance in an individual's cognition, emotion regulation or behaviour
that reflects a dysfunction in the psychological, biological or developmental
processes underlying mental functioning); injury (road injury including bicycle,
motorcycle, motor vehicle, pedestrian injury, falls, drowning, burns, and self-
harm); HIV/AIDS (a disease of the human immune system caused by infection with
human immunodeficiency virus); diabetes (metabolic diseases in which a person
has high blood sugar); and migraine (a chronic neurological disorder characterised
by recurrent moderate to severe headaches) are other leading causes of death
and disabilities in Nepal.
Table 4 shows some of the top risk factors (in order of higher to lower effect) that
Nepali people faced in 2010. Each of these factors was associated with developing
diseases that caused premature death.
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Table 4: Risk factors contributing to the causes of premature deaths and disabilities
in Nepal
1. Dietary risk
2. Household air pollution
3. High blood pressure
4. Tobacco smoking /chewing
5. Ambient (outdoor) particulate matter pollution
6. High fasting plasma glucose
7. Alcohol use
8. Underweight during childhood
9. Physical inactivity
10. Occupational risk
11. Sub-optimal breast-feeding
12. Sanitation
(Source: IHME, 2013)
Dietary risk has been the number one risk factor for premature deaths (Table 4) in
Nepal. Dietary risk generally refers to dietary deficiencies or failure to assess the
risks (Box 2) as well as being unable to consume a minimum number of servings
from one or more food groups represented in the Food Guide Pyramid (Fig. 1) and
follow the Dietary Guidelines (Box 1); this leads to impaired or endangered health
status (The National Academy of Sciences, 2002). Nepal also published Food-
Based Dietary Guidelines in 2004 (FAO, 2004) which highlights seven directions
to “(1) eat a variety of foods every day, (2) eat four times a day, (3) encourage
eating traditional and festival foods, (4) consuming livestock products (fish, meat,
milk, eggs) everyday, (5) encourage eating locally available dark green, yellow and
other vegetables and fruits, (6) use iodized salt and (7) use fats/oil in moderation”
(FAO, 2004). Despite this publication, the food-based dietary guidelines are vague
and not clear enough to apply them in daily life.
Household air pollution is the second leading risk factor, contributing to developing
acute respiratory infections among children and chronic obstructive pulmonary
disease and lung cancer in adults in Nepal. According to the NDHS, 2011, over
80% of Nepal’s population live in rural areas (GoN, 2012). Almost all of them
depend on their traditional indoor stoves using solid and biomass fuels (e.g.
firewood, dung, and agricultural residues) and coal for cooking and heating (GoN,
2012; MoH, 2011). This cooking and heating technique results in high levels of
indoor pollution containing small particles, carbon monoxide and excessive levels
of particulates (WHO, 2014). Tobacco smoking and ambient (outdoor) particulate
matter pollution are further causes contributing to problems related to respiratory
complications (WHO, 2014). Likewise, people who are economically well-off and
have sedentary lifestyle or who are physically inactive are increasingly developing
high blood pressure, high fasting plasma glucose (diabetes) and other risk factors
as outlined in Table 4, which adds further risks.
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Figure 1: Pyramid guide for food choice
Box 1: The dietary guidelines for
Americans
• Let the Pyramid guide your food
choices.
• Choose a variety of grains daily,
especially whole grains.
• Choose a variety of fruits and
vegetables daily.
• Keep foods safe to eat CHOOSE
SENSIBLY.
• Choose a diet that is low in saturated
fat and cholesterol and moderate in
total fat.
• Choose beverages and foods to
moderate your intake of sugars.
• Choose and prepare foods with less
salt.
• If you drink alcoholic beverages, do
so in moderation.
(Source: USDA/HHS, 2000) from The
National Academy of Sciences, 2002.
Box 2: Dietary risk assessment
indicators
• Inadequate/Inappropriate nutrient
intake
• Failure to meet dietary guidelines
(Box 1)
• Vegan diets
• Highly restrictive diets
• Other dietary risk
• Inappropriate infant feeding
• Early introduction of solid foods
• Feeding cow’s milk during first 12
months
• No dependable source of iron for
full-term
• Infants at 6 months of age or later
• Improper dilution of formula
• Feeding other foods low in essential
nutrients
• Lack of sanitation in preparation/
handling of nursing bottles
• Infrequent breastfeeding as sole
source of nutrients
• Inappropriate use of nursing bottles
• Excessive caffeine intake
(breastfeeding
• woman)
• Inadequate diet
• Inappropriate or excessive intake of
dietary
• Supplements including vitamins,
minerals, and herbal remedies
• In adequate vitamin/mineral
supplementation
• Inappropriate feeding practices for
children
Source: Food and Nutrition on Service
(FNS, 1998) from The National
Academy of Sciences (2002)
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6. Changing pattern of health problems over time in
Nepal
Understanding the changing patterns of diseases is crucial for identifying the
intensity and effect of each disease over time. Table 3 presents the top 20 diseases
responsible for premature deaths and disabilities in 1990 and 2010 in Nepal. The
last column of Table 3 presents the changing trends of diseases according to
their impact (ranking) in 2010 compared to 1990 and also displays some newly
emerging illnesses, majority of which are related to noncommunicable (chronic)
diseases and psychological disorders.
Accounting for only the top 20 among 168 causes of illnesses between 1990 and
2010 in Nepal, the disease burden in 1990 was dominated by communicable,
maternal, neo-natal and nutritional disorders (60%), followed by non-communicable
disease (25%) and injuries (15%). However, this trend in 2010 shifted to be
dominated by non-communicable diseases (50%) followed by communicable,
maternal, neo-natal and nutritional disorders (40%), and injury (10%) (although
top three causes of mortality and morbidity in 2010 were still from communicable
diseases). The burden from non-communicable causes comes especially from
musculoskeletal disorders (e.g. low back pain), ischemic heart disease, stroke,
asthma, diabetes, migraine, anxiety disorders, major depressive disorders and
congenital anomalies.
7. Social determinants of health to address the burden
of diseases
In order to address the issues related to the burden of diseases, we have to first
identify the root cause(s) of these diseases. Theoretical evidence (Figure 2) (Tarlov,
1999; Keon & Pepin, 2009) clearly shows that the origin of these health problems
facing Nepal have very little to do with access to quality healthcare services, albeit
healthcare services are very important for treatment of diseases; they are primarily
related to the range of socio-economic and environmental conditions in which
people live and interact (Marmot, 2005).
Figure 2: The determinants of health as set out by Dahlgren and Whitehead (1992)
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Dahlgren and Whitehead’s (1992) social health framework, commonly known
as ‘multi-level rainbow model’, supports this idea (Figure 2). According to this
model, there are five levels where different factors contribute to (the origination of)
disease(s) which impact our health. They are:
1. Biological factors: This includes any biological factors such as age, sex and
heredity.
2. Individual life style factors: (micro-level) that refers to our individual behaviours
such as diet, substance abuse, sexual behaviour, physical activity, which can have
positive or negative impacts on our health. If our behaviour is linked to smoking,
drug and alcohol misuse, poor diet and lack of physical activities, the origin of
diseases such as respiratory infections, diarrhoea, or diabetes may begin.
3.Social and community networks (meso-level): refers to family (e.g. parents, wife,
children, and siblings), friends, and the wider social circles around us. The quality
of social and community networks are a protective factor to promote health, but if
the healthy and joyful relationship between these networks cannot be maintained,
this leads to psychological stress by which health complications begin.
4.Living and working conditions (macro-level): refers to accessibility of welfare
services, such as the national or local health system, education, social services
(especially public), transport, leisure facilities, training and employment, housing
and amenities. It also includes facilities like running water and sanitation, and
having access to essential goods like food, clothing and fuel. If any imbalance
in these living and working conditions is experienced, they negatively impact our
health and a range of health problems can originate.
5. General socio-economic, cultural and environmental conditions (macro-level):
refers to factors such as wages, disposable income, availability of work, taxation,
and prices; fuel, transport, food, clothing, and health policies etc., that impact
health and wellbeing. Furthermore, these general conditions can directly affect
government spending capacity, and in turn have a direct influence on health and
social policy priorities. These factors related to our living conditions of where we
are born, grow, live, work, and age are considered determinants of health.
Tarlov (1999) has quantified the extent our health can be determined by different
factors of SDH. He believes that genes and associated biology, as well as health
behaviours, account for about 25% of the impact. The remaining three layers
of determinants are: social characteristics (e.g. discrimination, gender, culture),
physical or total ecology (e.g. where people live) and the social structural element
beyond the remit of public policy such as social and community aspects of health
services or medical care (e.g. access to quality health care and having or not
having insurance); altogether these account for about 75% of the impact on our
health. A report by the Canadian Senate in 2009 also stated that 75% of the factors
that influence population health are not related to any healthcare delivery system
(Keon & Pepin, 2009). This evidence affirms that our living conditions alone
are responsible for creating 75% of our health problems. This also confirms the
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previous assumption that clinical care alone can fix all of our health problems
was inaccurate; indeed, advanced clinical systems can only provide treatments
for these diseases that are created by the interactions of different factors from
our living conditions (see WHO, 2010a, Social Determinants of Health Discussion
Paper 1 for details).
Whitehead (1992) showed that there may be measurable differences in health
experiences and health outcomes between different population groups according
to age, disability, ethnicity, gender, and socio-economic status. If these differences
occur, then health inequalities are likely to exist. These inequalities can be either
avoidable or unavoidable. For example, the difference in mobility between an 80
year old grandfather and his 20 year old grandson attributable to the ‘biological
health determinant’ may not be possible to change. When a health outcome is
unavoidable and is called ‘health inequality’. Similarly, there are measurable
differences in opportunity for disparate population groups which results in unequal
health status. For example, infant mortality rates between people from different
social classes of Nepal such as Newar, Brahmin, Dalit and Janjati are different
(MoH, 2012). This measurable difference in infant mortality rates is avoidable and
can be judged to be ethically unfair and unjust (Whitehead, 1992: WHO, 2008).
Such ‘health inequalities’ are called ‘health inequity’ (Gwatkin, 2002). This health
inequity results from social structures and power relationships establishing barriers
to health equality (Mikkonen et al., 2010; WHO, 2008). Nepal is not an exception.
This suggests that identifying SDH applicable to Nepalese context would allow us
to pinpoint the gaps to improve the SDH factors affecting health and thereby allow
us to address them. Doing this can enhance the better health of Nepalese people
which ultimately promotes sustainable livelihoods.
8. Social determinants of health: a neglected paradigm
in Nepal’s health policies
Since 1965, the Government of Nepal has been continuously trying to improve
the health of its people and has been working in collaboration with national
and international communities. In 1986, world health leaders attended the first
international conference called "Ottawa Charter for Health Promotion” in Ottawa,
Canada which emphasised collectively the influence of contextual factors on health
(WHO, 1986). Nepal also agreed on the decisions but could not implement this
concept in the Seventh Development Plan (1985-1990). This plan was the first of
its kind in the history of Nepal, in which a comprehensive set of policies focussing on
population-health, agriculture, forestry, urbanisation, manpower and employment,
education, women empowerment, as well as community development were
established (MoHP, 2012). Subsequently, the government of Nepal introduced a
comprehensive National Health Policy (NHP) in 1991 aiming to enable its citizens
to live more healthy lives by improving their overall health conditions. This policy
adopted a primary health care approach and aimed to extend health services,
including modern medical facilities and trained health care providers, to address
both preventive and curative services to the rural and remote areas of Nepal. A
year after this policy was implemented, Dahlgren and Whitehead (1992) from
WHO, Regional Office for Europe published a report highlighting the importance of
social determinants on people's health. Nepal’s Eighth Development Plan (1992-
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1997) was introduced in the same year which gave continuity to the health policy
priorities of 1991 (NPC, 1992). Until that time, there was no clear awareness about
the concept of social determinants of health in Nepal.
Over time, fairly comprehensive frameworks of health policies, strategies and
plans have been formulated. In 1997, the second Long-term Health Plan (1997-
2017) and the Ninth Development Plan (1997-2002) were formulated. They
followed the strategic analysis to operationalise the second long term health plan
(2002-03), the medium term expenditure framework, Nepal Health Sector Program
Implementation Plan (2003-2007), the Tenth Development Plan (2002-2007), and
the Nepal Health Sector Program - I (2004-10). Later, along with the interim
constitution 2007, a three-year National Plan was introduced. Since 2010, Nepal
Health Sector Programme-II (NHSP-II; 2010-2015) has been in operation (Ministry
of Health and Population, 2010). Now Nepal is in the process of preparing NHSP-
III for 2015-20. However, thus far the Nepal government and other stakeholders
working in population health sectors have not integrated the concept of social
determinants of health into health policies in a meaningful way. This situation also
hampers several public/population health institutions (e.g. Institute of Medicine or
Academy of Sciences) as they lack a foundation of scientific literature in Nepal’s
context to refer to in order to develop a comprehensive public health curriculum
which embraces SDH for Bachelors and Masters degrees. Otherwise, this prevents
awareness and training of the next generation of those working in the health care
system. In this context, Shrestha and Pathak (2012) state that, “the new health
policy should be broad enough to include issues not only of the health sector but
also of population and nutrition .... and should cover the SDH" (p 24). However, until
now it can be argued that social determinants of health have still been neglected
in Nepal’s health policies and programs.
9. Identifying social determinants of health in Nepal
A variety of conceptualisations of SDH have been developed over time in the
international arena (Table 5). Social context of a nation or society is the most
important feature for identifying SDH applicable to that nation or society.
SUSTAINABLE LIVELIHOOD SYSTEMS IN NEPAL
Principles, Practices and Prospects
325
Ottawa
Charter
(1986)
Dahlgren and
Whitehead
(1992)
Health Canada
(1998)
World Health
Organization
(WHO, 2003)
Center for
Disease Control
USA
(CDC, 2005)
- Peace
- Shelter
- Education
- Food
- Income
- Stable
ecosystem
- Sustainable
resources
- Social
justice
- Equity
- Agriculture and food
production
- Education
- Work environment
- Unemployment
- Water and
sanitation
- Health care
services
- Housing
- Income and
social status
- Social support
network
- Education
- Employment
and working
conditions
- Physical
and social
environments
- Healthy child
development
- Health
services
- Gender
- Culture
- Social gradient
- Stress
- Early life
- Social
exclusion
- Work
- Unemployment
- Social support
- Addiction
- Food Transport
- Socio-
economic
status
- Transportation
- Housing
- Access to
services
- Discrimination
by social
grouping
- Social and
environmental
stressor
Source: Bryant et al. (2010):p3
SDH not only concentrates on how these determinants shape health outcomes in
general, but also focuses on how the inequitable distribution of these determinants
causes health inequalities (Bryant et al., 2010); this scope is the most important
factor to inform policies for sustainable population health outcomes, which is one
of the fundamental characteristics of sustainable livelihoods. In Nepal, no SDH
have been identified yet. However, considering Nepal’s commitments to take
action on SDH (following recommendations from the World Health Organization)
as a means of reducing health inequity, identifying social determinants of health
applicable to the context of Nepal is important. This paper, for the first time,
contributes to this endeavour, focusing on how social determinants shape health
outcomes considering the conceptualisations of SDH given in Table 6 as a basis.
The concept of social gradient and double burden of diseases are important for
understanding Nepal’s current context in connection to SDH.
10. Social gradient and triple burden of diseases in Nepal
The concept of leading healthy lives is easy for some, but difficult for many, is known
as the ‘social gradient in health’ that runs from top to bottom of the socio-economic
spectrum (WHO, 2014). This means, the lower the socio-economic position, the
more inferior the health status. Normally, people with such poor health status in
high income countries tend to be suffering from the burden of noncommunicable
diseases, but in low income countries it is expected to suffer from the burden
of communicable diseases. However, Nepal, even being characterised as a low-
income country, is suffering from the triple burden of diseases: (i) communicable,
(ii) noncommunicable (MoHP, 2011), and (iii) injury-violence and disaster. Box 3
presents a simple story of the complex set of factors/conditions that determine the
burden of diseases in Nepal.
Table 5: Various conceptualisations of the social determinants of health
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Box 3: A scenario of living conditions that determine the burden of diseases
(a) A scenario of a poor rural 11-year illiterate
girl
(b) A scenario of a rich and college
graduate urban 35-year woman
Q: Why is Shanti in the health post?
A: Because she has a bad infection in her foot.
Q: But why does she have an infection?
A. Because she has a big cut on her foot and it
has got infected.
Q: But why does she have a big cut on her foot?
A. Because whist trying to collect firewood by
chopping a log, her hand accidently slipped and
her rusted axe jabbed into her bare foot.
Q: But why she was collecting firewood at such
an early age?
A. Because as the first child among her 5
siblings and being from a poor family she has
the responsibility to help her parents to provide
for the family. She has a daily routine to go to
forest with other villagers to collect firewood in
the morning and looking after her siblings during
the day.
Q: But why don't her parents send her to
school?
A. Because her parents are so poor and living
in a miserable condition. They are not even
able to sufficiently feed their kids despite their
hard work. Sending her to school is out of the
question.
Q: But why are her parents so poor?
A. Because they only have a small plot of land,
which is not enough to grow adequate food and
vegetables to feed the family even for 3 months
in a year. They are uneducated and have to
work hard for daily wages just to feed the family.
Q: But why?
Q: Why is Sonu in the hospital?
A: Because she is suffering from type-2
diabetes and high blood pressure.
Q: But why does she have diabetes
and blood pressure?
A. Because she is overweight and
under lots of stress.
Q: But why?
A. Because she does desk work, she
does not have regular designated
meal times, but when she eats, she
has a very heavy meal and does not
do any exercise.
Q: But why?
A. Because she thinks that living the
good life is only based on eating high
calorie delicious food and staying with
sedentary life style.
Q: But why does she think so?
A. Because she has grown-up in such
an environment where most members
of society perceive that spending
money on expensive food (e.g. alco-
holic beverage, meat and sweets) and
having a relaxed life will lead them to
be prestigious and are envied.
Q: But why?
A. Because money is thought to be
the key to prosperity, and citizens
are often not educated about healthy
lifestyles as a part of prosperous life.
Q: But why?
Note: This story is based on the discussions with key health researchers, and policy
makers in Kathmandu during February 1-16, 2014 and also personal observations
of author in rural villages of more than 50 out of 75 districts in Nepal.
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The conceptual framework developed by Brunner and Marmot (2006) on social
determinants of health and the pathways to well-being or illness is adapted (modified
from the original) to apply it to the Nepalese context. Figure 3 shows a process of
pathways which starts from social structure and ends at well-being, morbidity and/
or mortality. It is clear from the figure that social structure influences the living and
working conditions of people which shapes one’s health and well-being, operating
through the social environment, economic, psychological, material and behavioural
pathways. Genetics, early life and cultural factors strongly influence health in all
stages of life (Figure 3).
Figure 3: Social determinants of health and pathways to health and well-being adapted from Brunner
and Marmot (2006) p.9.
11. Social determinants of health that are directly
applicable to Nepal
Considering all of this evidence and conceptualisations of SDH related to the
particular context of Nepal, the following thirteen SDH are applicable to the nation
(Table 6).
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Table 6: Key social determinants of health that are directly applicable to Nepal
1. Politics, policy and governance 8. Poor housing, sanitation and living
conditions
2. Poverty 9. Physical infrastructure and transpor-
tation
3. Education and health literacy 10. Food security
4. Employment and working conditions 11. Early life and childhood develop-
ment
5. Gender 12. Stress
6. Ethnicity, religion and culture 13. Access to health care and seeking
behaviour
7. Social capital and safety net
Below the key social determinants of health are briefly summarised as they apply
to Nepal.
11.1 Key determinant: Politics, policy and governance
Politics, policy and governance are interlinked. For better or worse, they play
a critical role in health affairs, ranging from disease prevention to health care
reforms as well as the implementation of intervention programs aimed at reducing
inequalities (WHO, 2011a). Public policy that emerge from good politics and
effective governance systems positively affect housing, education, income, access
to food, the availability and quality of health care; all of these create the environment
in which we live (Harvard School of Public Health, 2011). Adopting appropriate
laws and policies and ensuring their effective implementation is necessary in
addressing existing as well as emerging health issues aiming to improve overall
population health.
In Nepal, a long transition period and general political instability has affected the
overall governance system, making it difficult to reduce or eliminate policy gaps
in the public health arena. Nepal is working towards a peace process after a
decade-long armed conflict, and was supposed to promulgate a new constitution
in 2010. However, the Constitution Assembly elected in 2008 failed to make this
constitution in time. Political trust and understanding between and within parties
remains fragile; the current state of governance is poor; the rule of law and civil
order are weak; corruption, crime and impunity are widespread and progressively
on the rise; and citizen-safety has become weaker (NPC/UNCTN, 2013). These
scenarios have negatively affected the well-being of Nepalese people, specifically
in regard to their contribution to the social determinants of health.
11.2 Key determinant: Poverty
Poverty is often defined in absolute terms of income or consumption. For example,
by most standards, individual earning less than US$ 1.25 a day are regarded
as ‘absolute poor’. The United Nations defines absolute poverty as a “condition
characterised by severe deprivation of basic human needs, including food, safe
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drinking water, sanitation facilities, health, shelter, education, and information.
Poverty depends not only on income but also on access to social services” (United
Nations, 1995: Chapter II, paragraph 19). Poor and marginalised groups tend to
have a higher risk of social exclusion, illness and disability, which in turn affect
household savings, learning ability and productivity; this also often leads to a poor
quality of life, thereby perpetuating or even increasing poverty (WHO, 2014).
Nepal, with a human development index of 0.463, and ranked at 157 out of 187
countries (UNDP, 2013), is one of the poorest countries in South Asia. This is the
situation in spite of the fact that Nepal has been working to alleviate poverty since
1956 and to eradicate extreme poverty and hunger since 2000 (GoN/NPC/UNDP,
2010). Despite political instability, ineffective policies and inefficient governance,
Nepal has made some progress in reducing poverty (NPC/UNCTN, 2013). For
example, in 1990, one-third (33.5%) of people in Nepal were living with an income
of less than one US dollar a day; and 42% of people were living below the national
poverty line. Through the Millennium Development Goals (MDG), Nepal targeted
to reduce these percentages by half their amount by 2015. The Nepal MDGs
Progress Report (2013) shows that by 2013, the first target had already been met,
dropping the proportion to 16.4%. The second target is also close to its goal, as the
proportion of those living below poverty line in 2013 is 23.82%.
Although poverty at the national level seems to be declining, over 2.7 million
people still live in abject poverty (NPC/UNCTN, 2013). Again, one fourth of
poverty reduction in Nepal comes from remittances sent by Nepali labourers, but
its sustainability is still doubtful. In the case that the flow of current remittances
was cut off, the incidence of poverty in Nepal would double. However, Nepal has
no additional plan(s) for creating jobs or a sustainable economic base and has
no concrete plan for reducing income disparities in the near future (NPC/UNCTN,
2013). Table 7 presents the distribution of wealth in Nepal based on wealth
quintile, and Gini Coefficient, which refers to the wealth distribution (0 being an
equal distribution and 1 being totally unequal distribution). The Table clearly shows
the unequal distribution of wealth across the country.
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Wealth quintiles Gini
Residence Lowest Second Middle Fourth Highest
Coefficient
N
Urban 3.7 3.3 7.8 23.6 62.3 0.12 6338
Rural 22.6 22.5 21.8 19.5 13.6 0.22 41785
Ecological zones
Mountain 41.4 30.7 19.8 7.7 0.5 0.18 3358
Hill 31.9 21.1 14.6 12.5 19.9 0.28 19501
Plain (Terai) 8.0 17.8 24.2 27.4 22.7 0.21 25264
Development regions
Eastern 16.2 18.9 20.3 23.8 20.9 0.21 11481
Central 13.7 18.8 20.7 20.7 26.1 0.24 16011
Western 14.8 21.4 20.7 22.0 21.0 0.22 9895
Mid-western 41.5 20.1 16.3 12.1 10.0 0.24 5911
Far-western 34.5 23.7 19.5 14.3 7.9 0.20 4826
(Source: MoHP, New ERA, & ICF International Inc, 2012) (Table 2.6)
The widespread poverty and unequal wealth distribution in Nepal lead many
people towards more hardship for survival. This misery compels them to face
poor physical health and chronic psychological stresses. Evidence shows that
poor people have limited options and their poor coping abilities for dealing with
stress further leads to vulnerability and diseases through biological pathways by
weakening the hormonal and immune systems (Mikkonen & Raphael, 2010). This
scenario proves that poverty and its distribution is one of the most important social
determinants of health for Nepal.
11.3 Key determinant: Education and health literacy
Associations between education, morbidity and mortality are not new. Education
opens the door for understanding different pathways to better health, equips people
with problem solving skills and improves one's ability to access and understand
information that helps them to stay healthy (Higgins et al., 2008). According to
Higgins (ibid), the level of education is highly correlated with income, employment
and social status in a society, which help educated people to move up their socio-
economic ladder and generally live with better health. However, if people are not
educated, they miss such privileges. Education can affect health in different ways
at different stages of their life cycle. Evidence also indicates that higher levels of
education have been shown to have greater impact on healthy behaviour, and
also on mental health outcomes in younger age groups and physical functioning in
older age groups (ibid).
Table 7: Distribution of wealth in Nepal by residence, ecological zones, and
regions
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In Nepal, a large section of the population is still illiterate. A large fraction of those
literate are still uneducated. Among the educated ones, a significant proportion of
them are still without a high school diploma. Therefore, a relatively small portion
of people in Nepal have achieved higher education. If we divide the educational
attainment by gender, the outcomes clearly favour males. For example, the overall
illiteracy rate (aged 5 and above) in Nepal is 34.1% in 2011. Among the 65.9%
literate people, 75.1% are males and 57.4% are females (Central Bureau of
Statistics (CBS), 2012). If we consider the adult literacy rate (15 year and older),
the fraction of literate people is much smaller, at just 56.5%, with wider gender
differences (71.6 % of males, and 44.5 % of females). However, if we review the
history of net primary enrolment rate for last 23 years, the recent achievement
shows an encouraging outcome: 64% in 1990 to 95.3% in 2013 with almost equal
gender parity (NPC/UNCTN, 2013).
Experience from Canada shows that people with low literacy skills are more likely
to be unemployed and poor, to suffer from ill health, and to die earlier than their
counterparts with a higher level of education (Mikkonen & Raphael, 2010). This
finding is equally applicable to Nepal. Evidence from Nepal itself shows that the
nutritional status of children of educated mothers was far better than the nutritional
status of children of uneducated mothers (Dahal, 1999). Furthermore, recent
evidence from the Nepal Demographic Health Survey 2011 (MoH, 2011) and the
Nepal MDG Progress Report 2013 (NPC/UNCTN, 2013) consistently confirmed
this finding. In addition, educated married males in Nepal were more likely to adopt
permanent family planning methods to limit their family size and to promote their
wives’ health and well-being compared to their uneducated male counterparts
(Dahal et al., 2008; Dahal, 2008).
Nonetheless, being literate does not always mean to be health literate. It is because
health literacy is not just the ability to read and write but also to encompass a
much wider spectrum to which individuals have the capacity to obtain, process,
and understand basic health information and services needed to make appropriate
decisions and to have the ability to apply these skills to promote their health and
well-being (AHRQ, 2011). Even educated people with low health literacy cannot
fall under the category of health literate; this concept, to a large extent, reflects
Nepal’s current situation [see Box 3(b)]. Therefore, education and health literacy
are important social determinants of health for Nepal.
11.4 Key determinant: Employment and working conditions
Studies have shown that employment and better working conditions are associated
with better socio-economic status and better health. Thus, unemployed or
underemployed people tend to have inferior health because of their lower income
and stress associated with their deprivation (ILO, 2013). In Nepal, about 400,000
youth enter into the labour market every year (NPC/UNCTN, 2013). Since Nepal
has little scope of employment other than in agriculture and some service sectors,
about 300,000 youth of different age groups emigrate to different countries in
search of employment (ibid).
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On the positive side, this migrant labour force remits money home and contributes
to the reduction of family poverty, helps with the education of their children and
siblings, and adds to the sustainability of the national economy (NPC/UNCTN,
2013). On the negative side, many of these semi-skilled labour migrants are
compelled to face life-threatening working conditions when seeking employment.
They also often face discrimination by their employers. A range of unfavourable
working conditions cost many lives of labour migrants (The Guardian, September
25, 2013). The economic and psychological impact of this death toll on their
dependents and family members is catastrophic and irreparable.
These tragic events have not deterred the youth, who are the main forces behind
the productivity of the agricultural sector (which accounts 35% of GDP) from
migrating to foreign land every day. This draining of the country’s productive labour
force has been weakening Nepal’s agricultural sector (NPC/UNCTN, 2013). Other
sources of employment sectors in Nepal, such as the service sector, tourism and
manufacturing, have relatively limited contribution to employment and the national
economy.
In addition, a large proportion of youth are unemployed in the country and are
facing difficulty for survival with no other options for life chances. As a result, they
face prolonged stress linking to health risks. Evidence from a range of countries
shows that even after allowing other factors, unemployed people (given there is no
other source of income) and their families suffer substantially more with increased
risk of premature deaths and disabilities (Wilkinson & Marmot, 2003). Therefore,
employment and working conditions are significant social determinants of health.
11.5 Key determinant: Gender
One’s sex, classified as either a male, female, or intersex, is biologically determined
at birth. However, the gender roles of a 'man' or a 'woman' are both personally
and socially defined; these classifications are determined by social norms, called
gender. Gender norms can be quite different from one culture to another (Nobelius,
2004). A growing body of evidence on the social determinants of health shows that
health outcomes are not attributable to biology (Wilkinson & Marmot, 2003). The
WHO (2010) recognises gender as an important determinant of health because of
two main reasons: firstly, “gender inequality leads to health risks for women and
girls globally; and secondly, addressing gender norms and roles leads to a better
understanding of how the social construction of identity and unbalanced power
relations between men and women affect the risks, health-seeking behaviour and
health outcomes of men and women in different ages and social groups” (Men et
al., 2011; Dahal, 2008).
Global trends show that women generally live longer than men. However, due
to mixed effects of social and biological factors, women may experience more
adverse health impacts than men as only women have the biological capacity to
give birth and, as a mother, they carry more responsibilities for raising children and
taking care of household works. Similarly, many of them suffer socially because
they are female and also a member of a minority, disadvantaged or marginalised
group (Dahal et al., 2007). Although the status of women in Nepal is improving
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substantially compared to the previous decades, women still face multiple facets
of discrimination (MoH, 2011; NPC/UNCTN, 2013). For example, giving birth
to male children is associated with family pride in most families across all social
groups in Nepal, and limiting child birth only starts after having at least two sons
in the family regardless of the number of daughters they already have (Dahal et
al., 2008; Dahal, 2008). Compared to boys, girls in the family have a lower social
status; get less opportunity for nutritious foods and quality education; and face
early marriage and the burden of heavy responsibility of domestic and agricultural
work, especially in marital households and, give child birth at a young age (NPC/
UNCTN, 2013). Similarly, women have been given less opportunity to be involved
in decision making processes, whether the decision is related to the family or
nation (Basnet & Adhikari, 2007). The unequal and unfair treatment of women are
the sources of prolonged stresses on them, and that of the developing risk factors
for different diseases, disabilities and premature deaths (Table 4).
11.6 Key determinant: Ethnicity, religion and culture
Differences in health in terms of both morbidity and mortality across ethnic groups
and religions due to their specific culture have been reported elsewhere (Rogers,
1992; Stewart et al., 1999; Gupta et al., 1995; Sheldon & Parker, 1992). This
situation arises when the socio-economic inequalities exist between and within
different ethnic, religious and cultural groups. In Nepal, widespread poverty and
deprivation, inequality in wealth distribution, education and employment, gender
discrimination and conflicts over the ethnic identity agenda are major contributing
factors for developing stresses, diseases, disabilities and premature deaths (Table
4). There are differences in health outcomes based on the layers of categories of
caste, religion and culture (Bennett & Dahal, 2006).
11.7 Key determinant: Social capital and social safety net
Social capital generally refers to the set of norms, networks, and organisations
through which people gain access to power and resources, thereby decision
making and policy formulation occurs (World Bank 1997, p78; Coleman 1993). So,
social capital is embodied in social organisation, which facilitates coordination and
cooperation for the mutual benefit of the group members (Putnam 1993; World
Bank 1997, p78). Similarly, the social safety net refers to a range of programs
that are implemented by such social or public institutions to protect citizens
from transitions during large life changes, such as having and raising children,
attaining education and employment trainings (Mikkonen & Raphael, 2010).
Likewise, people may face unexpected life events, such as having an accident,
becoming unemployed, developing a physical or mental illness or disability that
can affect health. Such circumstances threaten health and ruin peace increasing
the conditions of economic insecurity and aggravating psychological stress, which
are all important aspects of social determinants of health.
In Nepal, apart from some limited provisions of old-age, disability allowances
and travel allowance to pregnant women who get admission to health facilities
for delivery (as well as some other small incentives) (GoN, MoHP, 2010: Nepal
Health Sector Programme II, 2010-2015), the scope of having facilities under social
security are almost non-existent. People have to face and manage problems by
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themselves, no matter what happens in their lives. They have to pay out of their
pockets for all the expenditure involved in their health care and family affairs (Puri
et al., 2008). Politicisation of ethnicity and identity among groups in the recent
past has threatened to destroy social harmony on one hand, and interlocking
community cooperation based on the 'we' and the 'other' principle on the other.
The institutionalised corruption across sectors including civil service (NPC/UNCTN,
2013), the practice of syndicating and curtailing in business sectors and the
emergence of widespread pernicious networks operating with detrimental effects
to the wider society are all eroding the value of social capital, thereby giving rise
to the downside of social capital (Adhikari & Goldey, 2010). The over politicisation
of the families and communities by different political parties has further eroded the
value of social capital and peace within and between families. The families and
communities that do not have other safety nets such as wealth and resources, are
the ones most affected for livelihood crisis.
11.8 Key determinant: Poor housing, sanitation and material living conditions
Poor housing, sanitation and material living are intricately linked to the state of
poverty which has been previously discussed. Studies show that housing quality
profoundly influence population health and well-being (Mikkonen & Raphael,
2010). According to UN Habitat, quality housing refers to affordable, decent, safe,
and accessible; housing should also have a reasonable amount of space free from
hazards, and be centrally located (Table 8). Housing which cannot meet these
parameters is considered as substandard housing.
Children exposed to substandard housing conditions have been associated
with many common chronic diseases such as asthma, respiratory complications
and infectious diseases (Lanphear et al., 2001). Mounting evidence shows that
higher exposures to infestations of cockroaches, rats and mice, as well as poor
ventilation, excess moisture and mold which are associated with poor housing can
contribute to childhood asthma (IoM, 2000; Rosenstreich et al., 1997; Lanphear et
al., 2001; Acevedo-Garcia et al., 2004). Overcrowding and unsanitary conditions
adds to higher rates of infectious diseases, such as rheumatic fever, tuberculosis,
hepatitis, and respiratory infections (Healthabitat Pvt. Ltd., 2013). Studies have
found that over 40% of asthma cases could be attributed to residential exposures
such as cockroaches, dust mites, environmental tobacco smoke or pets in the
home (Lanphear et al., 2001). The continuous exposure with cockroaches further
worsens children’s asthma with additional wheezing and breathing difficulties.
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Affordable If it does not cost more than 30% household income;
Decent Clean, with good ventilation, free from excessive heat
and cold, leaks and mold, bad smell, garbage, graffiti and
regularly maintained;
Safe Locks that work on doors and windows;
Accessible Particularly for seniors and with disabilities;
Enough space Free from crowding for those who live in;
Free from hazard Toxic chemicals, lead paint, rodent and cockroach infes-
tation etc;
Centrally located In reasonable reach of shopping, public transportation,
recreation, and health and human services, and with
good neighbourhoods with playing space and greenery.
Table 8: Characteristics of quality housing
(Source: United Nations, Human Settlements Programme UN-Habitat (online): http://unhabitat.org/)
Homeless families and those in unsanitary conditions are imminent victims of
these hazards (Krieger & Higgins, 2002). Significantly higher proportion of upper
respiratory infections, skin infestations (e.g. lice and scabies), gastrointestinal
problems (e.g. diarrhoea), and ear infections have been found in homeless children.
Children, who are exposed to lead and arsenic generally from contaminated house
dust or environmental pollution, can experience adverse cognitive and behavioural
effects (Lanphear et al., 2000; Parajuli et al., 2014a). Also poor families who
cannot afford costs associated with housing are compelled to make trade-offs
between rent and other basic necessities, such as food or medical care. This
leads to food insecurity, malnutrition, and missed preventative medical care, all
of which have lasting effects on family health and development. In addition, high
exposure to violence and crime victimisation due to hardships within family circles
and neighbourhoods (Anderson et al., 2002; 2003) result in prolonged stress and
stress-related disorders (Anderson et al., 2002).
Direct contact with animals, vermin and insects in the housing environment cause
many diseases, such as malaria (caused by mosquito bites), chronic gut diseases
(caused by a parasites carried by dogs) and eye disease (caused by flies carrying
trachoma bacteria) (Health abitat Pvt Ltd., 2013). Unsealed roads or vacant land
in the rural community are the source of dust which causes irritation, eye diseases,
respiratory disease and skin infections. Living in houses that are too cold or too
hot can contribute to a range of physical illnesses, as well as emotional distress
(Healthabitat Pvt Ltd., 2013). Similarly, exposure to dirt, soil (walking barefoot) and
improper hand washing (e.g. not using soap) can cause the intensity of infections
related to roundworm, hookworms and whipworm (Parajuli et al., 2014b).
Data from the 2011 census of Nepal (GoN, 2012) shows poor foundation and
walls of households, primarily constructed from mud-bonded and cement-bonded
bricks/stones, indicate sub-standard housing structure. Drinking unsafe water is
also a grave risk faced by the population as the majority of drinking water sources
THEME IV:
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are unsafe. Furthermore, cooking materials in the kitchen setting are found to be
unhygienic, with the burning of fire-wood and cow-dung in a congested space.
Similarly, four in ten households have no toilets. Although toilets are there in standard
houses, they lack enough water to flush, hand wash and clean. In addition, a large
proportion of people in Nepal come into contact with animals, vermin and insects,
as 88% of households have owned livestock (Food and Agriculture Organization
(FAO), 2011). They also use unsafe drinking water, and are exposed to poor
sanitation and a range of hazardous conditions (e.g. indoor air pollution, exposure
to cockroaches, dust particles, dust mites, tobacco-smoke). The accumulated
knowledge synthesised from a range of studies regarding the status of housing
and related conditions in Nepal clearly shows that the majority of people live in
sub-standard houses and suffer from a range of complications such as asthma,
respiratory complications and infectious diseases. These circumstances clearly
prove that housing, sanitation and material living conditions are important social
determinants of health in Nepal.
11.9 Key determinant: Physical infrastructure and transportation
Physical infrastructure and transportation plays a critical role for sustainable
development. They facilitate the movement of people, goods and services, as
well as promote access to necessary goods and services; it allows for market
expansions needed for various activities impacting economic and human
development (WHO, 2014). In Nepal, the Ministry of Physical Infrastructure and
Transport was established in 2000 to contribute to infrastructural development
and to effectively and efficiently manage infrastructural services. With continuous
efforts from the Ministry and its associated partners, a total of 62,579 kilometres
road network in Nepal has been built by 2013. Of that total, only 11.4% of the roads
are blacktop, with the rest being gravelled (26.3%) and earthen (62.3%) (Thapa,
2013). Although 815 village development committees (VDCs) out of the 3,915
total VDCs in Nepal have not still been connected with road networks (Upadhaya,
2014), 1,545,988 vehicles in Nepal are running on these earthen roads (Upadhaya,
2014); this creates dust clouds during dry seasons and large muddy ditches in
rainy seasons.
In recent years, construction of rural infrastructure is gaining momentum. However,
the current focus lies on increasing the scale of such infrastructure without
considering their quality and environmental impact. Due to the poor quality of
road networks, road accidents and injuries have been one of the major causes
of premature death and disability in Nepal. The statistics of Nepal Police Traffic
Directorate (Thapa, 2013) show that 13,582 accidents occurred in 2012/13 alone.
Of them, 1,816 were fatalities, 3,986 were serious injuries, and 8,000 were slight
injuries. In addition, the dust pollution caused by earthen roads has been contributing
significantly to irritation and diseases such as, eye diseases, respiratory diseases
and skin infections. If transport networks could be well developed and safe, and
could promote cycling, walking and the use of public transport, health could be
promoted in three ways: providing healthy exercise, reducing fatal accidents and
reducing air and dust pollution.
SUSTAINABLE LIVELIHOOD SYSTEMS IN NEPAL
Principles, Practices and Prospects
337
11.10 Key determinant: Food security
Food security, or adequate food supply with nutritious diet, is the key to good health
and well-being. “When all people at all times have physical and economic access
to sufficient, safe and nutritious food which meets their dietary needs and food
preferences for an active and healthy life” (FAO, 2011), they can live healthy lives.
However, if people experience “a shortage of food and lack of variety as needed for
subsistence livelihood” then, this causes malnourishment and immune deficiency
diseases. In Nepal, the situation of food sufficiency through local production is
gradually decreasing and 43 out of 75 districts have experienced food deficiency
(NPC/UNCTN, 2013). Across the country, 3.33 million people, most of whom
are from rural sectors, are estimated to be vulnerable to food shortages (MoAD/
WFP, 2012; Bohle and Adhikari, 1998; Parajuli et al., 2012). Overall about 27%
of rural households are food insecure with very poor food consumption patterns.
Women and children are the most disadvantaged groups. For example, chronic
malnutrition and low weights are common among children, where 49% of children
aged 0-59 months are underweight and 46% are stunted (UNICEF, 2009; Dahal
et al., 2009).
The top quintiles of economically well-off families in Nepal enjoy good housing and
sanitation and have less issues of nutritious food supply. Knowingly or unknowingly,
they have excess food intake. Evidence shows that excess food intake is also a
problem by which people easily develop cardiovascular diseases, diabetes, obesity,
dental issues, cancer and degenerative eye diseases (Wilkinson & Marmot, 2003).
When food supply and diets improve with housing and sanitation as a result of
economic growth, it causes an epidemiological transition from infectious to chronic
diseases. Emergence of a new and shifting of disease burden in Nepal, as shown
in Table 3, clearly indicates this scenario.
Although agriculture is a very important sector in Nepal, the performance of this
sector has been inadequate to meet increasing food demands and low agricultural
productivity has been a major cause of food insecurity. Therefore, food security is
an important SDH in the country.
11.11 Key determinant: Early life and childhood development
Evidence shows that building good health conditions starts from the earliest
developmental stage of the embryo (the zygote). During pregnancy, if mothers
suffer from poor nutrition, stress, exposure to smoking, misuse of drugs and
alcohol, insufficient exercise, prenatal care, and emotional support, the new-
born children of such mothers will suffer from adult ill-health and immature death
(Wilkinson & Marmot, 2003). Poor childhood development due to poor nutrition,
exposure to smoking and other forms of pollution and poor sanitation as well
as poor emotional support causes slow brain responses resulting in reduced
readiness for school, low educational achievement, problematic behaviour and the
risk of social marginalisation in adulthood (Ibid:14). Similarly, if an infant’s physical
growth is slow or retarded due to the impact of adverse circumstances, it can
lead to reduced development of cardiovascular and respiratory organs, pancreas,
kidney and their functions, which increase the risk of developing diseases related
to these organs in adulthood (Ibid:14).
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338
In Nepal, widespread poverty combined with ignorance and insufficient knowledge
related to the impact of early life and childhood development on adult life (as well
as rooted gender discrimination in the name of socio-cultural norms) have been
contributing to affect children’s growth and development of diseases even among
relatively educated masses. Similarly, a large prevalence of maternal smoking and
children’s exposure to second hand smoke (Dahal et al., 2009) and indoor air
pollution (GoN, 2012) has been contributing to the development of diseases and
premature deaths in early lives and beyond (Table 5).
11.12 Key determinant: Stress
As discussed earlier, various life conditions result in stress. For example, when the
national government and its policies cannot support citizens enough to manage
their minimum basic needs, and if the citizens have only limited means to survive,
they face several challenges in life (even simply meeting household needs).
Inability to meet basic family requirements such as sending children to school
or looking after elderly parents makes them feel frustrated, insecure, shameful
and worthless, often leading to them losing their hope and self-esteem. This
unfavourable socio-economic and psychological condition can cause anxiety and
social isolation which can result in a person being unpredictable, uncontrollable
and irrational (Mikkonen & Raphael, 2010).
In many cases, stress and high level of exhaustion drives individuals to adopt
unhealthy coping behaviours. They use to feel ‘short term momentary relief’
consuming excessive alcohol, and smoking tobacco and drugs (Mikkonen &
Raphael, 2010). If these conditions continue, the individual will be the victim of
depression. The WHO in 2014 revealed that depression is the predominant cause
of illness and disability, which does not only affect the victim, but also all family
members. Eventually, this leads to chronic illnesses and premature deaths (WHO,
2014; Marmot, 2003). Therefore, stress is an important social determinant of
health, but has been neglected in Nepal not only in societal level but also in policy
formulation.
11.13 Key determinant: Access to health services and health seeking behaviour
When people do not have favourable conditions related to all social determinants
of health as outlined above, the outcome is to be a victim of various diseases or
illnesses from multiple burdens. If the victim believes in and can afford the health
care system they go to health facilities for treatment. In some settings, people still
prefer to go to traditional healers rather than going to health facilities. “Who tend
to prefer which service option” also depends on the knowledge about the nature of
illness, exposure towards health facilities, affordability to access health care, level
of health literacy and trust on health care services (Dahal et al., 2013).
In any case, good population health depends on the effective supply (delivery) and
demand (health seeking behaviour) of health services. Effective health services do
not only depend on the facilities of diagnosis and treatment of diseases, but also
on the combined effect of the availability of funding, staff, equipment and drugs that
allow the delivery of health interventions in a sustainable manner (WHO, 2014).
Similarly preventive treatments and management of population health can only
SUSTAINABLE LIVELIHOOD SYSTEMS IN NEPAL
Principles, Practices and Prospects
339
be effective when the users are sincere enough to seek care in a timely fashion,
according to their needs. Improving access, universal coverage and quality
of services depends on the key resources available, on the ways services are
organised and managed and on incentives influencing providers and users (WHO,
2014).
The current situation of population health in Nepal, including structure, systems,
governance and health financing, are well documented (MoHP, 2010; WHO,
2007; Tiwari et al., 2012; NPC/UNDP, 2010; NPC/UNCTN, 2013). The overall
message of various research reports is that Government in Nepal has achieved
significant progress in strengthening health care systems over time, although the
magnitude of achievement is relatively small compared to the potential end goals.
To address the current policy challenges, Shrestha and Pathak (2012) stated 24
specific recommendations under four main themes to: increase access to and use
of health services, improve the provision not only of essential health care services
(but also of noncommunicable diseases), strengthen and expand health facilities
and improve the quality of health services.
In addition, the real challenge is to scale up services that are working and to
continually improve effectiveness and accelerate progress, and to strengthen the
value of universalism in health services. There is also a need to better target the
hardest-to-reach segment of the population who have been overlooked in the past.
This group includes the ultra-poor and those disadvantaged because of their sex,
age, ethnicity, disability, or geographical location. (NPC/UNCTN, 2013). Similarly,
people in rural areas still rely on traditional healers for the first attempts at treatment
and they seek care from health facilities only when this becomes unsuccessful
(Poudyal et al., 2003). The irony again is that most of the health facilities in the
rural areas are under-resourced and run without trained health staff. Therefore, the
level of access to health services combined with health service seeking behaviour
of people is an important social determinant of health.
12. Conclusion
This paper discusses in detail how SDH play a significant role in shaping population
health outcomes. The synthesis of facts as presented in this article highlights that
the origin of people’s entire burden of diseases, disabilities and premature deaths
rely on their social structure operating through the socio-psychological, material
and behavioural pathways which influence the living conditions into which people
are born, grow, live, work and age. However, these well documented facts on
social determinants of health have not yet been well recognised in the national
health policies and programs. Greater awareness of such information means local
people themselves can become active in managing many of the problems they
face. For instance, school teachers can play a significant role by educating their
students about SDH, and, over time, that could help to improve households and
communities through the information relayed by these students. Embracing social
determinants of health in Nepal’s health policies and programs, and raising public
awareness about them, is therefore crucial.
THEME IV:
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340
The primary step to succeed in achieving this goal is to help improve the living
conditions of Nepalese through the implementations of appropriate evidence-
based population health policies and programs. As population health and related
policies are linked with a range of social determinants of health explained in this
article, efforts of a Government Ministry (e.g. Ministry of Health and Population)
alone cannot be sufficient to effectively address the root-causes of entire population
health issues in Nepal. As elsewhere, this circumstance calls for effective
collaborations between relevant Ministries, international, bilateral and other local
partners. Similarly, collective actions of all partners including district authorities and
local community groups is essential to effectively address the social determinants
of health in order to reduce the current health equity gaps existing in Nepal.
It is hoped that this article will be useful for policy innovation and an important
resource for health institutions in Nepal moving forward for developing curriculum
on social determinants of health.
13. Acknowledgement
The authors would like to acknowledge the valuable comments and suggestions
of Dr. Krishna Adhikari (Oxford University, UK), Dr. Kalidas Subedi (Agricultural
Canada), and Michael Casey (CFFN), Dr. Ambika Adhikari (CFFN), Bishwa Regmi
(CFFN), Dr. Michael G. Tyshenko (University of Ottawa) and two anonymous peer-
reviewers. In addition, support of Ms. Grishma Dahal, Reshma Dahal (Faculty of
Social Sciences, University of Ottawa, Canada) and Ms Kusum Wagle (Public
Health Instructor - Om Health Campus, Kathmandu) for literature review is much
appreciated.
SUSTAINABLE LIVELIHOOD SYSTEMS IN NEPAL
Principles, Practices and Prospects
341
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Health and Sustainable Livelihoods
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without prior written permission of the copyright holders.
Adhikari, A.P., and Dahal, G.P. (eds.). 2015. Sustainable Livelihood Systems in Nepal:
Principles, Practices and Prospects. IUCN and CFFN. Kathmandu, Nepal.
xx + 306 pages
Price: Hard copy - Rs. 1,500 in Nepal; $20 for international individual buyers; $40 for
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Pdf copy - Rs. 1,000 or $15 for individual sale; $30 for institutions/libraries.
ISBN: 978-9937-8467-2-1
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Published in 2015
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Canada Foundation for Nepal (CFFN) is an Ottawa-based not-for-profit organization dedicated to
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promoting critical thinking and enhancing scholarly exchanges between Nepal and any interested
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www.cffn.ca
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This book is dedicated to the victims of
the earthquake that struck Nepal in 2015.
