Report No. 7498-NEP Nepal Social Sector Strategy Review (In Two Volumes) Volume II: Sector Reviews April 19, 1989 Asia Country Department I FOR OFFICIAL USE ONLY . ,~~~~~~~- .3~~~~~> Document of the World Bank This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. Exchange Rate Rs. 22.1 = US$1 (May, 1988) Rs. 25.7 = US$l (February, 1989) Fiscal Year His Majesty's Government of Nepal July 16 - July 15 Abbreviations and Acronyms Used BNP Basic Needs Program Cal. Calorie CRU Country Resource Utilization Study FP/MCH Family Planning/Maternal Child Health FY Fiscal Year GDP Gross Domestic Product ha. Hectare HMG His Majesty's Government of Nepal IDA International Development Association MT. Metric Ton MOE Ministry of Education MPHBS Multi-Purpose Household Budget Survey NCP National Commission on Population p.a. per annum PEP Primary Education Project PHC Primary Health Care Rs. Rupees TA/DA Travel Allowance/Daily Allowance TFR Total Fertility Rate UNDP United Nations Development Program UNICEF United Nations Children's Fund WHO World Health Organization FOR oMCAL USE ONLY ABBREVIATIONS AND ACRONYMS USED ADB Asian Development Bank ADBN Agricultural Development Bank of Nepal AHW Auxiliary Health Worker ANM Auxiliary Nurse/Midwife BNMT Britain-Nepal Medical Trust BNP Basic Needs Program Clv Community Health Volunteer CPR Contraceptive Prevalence Rate CRU Country Resource Utilization Study DEO District Education Officer DPHO District Public Health Officer EPI Expanded Program of Immunization FP/MCH Family Planning/Maternal Child Health FPAN Family Planning Association of Nepal FY Fiscal Year GDP Gross Domestic Product HA Health Assistant ha. Hectare H1MG His Majesty's Government (of Nepal) HP Health Post ICHSDP Integrated Community Health Service Development Project IDA Internationa: Development Association IFAD Interiational Fund for Agricultural Development IMR Infant Mortality Rate ioM Institute of Medicine MOEC Ministry of Education and Culture MOH Ministry of Health MPHBS Multi-Purpose Household Budget Survey MWRA Married Women of Reproductive Age NCP National Commission on Population NGO Non-Governmental Organization p.a. per annum PCRW Production Credit for Rural Women PEP Primary Education Project PHC Primary Health Care Rs. Rupees SFDP Small Farmers' Development Program SLC School Leaving Certificate TB Tuberculosis TFR Total Fertility Rate UNDP United Nations Development Program UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund VHW Village Health Worker VTE Vocational and Technical Education WDR World Development Repert WHO World Health Organization This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. NEPAL: SOCIAL SECTOR STRATEGY REVIEW VOLUME II - SECTOR REVIEWS Table of Contents PART I - EDUCATION Page No. I. INTRODUCTION - EDUCATIONAL STATUS IN NEPAL ......... .... 1 II. PROGRAMS AND CURRENT ISSUES IN THE EDUCATION SYSTEM ......................................... s . . . . . ... 5 A. Primary Education . .. .................................... . 5 B. Secondary Education ....................... ................. 13 C. Higher Education ......................................... . 16 D. Other Types of Education . ............. . 21 III. EDUCATION FINANCE.... .. ........ .... ..... ..23 A. Public Resources for Education ............. B. The Role of External Assistance ............................26 IV. THE OUTLOOK FOR THE FUTURE - SOME EMERGING ISSUES. 29 A. Education and Population. .......... , . ... . .29 B. Projected Resource Constraints . ..... ..... . 31 V. PROPOSED SECTOR STRATEGIES ................................. .34 A. Government Strategy ............... ................. .... .34 B. Priority Areas for Assistance ............................... 38 PART II - POPULATION AND HEALTH PART II-A POPULATION . .. 44 Is CURRENT SITUATION . ......................44 A. Population Growth ......... 44 B. Family Planning ... . .... 45 C. Migration. ...... . ... 46 II. INTERSECTORAL LINKAGES ....... .. .... . . .48 A. Fertility ..........................48 B. Mortality. . ..... ....... 50 C. P iUration PROJECTIOS ............... ......... 51 III. POPULATION PROJECTIONS ..................... 52 IV. GOVERNMENT STRATEGY AND PROGRAMS ................... ... ......... . 56 A. Population Strategy .... .. . ..... ......... ............. 56 B. Current Programs ............................ .......... 56 C. Institutional Arrangements ................................. 57 V. POPULATION PROJECTIONS AND BASIC NEEDS. 59 VI. PROGRAM IMPLEMENTATIONl STRATEGY .......... ............ 60 PART II.B HEALTH. FAMILY PLANNING, AND NUTRITION ..................... 62 VII. CURRENT HEALTH STATUS .. ........ ......................... ........ 62 A. Introduction . .. ............................................ 62 B. Mortality . ................................................. 62 C. Morbidity and Disability .. ................................ 9 9 * * . 63 D. Maternal Morbidity and Disability .............. ............. 65 E. Nutrition ........ ......................................... 67 F. Risk Factors ... . ........................................... 68 VIII. THE POLICY FRAMEWORK ....... .......................71 ............. 1 IX. THE HEALTH SERVICES SYSTEM ...................................... 73 A. Organization ......................................... . 73 B. Infrastructure ...................................... 75 C. Manpower .999999999 . ................... 77 D. Public Expend,ture .... ................... .............. 79 E. Non-Governmental and Private Services .........84 X. ISSUES IN HEALTH, FAMILY PLANNING AND NUTRITION . .87 A. Effectiveness ....... . ........87 B. Efficiency . . ....... ............ 88 C. Decentralization ........................................... 89 D. Integration . .... ............. .... 90 E. Regionalization ............................. ...... . 99 9 .91 XI. PRIORITY AREAS .*.*..... ......... * .* .......... ... **.*.*.... 92 A. Female Health and FP Workers . . ............................. 92 B. Residency Training in Rural Facilities ..................... 93 C. MCH and FP Priorities . . .................................... 94 D. Iodine Deficiency Disorders ................................ 95 E. Malaria ............. 96 PART II.C CONCLUSIONS ... 9............................9 9 9 9 9 9 9 999 XII. HEALTH AND POPULATION SECTOR STRATEGY ........................... 99 A. General ................................................ 99 B. Priority Areas for Assistance ....................................... 101 PART III - ASSESSMENT OF POVERTY IN NEPAL I I. ...... ........ ...105 II. POVERTY IN NEPAL IN A COMPARATIVE CONTEXT .................................. 106 III. THE DIMENSIONS OF POVERTY IN NEPAL ............................. llO A. The Poverty Line ..................... ... ................. . 110 B. The Distribution of Income in Nepal . ............... llO C. The Incidence of Poverty ........ .................. . ... . 113 IV. SOME ATTRIBUTES OF THE POOR IN NEPAL ....................... , 115 A. 'she Urban Poor ........................... ................ 115 B. The Rural Poor ......... .. . . ...... . 119 C. Women .......................................... . . . . . 124 V. TARGETTED POVERTY ALLEVIATION PROGRAMS ..... ..... A. Programs Covered Under the Basic Needs Strategy. 126 B. Other Programs ................. 129 VI. CONCLUSIONS AND POLICY IMPLICATIONS ............... . 132 A. General .......................................... . . . . 132 B. Country Strategy .... ... ......................... . .133 C. Assistance Strategy .............. ..... .. . 135 ANNEXES (following page 137) Annex I - Educacion Sector Annex I-1 - Gross Enrollment Ratios, 1972-1984 Annex I-2 - Drop-out, Repetition and Promotion Rates, 1983/84 Annex I-3 - Under-five Mortality Rates by Parental Education Annex I-4 - Public Financing of Education, 1974/75-1985/86 Annex I-5 - Projected Additional ResoLrce Availability for the Education Sector 1990-2000 Annex I-6 - Student Enrollment and Budget Allocation Unit Costs, 1983/84-1986/87 Annex II - Population and Health Sector Annex 11-1 - Characteristics of Contraceptive Users Annex II-2 - Population Projections Annex II-3.1 - Cases of Malaria in Nepal 1950-87 Annex II-3.2 - Maternal Morbidity and Mortality by Cause Group Annex Il-4 - Ministry of Health - Organization Charts Annex II-5.1 - Ministry of Health Budget 1975-87 Annex II-5.2 - Actual vs. Planned Health Expenditures Annex 11-5.3 - Breakdown of Health Expenditures Annex II-5.4 - HMG Expenditure on Family Planning Annex II-5.5 - Teaching Hospital Budget Annex II-6 - Donor Assistance for FP/MCH Annex II-7 - Hospital Distribution and Constrtction Program Annex II-8 - Estimate of Basic Needs Manpower Requirements Annex III - l verty in Nepal Annex III-1 - The Poverty Line Annex III-2 - The Multi-Purpose Household Budget Survey Annex III-3 - Targetted Rural Credit Programs PART I - EDUCATION SOCIAL SECTOR STRATEGY REVIEW - VOLUME II PART I - EDUCATION Table of Contents Page No. I. INTRODUCTION - EDUCATIONAL STATUS IN NEPAL ...................... I II. PROGRAMS AND CURRENT ISSUES IN THE EDUCATION SYSTEM ................................ .#*.............. . ..., 5 A. Primary Education ........................ .................. 5 B. Secondary Education ....................... ................. 13 C. Higher Education .................... ..................... .16 D. Other Types of Education .............................. 21 III. EDUCATION FINANCE ...... . ..... . ..... .. ....... 23 A. Public Resources f or Education .23 B. The Role of External Assistance ..... .......26 IV. THE OUTLOOK FOR THE FUTURE - SOME EWERGING ISSUES ...............29 A. Education and Population .......................... . 29 B. Projected Resource Constraints ............... 31 V. PROPOSED SECTOR STRATEGIES ........ ............. so ............. 34 A. Government Strategy .... ............................ . 34 B. Priority Areas for Assistance ......................... . 38 ANNEXES (Contained in Annex section following page 137) Annex I-1 - Gross Enrollment Ratios, 1972-1984 Annex I-2 - Drop-out, Repetition and Promotion Rates, 1983/84 Annex I-3 - Under-five Mortality Rates by Parental Education Annex 1-4 - Public Financing of Education, 1974/75-1985/86 Annex 1-5 - Projected Additional Resource Availability for the Education Sector 1990-2000 Annex 1-6 - Student Enrollment and Budget Allocation Unit Costs, 1983/84-1986/87 Chapter I - INTRODUCTION - EDUCATIONAL STATUS IN NEPAL 1.01 The education and training sector in Nepal is facing a number of serious problems- not the least of which is the rapidly growing population (2.6Z) and little evidence that the school age population growth rate will decline significantly over the twenty-two year period to 2010. Combined with underenrollment, low attendance rates, and significantly constrained financial resources (both public and private) available for the future expansion of the education sector, HMG is faced with a number of serious choices both within the education sector and between education and other government programs. This paper will attempt to highlight many of the problems facing the education sector together with the nature of the education sector choices likely to be available to the Government of Ekepal and especially to its Ministry of Education and Culture (MOEC). 1.02 While the problems and difficulties facing the education system in Nepal are highlighted in this paper, it must be emphasized at the outset that the HMG has achieved significant progress in the education sector since 1951 when efforts to modernize the economy were begun. While consistent data series on the development of education systems are hampered by poor quality information systems (which are being improved), Table 1 clearly demonstrates the outstanding growth of the education system since 1951, when there were only 416 educational institutions catering to less than 11,000 students- an extremely small proportion of the school age population. It is estimated that the national literacy rate in 1951 was only of the order of 2-3Z. Table l Growth of Education Sector, 1951-1985 Levels of Number of Institutions Student Enrollment Education 1951 1965 1975 1985 1951 1965 1975 1985 Primary 203 5,696 8,341 11,660 8,970 386,104 458,516 1,833,655 Middle 200 - 1,893 3,420 - - 174,143 266,639 Secondary 11 687 479 1,235 1680 58,207 62,214 228,502 Higher 2 34 79 69 250 8081 23,504 23,478 Total 416 6,417 10,765 16,384 10,900 452,392 718,377 2,352,274 Source: Strategies for National Manpower Development in Nepal, I.L.O., June 1986, p. 43. Data based on Ministry of Education and National Planning Commission statistical reports. - 2 - 1.03 The expansion of the formal education sector together with the simultaneous development of a series of small -lult education/literacy programs has resulted in an improvement in the irerall literacy rate which, as shown in Table 2, had reached 23.5? in 1981 and 34.8? by 1986. While these figures suggest a rapid improvement in overall literacy in the 1980's, the extent of the apparent achievement should be tempered by the possibility of overestimation in the 1986 sample survey and underestimation in the 1981 census. 1/ 2/ The figures also clearly demonstrate that improvements in literacy rates are primarily a function of males becoming more literate. Between 1954 and 1986 male literacy increased from less than lOX to almost 52Z, while female literacy had only increased to 18? by 1986 - a fact which clearly highlights the past under-representation of women in the education system, and a key policy issue for future educational development in Nepal. Significant disparities are also to be found between the literacy rates of urban and rural areas as illustrated in Table 3. Particularly noticeable are the relatively low literacy rates for rural females with only 162 recorded as literate in 1986. Urban females are, however, much more likely to be literate (47.5Z), a rate which is eimilar to the rural male rate of 49.9?. Table 2: Overall Literacy Rates by Gender 1952154 - 1986 (Population 10 Years and Over) 1952154 1961 1971 1981 1986 (a) Male 9.5Z 16.3Z 24.72 34.0? 51.8Z Female 0.7Z 10.8? 3.7? 12.0X 18.0O Total 5.3Z 8.9? 14.3? 23.3? 34.8? Note (a): Six years and over as reported by Demographic Survey 1986/87 (1987). Other data from censud information as reported in Population Monograph of Nepal (1987). 1/ Demographic Sample Survey, 1986/87, pp. 9-11. 2/ A Oliterate" person is defined as one who has the ability to both read and write in any language with understanding. However, the information collected does not result from a functional test. -3- Table 3: Rural-Urban Literacy Rates by Gender, 1981 and 1986 (percent) Urban Rural 1981 1986 1981 1986 Male 61.1 77.7 31.9 49.9 Female 38.2 47.5 10.3 16.1 Total 50.5 62.7 21.4 32.5 Source: Demographic Sample Survey 1986-87, National Planning Commission, Kathmandu, 1987. 1.04 The Government's recently launched Basic Needs Strategy has an objective of reaching "Asian standards of living by the year 2000'. It is appropriate to compare literacy rates achieved in Nepal with its regional neighbors. Table 4 clearly demonstrates that literacy rates in Nepal are low by regional standards and that Nepal has a considerable gap to narrow. Table 4: Literacy in Rural and Urban Areas in Selected Asian Countries (Latest Census or Survey Data available since 1970). (percent) Urban Rural Country Year Total Male Female Total Male Female Nepal 1986 63 78 48 33 50 16 Nepal 1981 51 61 38 21 32 10 India 1981a/ 41 18 China 1982 84 91 75 65 79 51 Thailand 1970 88 94 82 77 86 68 Philippines 1980 97 94 92 77 78 76 Bangladesh i981 48 58 34 25 35 15 Pakistan 1981 47 53 35 17 27 7 Source: Singh, Raja Roy. Education in Asia and the Pacific, UNESCO Bangkok 1986, p. 92. Nepal data from the Demographic Sample Survey, see Table 3. a/ India data for 1981 from National Literacy Mission, Ministry of Human Resource Development, Department of Education, GOI, April, 1987, pages 5 and 14. Urban data not available, overall literacy rate for the entire nation in 1981 was 362; males, 47Z; females, 25?. - 4 - 1.05 Nepal's literacy rates are to a large extent a function of the past development of the education system. Since 1971, when a major effort was initiated to modernize and expand the education system, gross enrollment ratios at all levels of the school system have expanded.3/ By 1984 gross enrollment ratios in primary schools (grades 1-5) had reached 822 from only 212 in 1972. At the lower secondary level (grades 6-7) gross enrollment ratios had reached 31.22 in 1984 (7.21 in 1972) and in secondary schools (grades 8-10) the figure was 20.5? (5.4Z in 1972). However, as Table 5 demonstrates, female enrollments at all levels of the school system have remained very low. At the primary level, the female gross enrollment ratio had only reached 50? by 1985 (111.5? for males). At the higher school levels, gross female enrollment ratios are only about one-third of the equivalent male ratio. Table 5: Gross Enrollment Ratios, Selected Years 1972-1985 (Percentage of school-aged population) Primary Lower Secondary Secondary Grades 1-5 Grades 6-7 Grades 8-10 Female Total Female Total Female Total 1970 7.1 21.6 2.3 7.6 1.8 5.4 1976 12.7 33.6 4.0 11.4 2.9 8.2 1981 38.4 68.7 8.9 21.1 4.8 13.0 1985 50.0 82.1 15.9 31.2 9.2 20.5 Source: Annex I-1. 3/ The gross enrollment ratio expresses total enrollment regardless of age as a percentage of the school age population. School age here assumed to be 6-10 years for primary, 11-12 for lower secondary and 13-15 for secondary levels. Chapter II - PROGRAMS AND CURRENT ISSUES IN THE EDUCATION SYSTEM A. Primary Education 2.01 Nepal has made significant progress in improving access to primary education since 1971 when the Government embarked on the implementation of the National Education System Plan (NESP). Prior to 1971 primary education had been the responsibility of local communities, except for a limited number of government-sponsored (largely urban) schools. With implementation of the NESP in 1971, primary education received a strong push, with the Government taking over additional responsibilities for education and significant financing and control of schools. In order to further improve access to primary education, schooling through grades 1-3 was provided free of charge from 1975176. In 1981, the structure of primary education was altered and the number of primary grades increased from 3 to 5. This coincided with the Sixth Plan (1980-85) which had a target of extending a primary education to 75? of primary school-age population (now 6-10 years). 2.02 Table 6 presents a summary of primary education development in Nepal to 1986. It is evident that the rate of increase in enrollments is falling over time. During the 1980'Q, the decline has been dramatic. It is particularly noticeable that the rate of increase in female enrollments - which in 1986 only accounted for 30 percent of total primary school enrollments - has fallen despite explicit policy measures designed to improve female participation in the school system. Table 6: Growth of Primary Education. 1971-1988 1971 1976 1981 1986 1988 Number of Schools 7,684 8,768 10,628 11,873 12,188 Annual Growth (U) 2.8 8.9 2.8 2.6 Number of Students Boys 348,898 612,066 1,014,266 1,270,449 1,298,177 Annual Growth (X) 12.1 10.6 4.6 2.2 Girls 64,107 160,408 878,786 641,649 659,481 Annual Growth (X) 18.6 20.0 7.7 8.3 Total 410,605 762,48 1,3888,001 1,812,098 1,867,868 Annual Growth (X) 18.2 12.7 6.9 2.6 Girls as X of total enrollment 16.6 19.7 26.9 29.9 80.1 Gross Enrollment Ratio (X) Boys 85.0 n.a. 98.8 111.6 n.a. Girls 7.1 n.e. 89.7 50.0 n.a. Total 21.6 n.a. 70.6 82.1 n.s. Source: Nepal Education and HumNn Resources Sector Asssament, January 1988, p. 4-14. for years 1971-85. 1986 figurso from Educational Statistics of Nepal at a Glance (1982-88), MOEC (1987). - 6 - 2.03 Enrollment Ratios provide another meaningful indication of primary education achievements, and an indication of the task ahead. Gross enrollment ratios express the total number of children of any age enrolled in primary school as a proportion of the estimated school age population. Net enrollment ratios express the number of school aged children enrolled in primary school as a proportion of the estimated school age population. Estimates of enrollment ratios are thus dependent on accurate school records and on age specific population data (often in other than census years). It is also necessary to appreciate what constitutes an enrollment in Nepal. Students are classified as enrolled if they register for school (considerable incentives exist for schools to have higher enrollment) and it does not necessarily follow that students enrolled actually attend school throughout the school year. Thus, care must be taken in interpreting both past and projected enrollment ratios. 2.04 The gross enrollment rate for primary schools published for 1985 by the National Planning Commission is 82Z.4/ The figure used by the HOEC is 77Z.5/ The difference being the result of using differing population projections for the 6-10 year age group. The recent Demographic Sample Survey 1986/87 also collected information on enrollment ratios which differ significantly to those reported above.6/ The gross enrollment ratio for primary schools was reported to be 63Z -- 44? for girls and 80? for boys. Because these figures are the result of a sample survey, they must be interpreted with care. However the figures are interpreted, it is obvious many potential students-- particularly girls--are not enrolling in school. 2.05 Net enrollment ratios - because of the need to have detailed information on the age structure of students enrolled in schools - are difficult to estimate in Nepal, but give a better indication of the school age population actually in school. It is clear that as much as 30? of enrollment consists of under-age or over-age children. The net enrollment rate for 1985 published by MOEC is 57Z,7/ while the rates reported by the 4/ As presented in Table 5 and Annex Table I-1. 5/ As reported in Nepal Education and Human Resources Sector Assessment. January 1988, pp. 4-15. 6/ Demographic Sample Survey 1986/87, National Planning Commission- Table A.8 (A), p. 37. 7/ Nepal Education and Human Resources Sector Assessment (January 1988), pp. 4-15. National Planning Commission for 1984 were 65Z (852 and 442 for males and females respectively).8/ The comparable figures presented by the Demographic Sample Survey (DSS) of 1986 give a total net enrollment ratio of 41X (with males at 512 and females at 292).9/ Subject to the limitations of the data source noted above, these figures suggest that in 1986, 49Z of males and 712 of females in the age group 6-10 were not enrolled in a primary school. For urban areas - a small fraction of the total population - it is estimated in the DSS that the net enrollment ratio is 732 for males and 602 for girls, for an average of 672. The Government has recently started new programs to raise female enrollment: free textbooks in grades 4 and 5, scholarships and uniforms for 52 of all girls. These programs are so new that effects on enrollment cannot yet be measured. 2.06 It is also instructive to consider relative differences across the various Development Regions and ecological zones. Table 7 presents the 1985 gross enrollments for boys and girls for each ecological zone. Among the five development regions, gross enrollment ratios range from over 10O2 in the Western Region to less than 702 in the Mid. and Far Western Regions. Clearly a strong effort to improve enrollment is required in the Terai. Table 7: Enrollment Ratios by Ecological Zone, 1985 (percent) Gross Enrollment Ratio Ecological Zone Male Female Total Mountains 112 37 75 Hills 128 59 94 Terai 88 40 65 Total 107 49 79/a Source: Nepal Education and Human Resources Sector Assessment (January 1988), pp. 4-15 & 4-16. a/ Corresponding net enrollment ratio estimated at 572. 2.07 The figures on enrollment trends indicate that with declining enrollment growth rates, and continuing high primary school age-specific population growth rates, the task ahead of raising enrollment ratios will not be easy. Further, while it is clear that a major effort is required to 8/ Population Monograph of Nepal, National Planning Commission, 1987, p. 146. 9/ Demographic Sample Survey 1986/87, National Planning Commission, Table A.8(A), p. 37. - 8 - raise female enrollments, it is by no means true that the enrollment problem is only a female one. Clearly many boys are also not going to school, particularly in the Terai. Five districts in the central Terai have gross enrollment ratios under 50X. In these areas the ratio for boys is between 402 and 50Z and the ratio for girls is about 202. Various social and economic reasons are advanced for this condition. It is agreed that simply building more schools would not solve the problem.lO/ 2.08 The MOEC has begun a systematic school mapping program in order to plan for universal access to primary school. This effort should be strongly supported, but it is not appropriate to view the enrollment problem in Nepal as only an access problem. It is true that in some districts terrain and walking time (a far better indicator of access than distance) to school is a problem. On the other hand, many families have one child at school but not others - indicating that walking time to school is not the key constraint preventing enrollment. 2.09 More important are other parameters of the primary education system. There is a need for analysis of the extent of private demand for primary education in Nepal. International evidence and the initial results of both the Bank's ongoing Primary Education Project and the Seti Zone education project clearly indicate that quality inputs do make a difference. Such inputs include recurrent teacher training, updated teacher guides, better school facilities, more educational materials, better teaching practices and more relevant curriculum. They have been found to contribute to enrollment growth by making schools more interesting, relevant and financially attractive. In view of the recent levelling-off of growth in primary enrollment ratios, such approaches are far more attractive than simple replication of the existing program. A reduction of current dropout rates by 502 would, for example, result in an increase in enrollment of 452 and thereby increase enrollment ratios. Keeping children in school is clearly as big a problem as attracting unenrolled children to school. 2.10 Teacher supply and quality are important issues in primary education. The overall student-teacher ratio in 1985 was 35:1, about right for a nation of the development status of Nepal. The Basic Needs Strategy plans call for prescribed ratios in the three ecological zones: 20:1 in the mountains, 30sl in the hills and 40:1 in the Terai. The overall ratio of 35:1 is in accord with these new targets. However, the overall figure masks great variations. For example, in the hills the District averages range from 23:1 to 38:1, and within one hill district, individual schools range from 8:1 to 53:11 This is more an indication of weak educational management than of lack of supply of teachers. The proportion of primary 10/ Nepal: Education and Human Resources Sector Assessment, May 1988, pp. 4-14 and 4-15. - 9 - teachers with a School Leaving Certificate (SLC)ll/ has improved from 58Z in 1976 to 732 in 1985. In more remote areas this proportion is far lower. While the educational attainment of teachers has risen, the proportion of teachers with pedagogical training has been falling: from 392 in 1976 to 32X in 1985. There is a clear need for more attention to primary teacher training. 2.11 Less than 102 of teachers are female, 70Z of whom are qualified and 412 trained--somewhat above the overall proportions. Although the Government has been encouraging the use of more females in teaching, the percentage has not been increasing because the supply of SLC holders is overwhelmingly male, and because there are social and cultural barriers to female employment outside the home. This situation creates two major problems for the system. First, more female teachers are needed to increase the enrollment of girls. Many parents are more comfortable sending their daughters to all the grades of a primary school if there are more female teachers in the village school. Second, most societies find that females make better primary teachers than males. Females usually have a better understanding and respect for young children and, in general, children respond better to women in the classroom. In summary, there are many reasons for a government to strive for more female teachers. At the present level of only 102, Nepal has a long way to go in this regard. 2.12 The Efficiency of Primary Schools. Aspects of the internal efficiency of the school system can be reviewed by considering repetition and drop-out rates. These rates are very high in Nepal - a fact which has a significant impact on the total cost to the public budget per graduate. Annex I-2 gives drop-out, repetition and promotion rates based on a 952 sample of all primary schools in 1983-84. Of those who enter grade 1, only 432 proceed to grade 2 in the subsequent year; 271 - a very high 11/ The SLC is a national exam taken after completion of grade 10. In 1985 about 100,000 youths sat for the exam. In the same year the total secondary enrollment was about 242,000, with roughly 80,000 in grade 10. It is customary for many of those who sit each year to be repeaters or to have finished grade 10 in earlier years. The pass rate averaged about 252 in 1984-86. Like similar exams worldwide, the SLC is the biggest event in a young person's life, controlling his opportunity for further education as well as job placement. The content of the exam is inappropriate and the methods under which it is administered and scored need great improvement. Yet, largely because of tradition, it persists as a principal feature of Nepalese secondary education. There are less formal exams at the end of each year of secondary education (grades 6-10) on which the pass rates are in the 842-902 range. For more information see Nepal: Education and Human Resource Sector Assessment, May, 1988, pp. 5-17 to 5-23. - 10 - proportion - drop out, and 302 repeat grade 1. In subsequent grades within the primary cycle approximately 702 are promoted each year, 16Z drop out, and 142 repeat each grade. The performance of girls is significantly worse than that of boys. As illustrated in Table 8, it takes over 12 years of schooling to produce one graduate through the 'ideal" five year cycle, resulting in an average "efficiency" of the primary cycle of 392. Given an average public unit cost per student per year enrolled of Rs 184.2 (1984/85)12/ it costs the public purse Rs 2,365 per graduate, compared to a cost of Rs. 921 if the system were completely efficient. 2.13 The potential resource gains from improving the internal efficiency of the school system are clearly very large. While it is a contentious issue and would have significant implications for educational practices in N&pal (including changes to the internal school examination- system and better enforcement of an existing policy not to admit underaged children), a more liberal promotion policy would clearly be desirable. Both the public (and significantly the private) cost of high repetition rates cannot be ignored. Furthermore, it is doubtful that such a policy would have a deleterious effect on the quality of primary school graduates. On the other hand, there is some evidence that if students can be kept in the system for the first 3 grades, they are more likely to complete primary school. This would result in a significant improvement for overall enrollment rates, and improve the average years and number of grades of study - i.e. the education status - of those who attend school. Nearly everyone in MOEC and most teachers would object to the implementa- tion of a more liberal promotion policy. Most teachers believe the grade 1 curriculum takes two years to teach; however, this is a case for seriously looking at the content of the curriculum - not a definitive case to extend the primary cycle by one year. Table 8: Indicators for the Internal Efficiency of the Primary School Cycle Indicator Total Girls Number of years needed to produce one graduate 12.84 14.18 Average study years per entrant 3.55 3.45 Efficiency of the primary school cycle 39Z 352 Graduation per 100 entrants 28 24 Wastage due to drop-outs 67Z 662 Wastage due to repeaters 332 34? Source: Nepal Education and Human Resources Sector Assessment (January 1988) Annex 4.6, p. 4-89. May 1988. 12/ Nepal Education and Human Resources Sector Assessment (January 1988), pp. 2-35. - 11 - 2.14 An additional way of looking at internal efficiency is illustrated in Table 9. Based on an analysis of the hours actually taught in World Bank project schools in Nepal, the overall efficiency of the school system is estimated at 28 percent. Table 9: An Estimate of Efficiency (Time on Task) of Primary Schools Enrollment 86 percent Average attendance: Pupils 71 percent Teachers 70 percent Days school open: Scheduled 220 per year Actual Average 180 per year Hours of teaching time: Scheduled 5 per day Estimated Average 4 per day Overall Efficiency 28 percent Sources Primary Education Project evaluation unit based on observations of school conditions in PEP schools - 1987. Note: Overall efficiency calculated as follows: .86 X .71 X .70 X 180/220 X 4/5 = 28 percent It is clear from Table 9 that the gains from focusing on these essential management issues - keeping schools open, and keeping teachers teaching - are also great, and this emphasizes the more general problem of the management of the education system - particularly the need to give more responsibility and training to headmasters. Another analysis of the efficiency of primary education status suggests that 9 1/2 years is required to complete the 5 year cycle and that the average efficiency is 532 instead of 39Z or 28Z as reported in Tables 8 and 9. Whichever study is used the fact remains that the efficiency is between half and a third of what it should be. 2.15 Management of primary schools is performed by District Education Officers(DEOs), their subordinate staff, headmasters (who also usually teach), and School Management Committees (SMCs). Since the Kingdom's 75 DEOs also have responsibility for secondary education, primary level matters often receive less than adequate attention above the school level. The DEO does play a key role in selection and assignment of new primary teachers, but often in ways not in accord with the preferences of headmasters and SMCs. Improvement of the primary education system requires more attention to the training of each of the several types of managers, especially headmasters. Such training is being successfully provided in the ongoing Primary Education Project (PEP), and this model could be used, with adaptations, in the remainder of the nation. - 12 - Table 10: Historical Evolutlon of the Secondary Education Syste of Nepal, 1971-1985 1971 1976 1981 1986 1. Number of Schools Lowor Secondary 677 2,289 2,788 a,678 Secondary 494 620 918 1,321 Tot l 1,171 2,809 8,704 4,899 2. Enrollment Boya I owor Secondary 44,266 67,788 136,203 188,819 Secondary 568812 Q1 624 117.085 187 191 Total !,8i7 119,10 252,268 878,010 Girls Lower Secondary 8,621 12,274 84,381 68,656 Secondary 10 229 12 586 27.288 66.278 Tote l II76 24,810 81,827 120,811 Total Lower Secondary 62,776 70,080 169,664 264,864 Secondary GO 841 74 080 144 331 242 467 Total 119,617 144,120 818,896 4W,Of! S. Enrollment Ratio (Porcentago) Boys Lower Secondary 16.8 17.6 38.4 40.7 Secondery 15.6 16.0 26.6 80.8 Total 16.4 16.2 80.4 86.1 Girls Lower Secondary 8.6 4.5 10.9 18.7 Secondary 8.2 8.6 8.8 10.5 Totl 8.4 8.9 8.6 18.1 Total Lower Secondary 10.0 11.6 24.7 19.7 Secondary 9.8 9.7 18.8 21.8 Total 9.9 10.6 20.3 24.9 4. Numbers of Teachers Lower Secondery Total - 7,930 12,245 11,120 Qualified (S) (IA Pass) - 68 76 84 Trained (U) - 88 40 42 Secondary Total - 8,449 4,909 7,242 Qualified (U) (BA Pass) - 97 98 98 Trained (U) - 60 68 58 5. Indicator Ratios a. Enrollment per School Lower Secondary 7S 81 G1 71 Secondary 136 142 167 184 b. Enrollment per Teacher Lower Secondary - 8.8 18.8 22.9 Secondary - 21.6 29.4 88.5 c. Girls as S of Total Enrollment Lower Secondary 18X 18X 20X 28X Secondory 15X 17X 1lx 283X Source: Nepal Education and Human Resources Sector Assessment, January 1988, Tables 6-i and 6-8. - 13 - B. Secondary Education 2.16 Secondary education is divided into two segments at present - lower secondary consisting of grades 6 and 7, and secondary comprising grades 8 to 10. The Government prefers to refer to the level as a single entity despite the fact that several administrative requirements necessitate separate records. Moreover, a third segment is to be added to the system when the 10+2 system is introduced, which will add grades 11 and 12 (para. 2.20). Historical development of the secondary school system is described in Table 10. Enrollment growth has been impressive--more than a three-fold increase between 1971 and 1986. This has been achieved through Government policy encouraging enrollment in response to the inevitable social demand created as primary enrollment grew. This demand probably will not abate in the near future despite the fact that demand for primary school places appears to be levelling off. Enrollment ratios in the lower secondary level reached almost 25? in 1981 but fell back to less than 20Z in 1985, a significant trend indicating that government resources are insufficient to meet social demand. 2.17 Other important conditions revealed by the data in Table 10 include: (a) Too many schools have been established in proportion to enrollment. Lower secondary schools average only 71 students in their two grades, or only one section of each grade. This means that it is difficult to provide the specialized teaching needed in secondary levels. A lower secondary school is, thus, often only an extended primary school. Secondary school size is equally low: only 184 students in three grades. This is far too low for effective utilization of specialized teachers, facilities and equipment. The rugged terrain is frequently given as the reason for having small schools, but this is a justification in only a few cases. If 11,000 primary schools are needed for coverage, the number of secondary schools should be in the order of 2,500 (instead of 4,900). (b) Enrollment of girls in both levels of secondary education is lagging even more dramatically than in the primary level. In 1985 the lower secondary enrollment ratio for boys exceeded 40? while the ratio for girls was under 17Z, a greater differential than in primary education. (c) Numbers of teachers in proportion to students is following an unusual pattern. In earlier years ratios were extremely low- only 9 students per lower secondary teacher in 1976. However as enrollment grew, teacher supply did not, especially in the secondary segment, where a ratio of over 33:1 now prevails. This is far too high--a ratio of about 20:1 for grades 8-10 is needed to provide quality instruction. It is also noteworthy that the ratio is significantly higher for secondary than for lower secondary, when international educational practice - 14 - would suggest just the opposite.13/ 2.18 Teacher qualifications and training at the secondary level are far better than the situation in the primary system. Teacher qualifications in the secondary level are well above those of the lower secondary level, as they should be. As lower secondary enrollment grows as a natural result of the expected growth of primary enrollment under the Basic Needs program, a shortfall in the numbers of suitably trained teachers for grades 6-8 can be expected. If these grades are considered part of basic education with a recognized exit point after grade 8, curricula for lower secondary grades need to be revised, resulting in new needs for special training of teachers. 2.19 The Government needs to reassess its program of secondary teacher preparation and renewal. All eyes are on the primary teacher supply and its training implications under the Basic Needs Strategy at present, and the future demands of the secondary level are not receiving the attention they deserve. The Faculty of Education of the University has the prime responsibility for this teacher training at present and probably should continue to do so. Some differentiation between the preparation of lower secondary and secondary teachers will be needed. International experience has shown that teachers for grades 6-8 need to have more of the attributes of primary teachers and lees of the subject matter skills of the secondary teacher. This will be especially true if grades 6-8 are made more practical. The Faculty of Education should be qualified to handle such a change. It may be possible to produce a lower secondary teacher in fewer years than a full secondary teacher. 2.20 The 10+2 movement has emerged as a major new policy initiative of the Government in the past year. It consists of a proposal that grades 11 and 12 would become an integral part of secondary education, thereby creating three instead of the present two segments. Grade 10 has always been too early to be the end of secondAry, so the new plan is in keeping with educational practice prevailing in neighboring nations of East Asia. Just as grade 10 is too early to end secondary, grade 11 is too early to start higher education. Many of the problems of tertiary education in Nepal result from the fact that the system must deal with students who lack sufficient numbers of years of schooling, and who are not physically, emotionally or socially prepared for university level study. As the 10+2 movement evolves it is obvious that it is being viewed as a distinct additional secondary level, and that grade 10 is intended to retain its present significance in the system, even to the extent of remaining the point at which the all-important SLC examination is administered. Now is the time for the Kingdom to consider a more comprehensive policy analysis of the entire secondary level extending from grade 6 to 12. This analysis 13/ This unusual reversal of international practice may be related to the policy of the Government to cover 752 of lower secondary teacher salaries and only 502 of secondary teacher salaries (para. 2.22). - 15 - should cover at the very minimum the curricula, teacher supply and training, criteria for minimum and maximum enrollment of schools, the grades to be included, especially the 10+2 scheme, and financial policies. 14/ 2.21 One of the weakest features of secondary education in Nepal as it is presently organized is its lack of exit points. There is really only one recognized point of exit other than dropping out: after grade 10. Students are thus left with only two choices - pursuing a fairly high level of academic education, or leaving the formal school system entirely. This is made even worse by the practice of finding space in the university for nearly all who pass SLC. which is taken by over 80X of those who complete grade 10. Serious consideration should be given to the introduction of more recognized exit points. A logical approach would be to create exit mechanisms after grades 8, 10 and 12. New examinations would be needed and a different approach to examinations should be introduced. The criteria for a student passing from grade 8 to 9 should probably be such that from one-third to one-half are not passed. On the other hand passage from grade 10 to grade 11 should be easier--only about 15? screened out, say. This would restrict grades 9-12 to only the more promising students with all the public resource savings this implies. In the longer run, the lower secondary grades, 6-8, would probably become a part of basic education in Nepal, as it has already become in much of Asia. This new structure would have implications for vocational education and skill development programs which would need to be geared up for the large numbers of young persons who would end their formal general education after grade 8. 2.22 Financing. Major issues prevail in the Kingdom's policies on the financing of secondary education. Nearly all secondary schools are nominally public-in 1984 there were only 338 private compared to 4,655 public secondary schools. However, the public schools are really not financed the way most public schools are in other nations. The government provides 75? of the salaries of the teachers in the lower segment and 50? of the salaries of teachers at the the secondary level. Moreover, the government limits the number of positions to which this arrangement applies in each school. Many schools employ added teachers totally without government participation in financing of their salaries. As a result most secondary schools receive less than half of their operating costs from the government. This practice has made it possible for the Government to reduce the share of its educational budget going to secondary education while enrollment has been growing. 2.23 Fees are really the only way secondary schools can raise resources to finance the gap between what the government provides and costs. While the fees may seem very reasonable to non-Nepalese, Rs.30 or so each month constitutes a large share of a family's disposable income. There is anecdotal evidence that at least one-third more students would enroll if fees were eliminated. This practice is especially unfair from an equity 14/ Although grade 6 is often part of primary education, in view of Nepal's lack of resources, the nation probably will have to continue to end primary school with grade 5. - 16 - viewpoint in the lower secondary level, where the nation badly needs to encourage successful but poor children, who have overcome the many hurdles placed in their way and have finished grade 5, to continue their education. Government coverage of 100Z of the teacaer salaries of the lower secondary level (now two grades but which should become three grades) may be the correct approach, but will require substantial budget increases. Some form of scholarship grants may be another alternative. If the decision is made later that the lower secondary grades 6 and 7 (or 6 to 8) are part of basic education which virtually all able students should complete, and the upper secondary grades (now 8-10 and later possibly 9-12) should only be open to the most able, the governmental financing policy should also vary accordingly. Clearly, the structure and financing of secondary education are both areas for the government to consider new policies. 2.24 Curriculum is a sensitive subject, on which outsiders should be careful not to offer excessive unsolicited advice. However, the Government needs to assess what is taught at each level and modify it to conform more closely to the needs of the society. This is a difficult process and one fraught with demanding choices. On the one hand, making the curriculum more in keeping with the lives of the students suggests making it more practical, perhaps even easier. A modicum of improvement along these lines has been achieved in neighboring countries in the past decade. For example, Thailand and Sri Lanka have introduced more practical subject matter into the general secondary curriculum with some success in overcoming the traditional bias of parents and teachers for ever-more academic content. But, at the same time, secondary education will remain for many students preparation for higher education, and there is ample evidence from the university that the present system does not adequately prepare grade 10 finishers for entrance to higher education. Adding grades 11 and 12 before higher education would be a constructive step. In addition efforts should be made to ensure that esoteric content is not included in secondary education which prepares students for neither life nor higher education. This is especially needed in grades 6-8, i.e. the basic education portion of secondary education. C. Higher Education 2.25 Higher education in Nepal can be summed up in two words: Tribhuvan University. In 1986/87 the univers4ty enrolled over 60,000 students at four levels (Table 11). An additional 17,000 students are enrolled in newly inaugurated "private' campuses of the university as shown in the lower portion of Table 11. Of the total 60,000 "public" enrollment, over two-thirds (42,792) was listed at the certificate level. This is somewhat misleading since all students are required to take the certificate before proceeding to the bachelors degree. A better way to look at the certificate level is to consider it the first two or three years after entry, equivalent to grades 11-13. The 2Y of the enrollment called lower level consists of students taking courses which do not lead to a certificate or to a bachelors degree. This type of work is offered in only four of the ten major subject areas of the University. Comparison of the columns in Table 11 headed "new admissions" and 'carry over' is most revealing. For the institution as a whole the two figures are almost the same (25,000 vs. 29,000). Nearly as many new students join each year as Table 11: Trlbhuvan University CTU) Students Enrollment in 1985/86 Levwel of Program Lower Certificate Bachelor Vaster Tot l 1lw Carry NMw Carry NOw Carry New Carry NOw C-rry I of Institute Admission Over Total Admission Over Total Admission Over Total Admission Over Total Admission Over Total Total Engineering 192 178 865 490 1,165 1,656 90 70 160 0 0 0 772 1,408 2,180 8.2 Agriculture 0 0 0 633 166 799 196 181 877 0 0 0 829 847 1,176 1.6 Medicine 405 67 472 898 410 803 78 120 196 11 a 14 88S 600 1,465 2.4 Forestry 0 0 0 125 289 884 42 88 125 0 0 0 167 822 S09 0.9 Total Technical 597 240 887 1,641 1,980 8,641 404 454 8S9 11 8 14 2,658 2,677 6,860 8.2 Law 0 0 0 1,774 2,167 8,941 198 768 966 0 0 0 1,972 2,935 4,907 18.6 Mabnagemet 0 0 0 8,50s 5,186 8,641 967 1,148 2,118 705 608 1,518 5,177 6,890 12,067 8.2 Science 0 0 0 2,640 8,666 6,205 567 264 841 140 114 262 8,845 8,968 7,808 22.7 Education 800 41 841 1,060 964 2,024 788 292 1,080 117 68 18S 2,265 1,865 8,680 7.8 Humanities 892 117 509 6,849 8,442 15,291 1,878 1,904 8,777 707 596 1,0s8 9,821 11,059 20,880 89.4 Sanskrit 0 0 0 84 108 192 89 12 51 46 45 90 168 16S 388 0.6 Tot I Rogular 692 18 860 16,912 20,882 86,294 4,422 4,406 8,828 1,722 1,481 8,158 22,748 26,877 49,126 91.8 GRANO TOTAL 1,289 a98 1,687 17,558 22,862 39,985 4,826 4,860 9,686 1,788 1,484 8,167 26,401 29,054 54,475 % of Total 2.4 70.0 18.5 9.2 100.0 100.0 Private Student Enrollment Science 0 0 0 667 782 1,899 0 0 0 0 0 0 66? 732 1899 - Law 0 0 0 Sol 254 665 0 0 0 0 0 0 801 2S4 SSS - Management 0 0 0 8,859 4,166 7,626 518 260 768 0 0 0 8872 4416 8288 - Humanities 0 0 0 8,891 8,594 6,985 so 50 180 0 0 0 8471 8644 7116 - Total 0 0 0 718 8,746 16,464 0 0 0 0 0 0 8811 9046 17867 - / Now a separate University. Source: Planning Office, Tribhuvan University - 18 - are already enrolled, implying very rapid enrollment growth. Other sources indicate the same - the Director of Planning of the University projects enrollment to reach 120,000 by the mid 19909. 2.26 The same planners even predict that enrollment could reach 200,000 by the year 2000 if the admission practices which now prevail are continued. Projections of higher education enrollment follow inexorably from trends in secondary enrollment which, in turn, are related to primary enrollment. The age cohort for higher education entry in 2000 is already beyond the age for entry into grade 1, so there is a degree of inevitability in the pressure for expansion. If the Government is successful in raising the enrollment ratio for grade 1, and if dropout and repetition rates in primary are reduced, the demand for lower secondary spaces will be greatly increased. This demand will almost surely be met through the political pressure of the people on their government and through the efforts of the private sector to create secondary school places if the government programs fall short of demand. In this way the number of grade 10 finishers will continue to grow, and the number of SLC passes will increase accordingly. If the Government continues to offer a university place to all SLC passes, higher education enrollment is bound to increase to the 200,000 level mentioned at the beginning of this paragraph. The Government needs to make a key educational policy decision as soon as possible on means to contain the flow of new students into the university, probably through use of an entrance examination separate from the SLC. A start along this line has been made in certain technical fields where an admissions test is now used. 2.27 The most promising avenue is adoption of the 10+2 program which would delay entry to higher education from after grade 10 to after grade 12. The enrollment data in Table 11 do not specifically show what portion of present university enrollment is at the equivalent of grades 11 and 12, but at least half would be a good estimate. Removal of these numbers of students from the responsibility of the university would bring university enrollments down to a level more in keeping with its management capacity; both in terms of quantity of quality faculty, and budget expectations. But this would only be temporary relief if the policy remains of admitting a large proportion of secondary finishers nearly automatically into the university. If that policy were continued after 10+2 is adopted, the situation could be even worse because an extra two years would have been added to the secondary system, with no corresponding reduction in the numbers going through university. The university entrance examination mentioned above would be the most reliable and effective means to separate secondary school completion from universitv admission. This issue involves critical decisions on exit points for the secondary system and related examination policies, such as the proper timing for the SLC - eg., after grade 10 or after grade 12. Perhaps some form of examination would also be needed after grade 8 if that is to become a significant exit point. Non- academic employment preparation programs (i.e. vocational) should be developed for grade 8 and 10 leavers. 2.28 Is higher enrollment of 120,000 or 200,000 excessive for Nepal? The present enrollment ratio of approximately 4Z (based on enrollment of 61,000) is only slightly above the median for developing nations of 3.7S - 19 - (Table 12). However, Nepal's primary and secondary enrollment ratios are well below the medians for developing nations, suggesting that the higher education ratio may be too high. Higher education enrollment ratios based on the projections of 120,000 in 1992 and 200,000 in 2000 would be in the 10-12Z range, above the upper quartile of developing nations and clearly far too nigh for Nepal. Table 12: Comparative Enrollment Rates for Nepal, Adjacent Countries, all Developing Nations (Percent) Level of Education Country Higher Secondary Primary Nepal 3.7 21 70 India 8.3 28 79 China 4.8 35 77 Developing Nations: Lower Quartile 1.0 14 60 Median 3.7 26 83 Upper Quartile 11.0 47 98 Number of Countries 85 91 92 Source: World Bank Education Indicators, January 1988 2.29 Over-enrollment is by no means the only issue in higher education in Nepal. Table 11 indicates that the distribution of enrollment among the four technical institutes and the five faculties (excluding Sanskrit) is not in accord with the development needs of the nation. Only slightly above one-fifth of the students are in the institutes and the science faculty - far too low a proportion. Enrollment in the faculties of law and humanities is too high for a country whose development depends on agricultural growth, technical improvements and industrialization. The size of enrollment in the Faculty of Education is directly related to the need for teachers in the secondary schools and for teacher trainers at the primary school level and appears to be at about the right level. Management - accounting, finance, marketing, business administration - is currently a popular field with young people as evidenced by its place as the field with the second highest enrollment; but without more high level manpower in the technical fields, there will be nothing to manage. 2.30 Even at the present enrollment level university administrators report that the quality of instruction is being eroded by the quantity of students. In the technical institutes and the science faculty, laboratory hours are being reduced because of shortage of physical space, equipment, - 20 - consumable materials and the services of trained laboratory technicians. Faculty size cannot keep pace with enrollment growth, not only because of budget limitations, but also because of a shortage of qualified personnel. Add to this the current evidence that SLC passes are poorly prepared for university study, and a picture of lack of quality emerges which is as important as the over-enrollment issue. What is needed first is an internationally-assisted assessment of the quality statue of the university on a discipline-by-discipline basis. The assessment could become the foundation for the university management to develop a comprehensive plan to improve quality in the next decade - the period it will take to undertake the faculty development which will become the heart of the quality improvement program. The government will not be serving its citizens well if it has to satisfy political pressures for higher education enrollment growth by sacrificing educational quality. 2.31 The Government should reconsider the high levels of subsidies and low fee levels which prevail in higher education. Parents are expected to provide more tuition for their children to attend secondary school than for higher education. Even lower secondary schools have higher tuition than the university. Since lower secondary grades are destined to become part of basic education to be offered to nearly all children, such a condition raises fundamental equity concerns. University fees should be increased manyfold so that Government resources may be conserved for use at the primary and lower secondary levels. At the same time schemes for financial assistance to deserving, but poorer, students should be developed. Moreover, university functions such as dormitories, food service and other student services should be managed on the principle of payment for benefits. 2.32 Another issue in higher education stems from the structure of the university with over 120 campuses throughout the country, about half "public' and half "private". However, private campuses enroll less than a quarter of the total students, and less than 10? of the bachelors level students. Although Nepal's difficult terrain and poor transportation system surely have accounted for some of the proliferation of campuses, there are roughly twice as many campuses as are needed in both the public and private realms. The 10+2 movement will surely precipitate a reconsideration of this unusual arrangement. Some campuses are used primarily for certificate work and may become superfluous, but this will have only minimal impact. There is evidence that the university administration may be unwilling to reduce the number of campuses even when economy of scale analysis makes a clear case for doing so. Whether there should be only one university or multiple public universities organized on geographical/political subdivisions, or on the basis of groups of related subject fields is another question which bears consideration. 2.33 Finally, there is the possibility that the nation would be well served to have a few private universities. This would introduce competition into the quality of instruction and help free the government budget from its present exclusive responsibility for financing higher education. On the other hand if competition were also introduced in the race to expand enrollments to meet insatiable social demand, the net result of private participation could be negative. The government would also - 21 - inherit a new role of licensing and accreditation of private higher education which has proven difficult for other governments. Privatization may be appropriate in some functions of public universities such as food service, dormitories and building and equipment maintenance. 2.34 In summary, the two post-primary levels of general education, secondary and higher, involve a myriad of complex problems. They must be treated together for a variety of obvious reason, the most prominent is the 10+2 proposal. D. Other Types of Education 2.35 Vocational and Technical Education (VTE) The Kingdom's efforts in VTE have been modest and remain underdeveloped. A program to introduce vocational subjects in secondary education was tried in the 1970s and floundered. The formal system of VTE at present consists of five technical schools and those parts of the University which are related to technical training, mainly the lower levels of the Institute of Engineering. The Government is now establishing a new Technical Education and Vocational Training Council to consolidate and probably operate the majority of VTE programs in the nation. What will probably happen is that the University will shed its lower level programs in the technical institutes (Table 11) and some of its certificate programs as well. These, as well as the existing technical schools, will be managed by the council, which will be part of the MOEC. 2.36 However, a more fundamental issue is that the formal VTE system does not enroll the segment of the population which needs skill training to contribute to national development. The technical schools do not offer much promise to meet this need since institutions with the words "technical" or even "school" in their names will almost always, by definition, provide education and training of longer than necessary duration, which is too academic and theoretical instead of practical, job- related training which could lead to immediate employment. The Kingdom urgently needs workers at the craftsman, tradesman and lower levels, and the output of the existing institutions does not fill this need. The training needed can be done in shorter segments, six months or less. Existing institutions have programs of two year's duration. The Ministry of Labor have begun in a modest way to address the need in what are called Labor Development Centers. 2.37 The nation lacks usable manpower information, even for the government service and certainly for the embryonic private sector. An unusual special problem in planning VTE in Nepal is the open boundary with India through which an almost unlimited supply of better educated and/or trained manpower flows to meet most demand as it arises. As a result perhaps one-third of the employment opportunities which could go to Nepalese manpower are taken by foreigners. Much of this is due to lack of Nepalese with needed skills, and some to a preference by employers for alien workers. What little Nepal does in VTE appears very expensive indeed; unit costs are about one-hundred times greater than those of primary education. These unit costs are based on newly established schools with very low enrollment. As enrollment grows and as training becomes more practical and of shorter duration unit costs will decline. - 22 - 2.38 Non-Formal Education. Perhaps the most successful area of operation of MOEC is its program of adult literacy training. High quality instructional materials have been developed, facilitators (teachers) have been trained, and budgets marshalled to enable about 70,000 participants to be served each year. Of course, with over 10 million illiterate adults in the population, 70,000 per year does not make a substantial inroad on the problem. Recognizing this, the Government should expand the program by at least five-fold. There appear to be no critical constraints to doing this. The supply of candidates for facilitator training is largely untapped, very appropriate instructional materials are already developed and can be easily and inexpensively reprinted, and the supply of potential participants is nearly unlimited. Experience to date indicates that about two-thirds of those who start the one year program complete it successfully, a very high rate of retention. Only a few of the 75 districts have been involved in the early years of operation. Of course, there is a budget constraint to rapid expansion, but in this case most of the development costs have already been expended so enlarging the scope would be relatively inexpensive. Perhaps the share of the MOEC budget going to non-formal would need to rise from the present 4.5Z to 6 or 7Z and the equivalent share taken from secondary and higher education (Table 14). HMG has recently announced its intention of expanding the program to a nation-wide campaign, and a regional pilot is currently being developed. Attention also needs to be given to the development of post-literacy materials needed to help newly literate persons retain their newly-acquired skills. 2,39 The existing adult non-formal literacy program does not include out-of-school youth except for a recent pilot trial. The same instructional materials could be used for part of a program for this audience, but would have to be expanded to include more of the primary school curricula. The adult program described above has many of the trappings of the very successful programs in Thailand, Indonesia and the Philippines, launched in the past two decades. In each of these nations the natural evolution was from adult literacy to programs for youth who had dropped out of primary and even lower secondary schools, as well as those who never even started grade 1. Often the programs for youth surpass those for adults in sustained interest. - 23 - Chapter III - EDUCATION FINANCE A. Public Resources for Education 3.01 Table 13 and Annex 1-4 document trends in public expenditure on education as a share of the budget and of GDP, together with changes in the government budget as a share of GDP. There has been a sharp rise in the share of Government spending in GDP. It rose from 9.1 percent in 1974/75 to almost 21 percent in 1982/83 and has subsequently maintained a 20 percent share of GDP, indicating that the government is constrained in the level of resources it can appropriate for public purposes. The share of education in total Government expenditure has remained remarkably constant over the 13 year period to 1986/87 at just under 11 percent. It is noticeable that during the period of rapid expansion of the public sector the resources devoted to educaticn- if anything- lagged behind public expenditure growth. 3.02 Historic trends indicate the public budget is unlikely to grow significantly faster than the economy, and competition for budget resources from other Government programs would seem to indicate that the share of education in the budget is unlikely to expand significantly without a conscious change of public expenditure policy. This implies that the public resources available for education are likely to grow at a rate largely determined by the performance of the economy. Over the period under review the average annual rate of growth of real GDP has been 2.67Z. 15/ (See further discussion in chapter 4). Table 13: Trends in Public Financing of Education, 1974/75 - 1985/86 (percent) Share of Gov't Share of Education Share of Education Year Budget in GDP in Gov't Budget in GDP 1974/75 9.1 10.2 0.9 1977/78 13.6 10.1 1.4 1980/81 15.0 9.4 1.4 1982/83 20.7 10.5 2.2 1984/85 20.1 9.6 1.9 1985/86 19.6 11.1 2.2 1986/87 19.0 11.0 2.1 Source: Annex I-3, 1986/87 data are World Bank staff estimates. 15/ Arithmetic average of annual real GDP growth rates in 1974/75 prices as presented in Economic Survey 1986-87, Ministry of Finance (1987), Table p. 1. - 24 - 3.03 Total expenditure on education in Nepal increased from Rs. 152 million in 1974/75 to Rs. 384 million in 1980/81 and to an estimated Rs. 1,168 million in 1986/87 (Annex I-4). Government budgeting and accounting systems do not allow a systematic comparison of allocations (budget and expenditure) of public resources within the education sector. It is not possible, from the information available, to determine the rationale for the education allocations between the regular and development budget 16/ or to split allocations between recurrent and capital Table 14: Total Education Budget Allocations (Regular and Development) by Category. Selected Years 1977/78 - 1987/88 (Rs million) 1977/78 1980/81 1984185 1986/87 1987/88 Primary 73.0 114.2 322.0 467.3 623.5 Secondary 60.5 79.5 145.1 196.8 215.7 Misc. Education Projects 3.3 11.8 3.1 55.3 96.1 School Administration/ Overheads 37.8 50.5 59.5 67.2 49.1 University 93.9 150.3 308.3 365.6 379.7 Technical&Vocational - - 13.4 - 26.9 Adult Education 3.0 3.1 2.6 3.2 4.5 All other 6.2 20.3 57.6 126.5 229.6 Total 277.7 429.7 911.6 1286.4 1625.1 Percent of Total Primary 26.3 26.6 35.3 36.3 38.3 Secondary 21.8 18.5 15.9 15.3 13.2 Misc. Education Projects 1.2 2.8 0.3 4.3 5.9 School Administration/ Overheads 13.6 11.7 6.8 5.3 6.3 University 33.8 35.0 33.8 28.4 23.4 Technical & Vocational - - 1.5 - 1.7 Adult Education 1.1 0.7 0.3 0.3 0.3 All other 2.2 4.7 6.3 10.1 14.1 Total 100.0 100.0 100.0 100.0 100.0 Source: Annex I-4. 16/ Nearly all primary education expenditure, consisting largely of teacher salaries, is to be found in the development budget. The rationale for this is not entirely clear, but it has probably been placed in the 'development' budget because aid donors are interested in it rather than for any other internal managempnt reasons. - 25 - expenditures. It is also difficult to allocate many categories of educational expenditure to the different levels of the education system. Information on budgeted and actual expenditure by the line items of the education sector are not available, although at an aggregate level actual expenditure over the period 1982/83 to 1985/86 has been about 91Z of budgeted expenditure. There is some evidence to suggest a significant proportion of this under- expenditure occurs on capital works expenditures associated with foreign funded development projects. 3.04 Despite these important management information deficiencies, it is possible on the basis of budget allocations to develop a reasonable picture of total resource allocations (capital and recurrent) from the Government budget to education, and their allocation across the various elements of the education system. Table 14 illustrates education resource allocations by level/type of education for selected years 1977/78 - 1987/88, and Annex I-4 presents detailed information for the period. A number of important observations can be made concerning this information. (a) The share allocated to primary education has been expanding since 1980/81 as a proportion of the education budget. It has risen from just over 26Z of budget allocations to over 38Z in 1987/88. (b) The Miscellaneous Education Projects category which has expanded dramatically over the past two years is probably largely also allocatable to the primary education sector. In 1987/88 this constituted 5.9 percent of budget allocations - probably a reflection that key elements of the Primary Education Project and the Seti Zone Project are financed from this particular budget item. Thus total allocation to the primary education sector may have reached 44Z - a significant achievement. (c) The share of the budget allocated to secondary education has fallen from almost 22Z in 1977/78 to 13.2Z in 1987/88. This dramatic decline is a reflection of government policy on the financing of secondary education rather than a reflection of enrollment trends. As indicated earlier in Table 5, gross enrollment ratios improved significantly in the 1980's. In 1974/75 HMG implemented a policy of financing 75 percent of salaries for lower secondary teachers and 50 percent of salaries for secondary teachers. In 1981 the Government began strictly controlling the number of posts it would partly finance in secondary schools (based on approved staffing patterns at approved schools). This practice was designed to discourage indiscriminate hiring of teachers by the schools, and also to encourage more contributions to the costs of education by the schools and local communities. During the current (7th) plan period 1985-1990, this encouragement of private financing of secondary education has been further developed by an effective decision not to approve new posts for the purpose of attracting grants in aid. Thus, most expansion of the secondary school system since 1985 has been privately financed. - 26 - (d) School Administration/Overheads as a share of the total budget has fallen significantly during the 1980's from almost 12Z to just over 6X- although some additional elements of this category, supporting the primary education system, may be found under the Miscellaneous Education Projects category. While it can be expected that overheads will fall as a share of the budget in an expanding education system, the rapid fall experienced in Nepal is probably more an indication of reduction in support staff operating budgets below acceptable and efficient levels. This observation is further reinforced by the observations that the Curriculum Textbook and Educational Materials element of this category of the budget has also begun to expand as efforts are made to improve the supply of text books in schools. Field observations also suggest supervisory staff do little traveling because of budget constraints. (e) Tribhuvan University - which is responsible for all post secondary education in some 120 campuses throughout the country, but has only just over 2? of students currently in training in Nepal, takes a very large share of the education budget. This share has, however, fallen significantly during the 1980's from 35Z to 23.4? in 1987/88. While this is an encouraging trend it is doubtful that this trend can continue given current rapid enrollment projections. The University faces many important management and resource allocation problems. (f) The technical and vocational education section of the MOEC has emerged in its present form during the 1980's in response to the decision to abandon a secondary technical school program. It currently consumes 1.7 percent of the budget. There are five technical colleges. Given current plans of the Technical and Vocational Education Division of MOEC to expand the number of colleges, the share of the budget allocated to this subsector can be expected to increase moderately in the future. The 7th Plan provides for a doubling of capacity. A project has been developed to give effect to these plans and has recently been appraised by the ADB. (g) The Adult Education program has declined in importance judged by the share of the education budget allocated to it. In 1977/78 it was allocated more than 1 percent of the budget but during the 1980's it has declined to 0.3 percent of all resources. As noted in the context of the discussion of literacy in Nepal, the importance of this program should not be underestimated. Clearly it would be disappointing if, given Nepal's current low literacy levels, sufficient resources were not allocated to this program. B. The Role of External Assistance 3.05 While it is difficult to quantify the full value and nature of external assistance to the education sector in Nepal on the basis of available data, it is clear the aggregate flows of external assistance are - 27 - very important, as illustrated in Table 15. Over 23Z of education expenditure over the five year period 1981/82 to 1985/86 was financed by external assistance. Loan assistance, which only began in 1978/79, has grown significantly but grant aid remains the most important component of external assistance, constituting 742 of total disbursements over the same period. Table 15: External Assistance to the Education Sector (1981/82 - 1985/86) (Rs millions) 1981/82 1982/83 1983/84 1984/85 1985/86 Total Expenditure 519.1 734.0 815.8 825.8 1087.0 Foreign Commitments 289.3 353.2 248.3 341.4 47.3 Loan Disbursements 27.1 27.4 57.9 52.7 74.1 Grant Disbursements 76.8 167.9 138.8 101.9 194.6 Total Foreign Assistance Disbursements 103.9 195.3 196.7 154.6 268.7 Total Disbursements as Z of Total Expenditure 20.0 26.6 24.1 18.7 24.7 Sources Nepal Education and Human Resources Sector Assessment, January 1988, USAID, Table 9-1. 3.06 Many donors are involved in the education sector. Each level of education has at least one significant donor involved in its operations. Two key problems relating to the nature of aid and aid administration in Nepal are consequences of the fact that Nepal does not have a strong public expenditure planning system. Firstly, the system allows donors to define projects with MOEC (and other agencies) and develop separate project administrations to implement projects which are not fully integrated within the MOEC management structures. This has a number of important implications: (a) the MOEC management structure is fragmented unnecessarily; (b) the potential benefits of flow-ons in management and other system developments resulting from project activities are not institutionalized in ongoing systems; and (c) initiatives based on different models and cost structures are often financed by different donors within the same sub-sector without serious consideration to replicability across the country. - 28 - 3.07 Many of these problems arise because external assistance in Nepal is often viewed as a free good which does not have opportunity costs. This is unfortunate since foreign assistance clearly does have opportunity costs, in that it can be used for alternative uses, it can be managed by HHG, and subject to specific constraints of donors, can be used to support a wide range of alternative activities within (or between) sectors in much the same way as domestic resources can be re-allocated. Strongly defined sectoral priorities by HMG and MOEC - albeit developed with assistance from donors where appropriate - together with specific plans on where government wants assistance to support domestic expenditure priorities would significantly improve the benefits of external assistance to the education sector. 3.08 Secondly, projeu.s financed by foreign assistance are not fully integrated into the Government's budgeting system, and the implications of project initiatives on costs (and replicability in other respects) are not evaluated before concurrence is given for specific aid financed projects. The public expenditure planning system does not provide management with forward estimates outside development plan indicative resource allocations. Nor does it separate resource allocations between capital and operating budgets. This means that management does not know at any given time what future levels of operating budgets are implied by aid funded development projects. Further, it is common practice in Nepal among both loan and grant donors to finance a significant share of operating costs during the life of a project. It is not at all clear that adequate operating budgets have been planned when donor agency commitments on a specific project are completed. This is a serious situation for any sector, but in education it is particularly serious because of the high recurrent operating costs of most initiatives in the sector. 3.09 External assistance can and should be of strategic importance to the future development of education in Nepal, as efforts are made to extend the school system (particularly primary education); design strategies to get all potential students (particularly girls) into school and keep them there; to improve the quality of education and efficiency in schools; and to restructure and extend technical and vocational training both within the University, and in the basic level training system throughout government in accordance with skill requirements. However, this will not be possible without strong policy guidance by HMG and MOEC in particular, and a recognition by all that development is a partnership, requiring all parties including donors to support an agreed strategy in the sector. It will also require, to be successful, the full commitment of counterpart resources by HMG and a full commitment to activities after donors have finished their commitments. - 29 - Chapter IV - THE OUTLOOK FOR THE FUTURE SOME EMERGING ISSUES 4.01 Several factors impinge on the future development of education in Nepal - each having significant implications for the range and nature of viable policy options in the education sector. However, two strategic constraints - namely demographic pressures and finance available for education in the future- will largely determine the room to maneuver in the choice of alternative policies to develop the education sector. A. Education and Population 4.02 Demographic Trends. The potential demand for education services in Nepal - leaving aside such important issues as the capacity to pay, cultural factors (including gender), and cost, which clearly limit effective demand - will be determined by the rate of growth of the school age population. These rates have been very high historically as illustrated in Table 16, and current projections leave no room for complacency in the future. The expected primary school age population growth rates are only projected to fall very marginally from 2.64X (1985-90) to 2.56Z (1985-2005).17/ Even under the most optimistic assumptions the growth rate for the period 1985-2005 is only expected to fall to 2.322 from the current 2.56Z rate of increase. For the secornary education age group, it is expected that even under the most optimistic assumptions the growth rate over the period to 2005 will increase from 2.01 percent (1985-90) to 2.352. These rates are clearly very high. In fact, the expected rate of growth of primary age children is greater than the current primary school enrollment growth rate (1985-86) of 2.5X. Table 16: Projected Rate of Growth of Primary School Age Population (6-10 years) and Secondary School Age Population (11-15 years), 1985-2005. Period Primary Secondary Optimistic Expected Pessimistic Optimistic Expected Pessimistic 1985-1990 2.5X 2.52 2.62 2.02 2.02 2.0O 1985-2005 2.32 2.62 2.72 2.42 2.5Z 2.52 Source: Mission Estimates. 17/ These rates are considerably higher than those being used by the National Planning Commission for planning purposes. Current education planning is on the basis that the primary school age population will grow at 2.012 to the year 2000. - 30 - 4.03 Education in Relation to Fertility and Health. While many factors determine the rate of growth of the population, international evidence clearly suggests a link between education and fertility. This relationship, while not yet fully understood because of its complexity, strongly suggests that education affects fertility indirectly by influencing factors such as age at marriage, contraceptive use, and desired family size. A recent review of the evidence concluded that "In most cases, if the relationship was not monctonically inverse, fertility first ros'i with education and then fell' and that "in these cases, peak fertility was generally found at lower primary education".18/ Significantly, it is also argued that female education is more often inversely related to fertility than is male education. These are important conclusions. While education may not reduce fertility in all circumstances, evidence does point to the fact that universal primary education is likely to curb the rate of population growth. 4.04 Other aggregate level data also demonstrate the potential impact of education on fertility. One study of 37 developing countries shows that the primary enrollment rate in all countries was at least 802 at the date of the historic decline in fertility.l9/ Further, secondary gross enrollment rates were also high, averaging 37Z. The authors conclude: "The evidence from most of the studies of the links between enrollment and declining fertility in developing countries suggests that a sharp fall in fertility appears to coincide with rising secondary school enrollment in an environment where universal primary education was either already established or close to achievement. At the early stages of development, however, "fertility is much less sensitive to socio-economic changes, including increases in school enrollment, than to influences such as improvements in life expectancy at birth".20/ It is also clear however that the level of education in the community, particularly when it is synchronized with other inputs (health services, water supplies agricultural extension, etc.), positively influences life expectancy of children. 4.05 An illustration of the potential impact of education on the life expectancy of children is provided by analysis of the effects of parental education on child mortality - particularly mother's education - which shows that on average an additional year of mother's schooling was associated with a 9 per 1000 reduction in child mortality -- 6 per 1000 was the result of mother's education, and 3 per 1000 being the effect of the 18/ Cochrane, Susan H. The Effects of Education on Fertility and Mortality. Education and Training Department, World Bank Discussion Paper, May 1986. 19/ Psachanopoulos and Woodhall, Education for Development, World Bank 1984, p. 301. 20/ Psacharopoulos and Woodhall, 1984, p. 303. - 31 - fact that she was married to a more educated, higher income husband.21/ Subsequent research on 28 developing countries including Nepal shows a fairly uniform relationship: (a) Average under age 5 mortality falls from 152 to 67 per 1000 as the level of mothers' education increases from 0 to 7+ years and from 148 to 84 per 1000 over the same range of husbands' education. (b) Assuming the average education of the 7+ group is 9 years, there would be a reduction of under age 5 mortality of 9.4 per 1000 per year of schooling as a result of mothers' education and 7 per 1000 for the husband.22/ Data for Asia and Pacific countries used as a basis for the above conclusions are shovn in Annex I-3. The data for Nepal and the region conform to the general relationships outlined. 4.06 While high population growth rates will significantly add to the rebiurce requirements of the educaticn sector, international evidence suggest that delays in expanding the education and literacy levels of the population in a country with the characteristics of Nepal will make it far more difficult to achieve significant reductions in population growth rates. Further, the evidence would suggest Nepal is currently at a critical stage where a major push on literacy and primary education given current educational achievements would result in significant returns. B. Projected Resource Constraints 4.07 The largest determinant of resources available for the further development of education in Nepal is clearly the potential to expand public resources devoted to the education sector. This constitutes the second major strategic constraint to educational development. A series of scenarios of possible (likely) resource availability for the education sector is presented in Annex I-5. These are far from reassuring. The medium scenario, while reasonably optimistic (given past economic performance in Nepal and the prospective aid environment) provides a realistic basis to discuss likely future education resource availability. Table 17 illustrates the results from the medium case scenari- . Clearly if the share of education in the budget remains at 11 percent (sc nario A), the resources available for education are severely constrained, with an average growth rate of about 3.2Z to 1995 and about 2.7? to 2000/01. Given the rate of growth in the school age population, it would not be possible to maintain current enrollment ratios nor achieve a modest expansion. A policy decision to expand the priority of education in the Government budget (scenario B) would significantly improve the number of degrees of freedom available to MOEC. This would however imply a significant departure from past trends and involve a strong shift in public expenditure priorities. 21/ Cochrane, (1986). 22/ hobcraft, McDonald and Rutstein 'Child Spacing Effects on Infant and Child Mortality", Population Index (49,4) Winter 1983 as quoted by Cochrane 1986. - 32 - Table 17: Public Resources available for Education 1986187- -2000101 (Medium Case Scenario) (Rs million 1986/87 prices) Initial Conditions 1986/87 GDP 56,013 GDP Growth Rate 1974/75 - 1985/86 2.67Z Primary School Age Population Growth (1985-90) 2.54Z Government Budget (1986-87) 10,614 Education Budget (1986-87) 1,168 Share of Education in Gov't Budget 112 Assumptions /a GDP Growth Rate 3.0? Revenue Share of GDP Improves to 11.0Z (from 9 Z) Aid Drawdowns (Average p.a.) 4,500 Scenario A Scenario B Share of Education in Total Budget (11X) (rises to 14 Z) Projections 1995/96 Expected Budget 1500 1773 Increase in Education Budget 332 605 Increase Needed to Maintain Initial Enrollment Ratios lb 246 246 Surplus 86 359 Rate of Increase of Education Budget 3.182 5.362 2000/01 Education Budget 1660 2113 Increase in Education Budget 492 945 Increase Needed to Maintain Initial Enrollment Ratios lb 459 459 Surplus 33 486 Rate of Increase of Education Budget 2.76? 4.67? Sources Annex I-5. Notes: a/ Explained in detail in Annex I-5, pp. 3-6. b/ Assumes total education budget would need to increase at same rate as the 6-10 age specific population growth rate projected for the period 1985-2000 (2.58Z). - 33 - 4.08 What the analyses in Table 17 and Annex I-S shows, is that under likely conditions, MOE will require almost all the resources available to it just to keep enrollment rates at their present (relatively low) levels - because of the increase in school age population. This means that nothing additional would be available for quality improvements, upgrading of the university, or the hundreda of other needs in the education sector. If, on the other hand, one really wanted to attain universal primary education by the year 2000, then this would require roughly a doubling of the primary education budget over the next 12 years in real terms (based on a 2.5Z p.a. growth in school age population, and an increase in real enrollment and attendance from about 65Z to 1001 - and assuming a linear increase in costs). While this analysis is somewhat simplistic, it does emphasize the magnitude of the problem. 4.09 Given that the past 12 year growth rate of GDP (1974/75 - 1985/86) has been of the order of 2.71, and that the current environment for aid flows (even for Nepal) is not extremely bright, the low case scenario outlined in Annex I-5 cannot be ruled out as a distinct possibility. This indicates Nepal would not have the resources to maintain enrollment ratios (Annex I-5, page 1) unless it significantly expanded education as a share of Government expenditure from the current 112 to 141 (Annex I-5, page 2). Even under these circumstances, the MOEC would have very little scope to expand enrollment ratios. Education expenditure could only be expected to grow at 2.79Z per annum in real terms to the year 2000/01. - 34 - Chapter V - PROPOSED SECTOR STRATEGIES 5.01 The education systems of the Kingdom have been described level-by- level and type-by-type. The systems have been critiqued to indicate areas for potential improvement. Two overriding constraints related to demographic trends and and budget resources were featured in the descriptions. In the context of this earlier analysis, the following sections set forth recommended education and training strategies for the Government and for the donor community. A. Government Strategy 5.02 The Government is placing its highest priority on the Basic Needs Program, which is largely confined to the primary level in its application to education. Not only is this in keeping with the Government's concern with the populaz Basic Needs movement, but it also fits with the need of the nation to develop its educational system by an evolutJonary process -- from the bottom up. With a shortage of resources other than human, Nepal must proceed in this way. Primary education has been found Jn Nepal and elsewhere to have a direct beneficial effect on Nepal's two most persistent problems: continued excessive population growth, and shortage of food, fodder and fuel. Primary education causes adults to have a better grasp of population and family planning issues. It helps to lower infant mortality which reduces the need to have additional children to replace those expected to die young. Farmers and foresters with a primary education are demonstrably more likely to adopt modern techniques to extract more from overused and scarcer land. Finally, primary education consistently shows a higher rate of return to investment than the other levels of education--282 compared to 172 and 142 for the secondary and higher levels in a study of 26 developing nations. 23/ 5.03 Specifically, the Government's planning under the Basic Needs Strategy calls for great increases in the numbers of primary schools, as well as school construction and teacher training necessary to bring the enrollment ratio up to the target of 1002 by the year 2000. This would result in greater benefits for girls than for boys since the present ratios for girls are so much lower than those for boys. Several of the implementation plans set forth under the education portion of the Basic Needs Strategy are not well conceived and will result in significant problems in the years ahead. The weaker parts of the implementation plans are: (a) the emphasis on increasing the numbers of primary schools, (b) the crash plans for teacher training, and (c) the financial demands of the Basic Needs program on the national budget. Elaboration on these points is provided below. However, the basic thrust of the program is in the right direction. 23/ Nepal: Education and Human Resources Sector Assessment, Hay 1988, Table 2.22, pp. 2-44. - 35 - 5.04 The ongoing Primary Education Project (PEP) and the Seti program are seen as models in the Government's program. The major successes of these programs are: (a) more effective delivery methods for teacher, administrator and supervisor training, (b) the creation of small units for school management (clusters) and the establishment of resource centers for each of these units, (c) improved supervision, and (d) strengthened instructional materials. However, it will be a major undertaking to extend the model from the present coverage of six districts in PEP and five in Seti to all 75 districts of the country. Difficult as it may be, it would probably be better to try to implement the new program in a portion of every district each year rather than to complete an entire district before going on to remaining districts. The Government is concerned that some districts are being favored under PEP and Seti and now believes, correctly, that it is time to show some tangible progress in all districts soon. The strong features of the PEP and Seti are replicable to the entire nation - the pace of the process is the issue. 5.05 The Government's plan to sharply increase the number of primary schools is the most apparent weakness in the Basic Needs implementation plan. The present number of schools is about 12,000 which makes possible a gross enrollment ratio of 78Z (enrollment is about 1.9 million and the number of teachers is 51,000). The implementation plan calls for slightly cver 2.9 million enrollment in 2000 wheia the 100l enrollment target is to be reached.24/ The error is in the assumption that more enrollment automatically means a need for more schools. What the Government's plan overlooks is the fact that the present enrollment ratio for boys is over 1002 while the ratio for girls is less than 502 (Table 7). Almost all of the non-enrolled girls are sisters of enrolled boys. So it is obvious that the existing school locations are close enough to most homes to serve the larger enrollment. A modest number of additional schools may needed since existing school sites could not fully absorb the expected enrollment. The plan calls for over 17,000 schools, a 402 increase, in 2000 when only about 13,000 would probably suffice. There would still be a need for heavy expenditures for additional classrooms, but there would be savings in the numbers of principals to be appointed and the number of locations to be supervised. 5.06 An even bigger defect in the education Basic Needs Strategy plan for implementation is in the teacher training segment. The Government should reassess its policy calling for all primary teachers to hold an SLC pass. In remote districts this standard will be difficult if not impossible to reach, because the annual number of teachers needed nearly equals, or even exceeds, the annual number of SLC passes. When gender is considered the situation becomes worse since the number of girls who pass 24/ Tirtha Bahadur Manandhar, "Basic Needs Programme for the Universalization of Primary Education," Shiksha, March 1988, p. 30. - 36 - SLC remains low. The Government has a constructive policy of favoring the appointment of females as new primary teachers, which the SLC standard will tend to negate. An even more fundamental issue is the appropriateness of such a standard for the country even if it could be attained. An SLC pass places an individual at about the 95th percentile in educational attainment in Nepal. Most nations do not use such persons as primary teachers. Moreover, such a select group will not usually find personal satisfaction in primary teaching and as a result turn out to be less satisfactory teachers than persons with somewhat lower educational attainment. The Government's plans for crash programs in teacher training of only about one month's duration are subject to question. It would be better to delay achievement of the target of all teachers being trained in order to have a longer duration of training. 5.07 The third, and perhaps the most fundamental shortcoming of the implementation plans for the Basic Need program, is its lack of suitable treatment of the budget implications of the greatly expanded enrollment, and corresponding increases in the numbers of teachers to be employed and classrooms to be constructed. The Basic Needs program in primary education translates into an annual rate of enrollment growth of 4.12 between 1985 and 2000. GDP growth is averaging only 2.52 p.a.. It is apparent that the budget and finance squeeze described earlier (paras. 4.07-4.09) is destined to become even more severe as the Basic Needs program is implemented. The plans call for meeting some of the constraint by increasing class size. This will be counter-productive, since student groups are already too large for teachers to handle. Community financing of needed classrooms is also proposed as a way to keep public costs down. However, the capacity for community finance is also limited both by the poverty of many villages, and by the same constraints on overall growth which restrict the capacity for public financing (para. 4.08). The Government should launch immediately a thorough study of how the Basic Needs program in primary education would be financed. 5.08 Increased priority should be afforded to non-formal education. The small scale efforts of recent years in adult literacy have been both successful and relatively inexpensive. This program merits wider implementation and should include efforts to reach out-of-school youth as well. Both the adult and youth programs should devote more attention to retention of literacy and numeracy once it is achieved. 5.09 However great may be the priority given to primary education, the Government cannot avoid giving attention to secondary education. By moving the 10+2 concept so prominently into public attention in the past year the Government has, in effect, created the principal element of its secondary education strategy for the remainder of the century; one that will also affect higher education profoundly. While many short range problems will be created by the 10+2 scheme, its positive contributions to a more effective and efficient education system will be great. Increased attention should be devoted to tighter management of all segments of the secondary system with particular emphasis on: avoiding the creation of excessively small secondary schools, developing means for poor but able students to attend, creating additional exit points (perhaps after grades - 37 - 8, 10 and 12), rationalizing pre-service teacher training to make more effective use of the Faculty of Education of the University, and reforming curricular content and examination methods. 5.10 In VTE, government strategy is intertwined with the creation of the new Council for coordination and implementation. The MOEC appears to place greatest emphasis on the addition of more technical schools; the ADB has recently appraised a project to assist the Government in this respect. Another approach is to expand and accelerate the process of transferring those parts of the University which offer trade and technician level courses to the proposed new Council (i.e. to MOEC). Within reason, this is a beneficial move - if nothing else it reduces the scope and management problems of the University. However, such cosmetic changes will not really improve the capacity of the nation to meet its manpower needs more effectively. While technical school and university programs will not address the overriding need for lower level skill development, there are important improvements to be made in existing programs by reducing the duration of courses (they are often twice as long as they need be) and developing curricula which are more related to the needs of employers. 5.11 In many cases the agencies most appropriate to address the needs of VTE are not MOEC or the University, but other ministries and even the private sector. In this regard the Council has great potential since planning and coordination should be the first steps. The programs of the Ministry of Labor in Skill Development Centers are a good starting point. Perhaps there are other ministries able and willing to begin training programs at the basic skill level. If the Council were properly designed and staffed for coordination, it would be the logical unit for the Government to look to for development of an initial plan. Unfortunately, the Council may simply try to capture existing training programs for MOEC operation. It may not be too late for the Government to rectify this situation. 5.12 The skill testing agency assisted by the World Bank's second VTE project appears to be less developed than it should be at a time when the society desperately needs a larger supply of certified tradesmen and craftsmen. The Council has indicated that it may wish to play a role in management of skill testing. Finally, the Government as a whole must address the problem for VTE of the open border with India and consequent free flow of labour. 5.13 Higher Education. Government strategy in higher education needs to be courageous and far reaching. Perhaps the precipitous introduction of the 10+2 scheme is an indication of constructive Government intentions. But, as pointed out earlier (para. 2.27) this would only offer a temporary reprieve if what happens now after grade 10 were permitted to happen after grade 12, that is, virtual universal acceptance into the university of all those completing secondary school successfully. An effective Government strategy in higher education should include attention to the following: - 38 - (a) An assessment, making use of international expertise as well as distinguished Nepalese, on a discipline-by discipline basis of the quality of the University should be the cornerstone of the strategy. This assessment should include all dimensions of university quality - curriculum, faculty qualifications and teaching loads, equipment, facilities, management and finance. It should be the equivalent of a full-scale university accreditation exercise. (b) Initiate policy dialogue within the University, in MOEC and elsewhere in the Government of alternative approaches to university admissions. This would have to take into consideration the probable 10+2 scheme. What is clear is that the rigor of the screening device for admission needs to exceed that of the present SLC. A separate university admissions examination would appear to be the best solution, but other ideas should not be ruled out without consideration. If more exit points are introduced in secondary education, some of the screening process would already have occurred, especially if admission comes after grade 12 instead of after grade 10. Standards of admission may need to vary among disciplines, and perhaps there should also be variance among campuses to promote admissions equity between the regions of the nation. (c) Examine the pattern of student choice among d.sciplines offered by the University (Table 11) and develop a policy to redirect students to those fields most related to natiorAal development needs. Quotas for disciplines and varying standards for admissions would be useful tools to accomplish this objective. The assessment mentioned above should provide information on disciplines to add or delete; increase or decrease. (d) The strategy should consider the advantages and disadvantages of a single university with many campuses, or a multiple institution arrangement. Consideration of a policy to permit and perhaps even encourage creation of private institutions of higher education should be included. Again, the assessment would contribute. (e) The strategy should also attempt to resolve the present unclear relationship between the University and HOEC. B. Priority Areas for Assistance 5.14 It is obvious from the analysis above, and in the previous chapters, that there is great need for external assistance in all aspects of the education and training system, both in terms of institutional strengthening and financial assistance. Since the need is great in all sub-sectors, determination of priorities could be difficult. However, consideration of the following three points make it clear that the selection of the primary/non-formal subsector is the first priority: (a) the momentum gained in establishing a model on which the primary education reform is to be based (i.e. the ongoing Primary Education and Seti Projects) must be continued lest the gains of tne projects up to now be - 39 - lost; (b) moreover, the essential need for education to contribute to improvements in population growth and agricultural efficiency argue most for assistance in primary and non-formal education; and (c) the budget and financial squeeze described previously (para. 4.07) suggests the priority of assigning funds to primary and non-formal education to sustain the growth in enrollment achieved in the past decade. Moreover, rates of return from primary are greater than from any other subsector. In these two subsectors - primary and non-formal - sufficient study and experimentation has been conducted so that the Government and the major donors have P. fairly clear grasp of next steps in development. 5.15 In the other subsectors - secondary, higher and VTE - additional analysis and policy dialogue are needed to develop new, operational assistance programs apart from those already underway. Carefully conceived technical assistance in secondary, higher and VTE should be considered as a means for preparing the ground for future operations. Leadership in helping the University launch the recommended assessment would be a prime example of such a case. No major new initiatives should be attempted in higher education before the assessment. However, donor assistance will probably be needed to help the Government address these issues. 5.16 Formulation of the next round of assistance in primary/non-formal education should consider the following: (a) The strongest features of the PEP and Seti projects should be combined for use in a program to be applied to the entire nation (para. !.O4). (b) Elements in the previous projects (PEP and Seti) which contribute to higher costs should be eliminated or reduced. Research now planned andlor in progress under both projects will help to identify these elements. (c) Existing capacities for school construction, teacher and supervisor training, materials development, etc. developed under PEP should become the basis for an expanded implementation program. Introducing the PEP/Seti model in over 60 districts will be a difficult undertaking. (d) Resources of multiple agencies would probably need to be assembled to meet the total costs of the program. This may be the place for the first jointly financed multilateral education project. Interested bilateral agencies would also be involved. However, the project should be a single effort requiring substantial coordination of the donors. 5.17 The donor community should firmly support expansion of the non- formal education program, which should have the same basic objectives as the support for primary education - increased literacy and numeracy to address the demographic and agricultural issues. Emphasis should be on younger adults and out-of-school youth, including children who were dropouts or who never attended primary school. Successful projects in Thailand, Malaysia and Indonesia could be used as models. - 40 - 5.18 As mentioned earlier, there is great need for assistance for the study of policy and programs to overcome Nepal's problems in secondary. higher and VTE. This should not be confined to technical assistance alone but should be developed as a policy-cum-investment-cum-technical assistance package that would provide the incentives required to encourage the Governmant to become committed to the many reforms which are needed. The three subsectors could be addressed in one operation because of the many ways in which they interact and overlap, examples of which include: (a) the 10+2 movement in secondary causing entry into higher education to occur two years later; (b) multiple exit points in secondary education (i.e. after grades 8, 10 and 12) which should diminish the flow of students through the secondary grades and thereby reduce the numbers seeking university admission, and at the same time provide points at which a switch to VTE could happen; and, (c) rationalization of the role of the university to begin after grade 12 would cause activities now provided by the university to be shifted to the general secondary system and to VTE, 5.19 The reluctance of the Government to utilize donor resources for specialist services is an obstacle to mounting such essential needs as the university quality assessment and examination reform where outside advice is critical. This points up once again the need for donor coordination in education. In the past years many instances have surfaced where donors have been working on projects with overlapping or even conflicting objectives. - 41 - PART II - POPUL&TION AND EALTH - 42 - PART II - POPULATION, HEALTH AND NUTRITION Table of Contents Page No. PART II.A POPULATION ... ............ .. ......... . . ........... . 44 I. CURRENT SITUATION ....................... . ................ 44 A. Population Growth ...... . ..........44 B. Family Planning ............ ....................... 45 C. Migration ............ ................. ... ....... 46 II. INTERSECTORAL LINKAGES 4 8..... .... *. ........... . .*. ..48 A. Fertility ................. ......48 B. Mortality ................. ......50 C-. Migration ................. ......51 III. POPULATION PROJECTIONS ............... ..*. ..........52 IV. GOVERNMENT STRATEGY AND PROGRAMS ...............56 A. Population Strategy .............. B. Current Programs ................................. ... 56 C. Institutional Arrangements ................57 V. POPULATION PROJECTIONS AND BASIC NEEDS .....................59 VI. PROGRAM IMPLEMENTATION STRATEGY ...........................60 PART II.B HEALTH, FAMILY PLANNING, AND NUTRITION .................... 62 VII. CURRENT HEALTH STATUS ........................... . ... * .... 62 A. Introduction ......................62 B. Mortality ................. ......62 C. Morbidity and Disability ........... ............ 63 D. Maternal Morbidity and Disability.. 65 E POLiCY ............................................. 67 F. Risk Factors ......................68 VIII. THE POLICY FRAMEWORK ........... .......**71 - 43 - IX. THE HEALTH SERVICES SYSTEM ........... . ........ ..73 A. Organization .................... . ......... . .73 B. Infrastructure .......................... ......... 75 C. Manpower 77...... ............ D. Public Expenditure ..... . ..... .. ........ ................. 79 E. Non-Governmental and Private Services ................. 84 X. ISSUES IN HEALTH, FAMILY PLANNING AND NUTRITION ........ 87 A. Effectiveness ....................... ................. . 87 B. Efficiex.cy ................................... ......... 88 C. Decentralization ...................................... 89 D. Integration ............................................. 90 E. Regionalization ........................................... 91 XI. PRIORITY AREAS .. ............... .. ....... .92 A. Female Health and FP Workers .......... .. 92 B. Residency Training in Rural Facilities ................ 93 C. MCH and FP Priorities . .... ....... 94 D. Iodine Deficiency Disorders ........................... 95 E. Malaria ... .96 PART II.C CONCLUSIONS g 9.. . .. ... ........... . 99 XII. HEALTH AND POPULATION SECTOR STRATEGY .99 A. General ........................99 B. Priority Areas for Assistance . .......101 ANNEXES (Contained in Annex section following page 137) Annex II-1 - Characteristics of Contraceptive Users Annex II-2 - Population Projections Annex II-3.1 - Cases of Malaria in Nepal 1950-87 Annex II-3.2 - Maternal Morbidity and Mortality by Cause Group Annex II-4 - Ministry of Health - Organization Charts Annex II-5.1 - Ministry of Health Budget 1975-87 Annex II-5.2 - Actual vs. Planned Health Expenditures Annex II-5.3 - Breakdown of Health Expenditures Annex II-5.4 - HMG Expenditure on Pamily Planning Annex II-5.5 - Teaching Hospital Budget Annex II-6 - Donor Assistance for FPIMCH Annex II-7 - Hospital Distribution and Construction Program Annex II-8 - Estimate of Basic Needs Manpower Requirements - 44 - PART II.A - POPULATION 1.01 This part of Volume II sets out the magnitude of the population problem, both in terms of growth and spatial distribution, considers the current and future government population program, and discusses the major issues and general strategy for the future if Nepal's population problem is to be effectively addressed. In the first chapter below the current situation is briefly summarized. Subsequent chapters add detail on the determinants of population change and linkages between sectors, provide plausible projections for alternative policy scenarios, summarize HMG's policies and service delivery programs, and, finally summarize the major issues and a strategy to address these. Details of the service delivery system and institutional issues which effect the delivery of both health and family planning services are discussed mostly in Part II.B, which deals with the health sector more broadly. Chapter I - CURRENT SITUATION A. Population Growth 1.02 Among selected countries in Table 1.1, the current rate of population growth in Nepal is exceeded by only Pakistan and perhaps Bangladesh. Indonesia and Sri Lanka are also included in the table to hold out the hope that, by emulation, the Nepalese situation can improve with an energetically implemented population strategy. Unlike Nepal, in both countries there are supportive linkages between sectors as well as strong family planning programs. Table 1.1: Demographic Indicators for Selected Countries (circa 1985) (per thousand unless otherwise indicated) Population Total Infant Growth Birth Death Fertility Mortality Country Rate Z Rate Rate Rate Rate Nepal 2.5 40 15 5.8 110 Bangladesh 2.6 40 1S 5.7 123 Bhutan 2.2 43 31 6.2 133 India 2.2 33 12 4.5 89 Pakistan 3.1 44 15 6.1 115 Indonesia 1.8 32 12 4.1 96 Sri Lanka 1.6 25 6 3.2 36 Source: World Bank, World Development Report, 1987. For Nepal, Central Bureau of Statistics. - 45 - 1.03 The current high rate of population growth in Nepal, estimated at 2.6Z for 1971 to 1981 (intercensal exponential growth) and currently estimated at about 2.5Z, is undermining efforts at economic and social development, Combined with a nearly stagnant agriculture sector, population growth has been rapid enough to keep the real value of agricultural output per capita approximately constant from 1976 to 1986. As noted elsewhere in this report, evidence is clear, whether in terms of population and arable land ratios, caloric intake, or cost and availability of social services, that a solution to the population problem must be found as a prerequisite for development and future provision of basic needs. B. Family Planning 1.04 The threat posed by population has been the target of Government and NGO programs and has led to the specification of a formal population strategy. Population is also recognized as a fundamental component of the government's Basic Needs Program (BNP). Organizational problems together with the extraordinary constratnts on logistics and supervision imposed by Nepal's terrain and communications infrastructure have restrained the population effort. In the face of these constraints, Nepal has increased the contraceptive prevalence rate (CPR), from 2.3Z in 1976 to 7Z in 1981 and 152 in 1986 (Table 1.2). Table 1.2: Percent of Married Women of Reproductive Age Using Family Planning By Method in 1976, 1981 and 1986. Method 1976 /a 1981 /b 1986/c Female Sterilization .1 2.4 6.8 Male Sterilization 1.5 2.9 6.2 Pill .4 1.1 .9 Condom .2 .4 .6 Injectables .0 .1 .5 IUD .1 .1 .1 Total 2.3 7.0 15.1 a/ Nepal Fertility Survey, 1976, Table 7.5, p. 66. b/ Nepal Contraceptive Prevalence Survey: Preliminary Report, 1981, Table 4, p. 8. c/ Nepal Fertility and Family Planning Survey, 1986, Table 10.23, p. 124. - 46 - 1.05 Although Nepal's contraceptive prevalence rate remains on the low side of the selected list of Asian countries in Table 1.3, the effort that has been expended over the last ten years to achieve the current level of 15Z is recognized as a good basis for further program development. However, to date the family planning program has largely involved a centrally managed campaign of sterilization (86Z of current users) and if the program is to be expanded to the levels required by the Government's Basic Needs strategy, the mix will have to be broadened to include a substantial proportion of users of temporary methods. To achieve this the existing training, organizational and logistics constraints will have to be addressed. Table 1.3: Contraceptive Prevalence Rate (CPR) in Selected Countries, 1984-1986 Country CPR(Z) Nepal 15 Bangladesh 25 Burma 5 India 35 Indonesia 40 Pakistan 8 Sri Lanka 57 C. Migration 1.06 Over 34Z of the current population of the terai was born elsewhere; 11 an estimated 85 to 903 of this new population is the result of internal migration from the hill and mountain districts of Nepal and the remainder is attributable to international migration (predominantly from India). Based on the estimated difference between the actual rate of increase and the natural rate of increase, the annual rate of migration was about 12 per 1000 out of the mountain and hill areas and 16 per 1000 into the terai between 1971 and 1981. Current data, while awaiting the more definitive measure of the 1991 census, indicates that this movement is continuing at about the same rate. Migration can be viewed as an efficient allocational response to economic incentives and this may have been the role of long term migration when expanded settlement in the terai was made possible by the malaria program in the 1960's. But, as arable land has filled in the terai, the continued long term movement of population is now primarily in response to the push of population growth in the hills and, without expanded labor productivity in the terai, may not be playing an economically positive role. 1/ HMG, Central Bureau of Statistics, forthcoming publication, 1988. - 47 - 1.07 One possible complication of the lack of arable land and population growth in the hills is an increase in urbanization in the future, but it is not clear whether urbanization is a current problem. In 1981, Nepal had only 23 areas of 10,000 or more people and only 6.22 of the population was urban 2/ . This compares to an average of 202 for other countries (excluding China) classified as low income in the WDR. Although this percentage was small it represented almost a doubling of the urban population ir. the decennial period between censuses. The terai, where there had been no urban places of 30,000 or more, experienced more than a 102 annual growth in urbanization, and now has 7 of the 12 places of more than 30,00C. Again, this can be economically efficient if it is in response to allocational opportunities. The percentage of population below an FAO defined subsistence level of consumption was 322 in rural and 20? in urban areas in a 1983 study. Also, urban to rural income ratios are about 1.5 after adjusting for income in kind in rural areas 3/ . Underemployment, measured as a percent of total available labor hours, is 422 in rural areas and 242 in urban. Much of the new employment in urban areas is in informal services that have come to mark rapid urbaslization in other countries. 1.08 International migration, which had been perceived in the past as a major issue, appears to have become smaller in scale and more temporary. However, reliable data on international migration are scarce and inconclusive, and a fuller picture will emerge once the 1991 census has been completed. A recent study 4/ by the Central Bureau of Statistics (CBS) indicators that emigration is almost exactly balanced by immigration, with a net rate into Nepal of -0.1 (per 1,000) for males and +3.1 for females. A new phenomenon, short term seasonal movements, occurs in both directions in response to the crop cycle. This movement has not been carefully studied yet but indicates the presence of seasonally fluctuating wage differentials, an active labor market in the terai and a fluid border between India and Nepal. 2/ Based on data in HMG, Central Bureau of Statistics, Population Monograph of Nepal, 1987. 3/ See Part III: Assessment of Poverty in Nepal. 4/ HMG, Central Bureau of Statistics, Four Month Statistical Bulletin, Table 1. - 48 - Chapter II - INTERSECTORAL LINKAGES AND THE DETERMINANTS OF POPULATION CHANGE A. Fertility 2.01 The total fertility rate (TFR) has fallen from about 6.2 in 1976 to 5.8 in 1986. 5/ This modest drop is attributable on a purely mechanical level to the increase in the CPR. However, family planning acceptance is itself a function of a number of proximate determinants and if substantial further reductions in fertility are to be achieved, the proximate determinants of fertility must be recognized and used to advantage in program design to achieve a higher CPR. Some of the most important of these are the educational level and social role of women, child health (especially, the infant mortality rate), and per capita household income. 2.02 Less than 12? of women in Nepal are literate, and education past the primary grades is negligible. Strong evidence exists from other countries of the inverse relationship between female education and fertility. This relationship is derived from economic effects as education increases the marginal productivity of women's time outside of child rearing responsibilities, social effects from changes in the awareness and status of women, and enhanced effectiveness of family planning information and services. At present, the level of female education in Nepal is too low to have produced noticeable economic and social effects, but the effects of education on family planning effectiveness are beginning to be evidenced in survey information. Fertility surveys in Nepal have shown that there is a slight rise in TFR with partial primary schooling for the mother, but a fall in fertility with further schooling. The traditional role of women appears to confound the effect of education in Nepal because many women leave school for economic roles in the household or for early marriage. The limited evidence that does exist suggests that with an increase in female completion of primary school the effectiveness of family planning and maternal and child health (PP and NCH) information and communications will be greatly enhanced. The 1986 fertility survey showed a direct and positive relationship between the education of women and their knowledge and practice of family planning (Table 2.1, also see the relationship with literacy in Annex II-1). 5/ op cit., Table 2. - 49 - Table 2.1: Relationship Between Education of Women and Selected Contraceptive Indicators Education Level No Primary Middle & Higher Contraceptive Indicator Education (Grade 1-5) (Grade 6+) MWRA Currently Using a FP Method (1) 14.1 21.2 33.9 MWRA Ever Using a FP Method (S) 14.7 22.2 37.3 MWRA with Knowledge of at least one Method (X) 53.5 78.1 89.3 Source: Nepal Fertility and Family Planning Survey, 1986. MWRA = Married women of reproductive age. 2.03 Child survival affects fertility both biologically, through the post partum period of reduced fecundity associated with nursing, and behaviorally, through the child replacement response. There is no clear evidence of this effect for Nepal but there is evidence from studies in other Asian cultures that a fertility response may follow a decline in infant mortality with a lag of about 10 years. Nepal is only now beginning to reach levels of infant mortality below 100 in urban areas and in select districts of the terai, but existing research demonstrates the mutual enhancement of programs that have child survival as one benefit, together with family planning. These programs could be child specific, such as immunization or oral rehydration, or more general, such as water, sanitation or malaria programs. 2.04 Based on evidence from other low income countries it is expected that an increase of income over time may be associated with a decline in fertility in Nepal as the structure of the economy changes and the economic motives for a large family become less important in agricultural households. There is, however, very little cross-sectional evidence in Nepal of a direct effect of per capita agricultural household income on the fertility of women. This may partially be explained by the relative flatness of income distribution in rural areas, and by the economic value (from the point of view of the individual couple) of children in an agricultural household. Some evidence exists that there is, in fact, a positive relationship between the size of livestock holdings and fertility. In urban households, higher incomes do appear to be related to smaller family size, but it is difficult to separate this effect from that of education and social differences. However, the inverse relationship between income and fertility is well established as part of the development process and there is no reason to expect that Nepal will follow a pattern that is any differenc than that of other more developed Asian countries in this respect. - so - B. Mortality 2.05 The infant mortality rate (IMR) has fallen from about 155 in 1970 to 130 in 1981 and, most recently 6/ about 110 in 1986. This drop is probably attributable to a modest expansion in the coverage of the infant population with preventive health services (especially the expanded program on immunization, EPI). But, as with the fertility rate, if substantial further reductions are to be achieved, the proximate determinants of mortality must be considered in program design. The most important of these are educational level of the mother, fertility, and per capita income. 2.06 The average IMR is 113, 103, and 28 in households where the mother has no education, primary education, and middle school or above, respectively. 7I This is consistent with a large literature on the link between education and child survival for other countries. While the Nepal data have not been controlled for differences in per capita income, this has been done in other studies and the strong relationship between education and infant mortality remains. As was noted above for fertility, the effects of education act both directly to alter maternal behavior to improve child survival and to increase the effectiveness of health programs. 2.07 The effect of fertility reduction on infant mortality has been demonstrated in Nepal and elsewhere 81 . In a cross country study looking at the relationship between birth spacing and infant mortality it is found that the risk of dying for a child born with less than a two year birth interval is approximately 60Z greater in the neonatal period and 10OZ greater in the remainder of the infant period than for a child born after more than a two year birth interval 91 . It is difficult to translate the recent reduction in fertility in Nepal into an effect on infant mortality operating through increased child spacing because much of the decrease has come through sterilization, but it is clear that if Nepal adopts changes in the family planning program that promote increased spacing and the use of temporary methods in the future, the effect on infant mortality could be substantial. 6/ HMG, Central Bureau of Statistics, Demographic Sample Survey, 1986/87, First Report, 1987, Table D.1, p. 73. 7/ HMG, HOH, FP/MCH Project, Nepal Fertility and Family Planning Survey, Table 8.3, p. 85. S/ See for example, A Fisher, 'The Gurkha Fertility Study; Pregnancy Spacing and Child Mortality, (mimeographed, 1977, Nepal/University of California Berkeley FP/MCH Project). 9/ Anne R. Pebley and Sara Millman, 'Birthspacing and Child Survivalg, International Family Planning Perspectives, Vol. 12, No. 3, September, 1986. pp. 71-79. - 51 - 2.08 Increased income is strongly associated with increased child survival 10/ . As with the effects of income on fertility it is difficult to separate the effects of income on mortality from those of education. Information and education interact with income to bring about improved consumption patterns beneficial to health status. The improved consumption includes better nutrition, a greater quantity and better quality of water, clothing, housing and health care, more fuel, transporta*ion, and betted hygiene. C. Migration 2.09 Migration of males occurs largely in response to the increasing pressure on arable land in the hills and mountains and in response to potential job opportunities as landless labor in the terai and, to a lesser extent, in urban areas. Females, based on survey evidence, migrate primarily for marriage. 2.10 Migration of men is slightly selective of people with an educational level greater than in either the place of origin or the destination. Approximately 55? of lifetime male migrants are literate compared with less than 30S for the general male population in the hills and 50S of the terai population. Literacy does not appear to be a strong factor in female migration. 2.11 Increasingly, compared with the 1971-81 period, migration, both internal and international, appears to be short term (less than six months) in response to the agricultural cycle. During the peak summer season in the terai there is migration of males from northern India (especially into the western and far western terai) for agricultural employment. In the winter, agricultural employment for landless labor in the hills becomes negligible and a reverse movement occurs into India and the terai. 10/ This relationship is well documented. See the discussion in W. H. Mosley and L. C. Chen, "An Analytical Framework for the Study of Child Survival in Developing Countries', Population and Development Review, Vol. 10, supp., 1984. - 52 - Chapter III - POPULATION PROJECTIONS 3.01 In order to test the effect of the intensity of HMG's population control efforts, national population projections for the period 1988 to 2018 were constructed based on very low, low, medium and high population growth scenarios. These scenarios describe the plausible course of population that might be expected if (1) there is no program or policy change and the status quo in 1988 continues into the future, (2) there is partial execution (either more or less slowly) of the program outlined in the Nepal Population Strategy and (3) there is full execution of the program outlined in the Nepal Population Strategy and the linkages between sectors are fully exploited. 3.02 Four sets of projections are presented, three of which cover the range of what may reasonably be expected given HKG's current capacity, and average experience in other countries. In addition a fourth set of projections has been prepared (the very low, or optimistic scenario), to illustrate what may be possible if HMG were to mount a very major population control effort. The high, medium, and very low scenarios are used in the main report to illustrate the range of possible implications for labor force, incomes, and land pressure. 3.03 The underlying TFR and IMR assumptions for the alternative scenarios are given in Table 3.1. The assumptions are judgmental and were set out to represent the plausible course of the total fertility rate and infant mortality rate with adoption of the specified programs. Table 3.1: Assumptions Used in Population Projections for Nepal 1985 to 2014 A. Total Fertility Rate (per woman) Years Scenario 1985-89 1990-94 1995-99 2000-04 2005-09 2010-14 High Growth 5.8 5.7 5.6 5.5 5.3 5.1 Medium 5.8 5.6 5.3 5.0 4.7 4.4 Low Growth 5.8 5.4 5.0 4.5 4.0 3.5 V. Low (Optimistic) 5.8 5.3 4.6 3.9 3.2 2.5 B. Infant Mortality Rate (per thousand) Scenario 1985-89 1990-94 1995-99 2000-04 2005-09 2010-14 High Growth 110 105 100 95 90 85 Medium 110 100 90 80 70 60 Low Growth 110 98 84 70 60 50 V. Low (Optimistic) 110 98 80 62 50 40 - 53 - 3.04 In the first of the four projections (the high growth, or status quo projection) some mortality and fertility reduction occurs spontaneously in response to urbanization and modest increases in literacy resulting from continuation of current education and development programs. The family planning program continues to provide sterilization services but the efficiency of the program declines, and the rate of sterilizations decreases to between 20,000 and 30,000 per year by 2005. The changes in program structure needed for an expansion of the use of temporary methods do not occur. The CPR remains constant at about the present level of 152. 3.05 In the second and third projections (the medium and low projections) it is assumed that the family plaiming program is revamped through a stronger effort to provide expanded use of temporary methods, irn addition to continuing to provide sterilizations at a level of 30,000 to 40,000 per year. The medium projection assumes a slow and partial execution of the population strategy; and the low assumes an immediate, but still partial, execution of the strategy. 3.06 The fact that there are two low (i.e. low and very low) projections reflects uneasiness as to the rate at which the government would be able to carry out needed program changes to expand the use of temporary methods. In the medium and low projections intersectoral reinforcement of the family planning program through increases in literacy, programs for women, and higher incomes does not occur on a large scale, but literacy in the terai, urban areas, and central accessible hill areas continues to expand at the current pace. The primary gains in family planning in these scenarios come from exploiting the difference between actual fertility (currently about 5.8) and desired fertility (currently below 4 11/ ). These projections reflect a partial adoption of the government strategy in the sense that there is a strong emphasis on the supply of family planning services, but the intersectoral links are not fully exploited and the program relies primarily on existing desired fertility. In the medium projection, with slow implementation of the partial strategy, the CPR reaches a level of 241 by 2005. In the low projection, with faster implementation of the partial strategy, the CPR reaches a level of 35Z by 2005. 3.07 In the fourth projection (the very low, or optimistic, projection) the family planning program is reinforced through a major effort to improve the economic status of women, adult literacy programs, wide scale primary school enrollment with an emphasis on female completion, and an increase in per capita income. Thus, the fourth projection represents gains from further changes in demand for family planning services as well as satisfaction of that demand through a revamped family planning program. The fourth projection requires full implementation of the government population strategy. The CPR reaches a level of 471 by 2005. ll/ Based on data in the World Fertility Survey (1977) corroborated by the Westinghouse survey (1981) and the 1986 FP/HCH survey. - 54 - 3.08 The projected size and growth of the population of Nepal under each of the four scenarios is s3mnarized in Table 3.2 and given in more detail in Annex 11-2. The tremendous threat of population growth is clear. Table 3.2: Projected Size and Growth of National Population /1 Total Population Ratio of Population (millions) Size to 1985 Base in: Scenarin 1985 2000 2015 2000 2015 Status Quo 16.6 24.5 36.9 1.5 2.2 (High Growth) Slow and Partial Execution of Population Strategy (Medium) 16.6 24.3 35.2 1.5 2.1 Rapid but Partial Execution of Population Strategy (Low) 16.6 24.0 32.9 1.4 2.0 Full Execution of Population Strategy 16.6 23.8 28.6 1.4 1.7 (Very Low) Average Annual Rate of Popultion Growth 2 Doubling Time at 1985-90 2000-05 2010-15 2010-15 Growth Rates Status Quo 2.442 2.75? 2.70? 26 years Slow and Partial Execution of Population Strategy 2.44? 2.532 2.402 29 years Rapid but Partial Execution of Population Strategy 2.44Z 2.29Z 1.90? 36 years Full Execution of Population Strategy 2.44? 1.99? 1.32? 52 years 1/ See Annex II-2. - 55 - 3.09 Because of the existing structure of the population and the dynamics of population growth, under all four of the scenarios the population will grow to 24 million or over by the year 2000. We must look beyond 2000 to see the effects of population policy. With a continuation of the status quo, the population will increase to at least 2.2 times its current level to reach 37 million in about 25 years time. Moreover, massive capacity for future growth will remain at the end of the projection period, with growth rates permitting a further doubling of population within another 26 years. Even the most likely scenario of a partial and slow execution of the population strategy together with further progress in reducing f pant mortality will result in only 1.7 million less people - or a population of 35.2 million in 2015. With a partial and rapid execution of the population strategy (the low scenario) the program should be able to contain the population to less than 32.9 million in 2015 and the growth rate would be less than 2Z. Finally, with a full execution of the population strategy (very low scenario), the expected population would be 28.6 million in 2015 with a growth rate of only 1.3Z and a doubling time ef 52 years. The implications of the projections for school age children, maternal and child populations and the dependency ratio are given in Annex II-2. - 56 - Chapter IV - GOVERNMENT STRATEGY AND PROGRAMS A. Population Strategy 4.01 In 1983 HMG adopted a formal population strategy. The major elements of the strategy are laudable and, if implemented, should be effective in reducing the rate of population growth. These elements include: (i) assignment of a high priority to provision of family planning services; (ii) integration of population programs in environment, forestry, agriculture, and rural development projects; (iii) development of programs that change the status of women, especially female education and employment; and, (iv) mobilization of panchayats and communities for population and fertility reduction programs. The service delivery element of the strategy would include continued expansion in the provision of permanent methods (sterilization) but would also build the basis for expanded temporary method use through the use of information, education and communications (IEC) activities to expand demand, and through strengthened user support with rural health services. The element of the strategy to develop programs to change the status of women would include formal education, with a target of 38Z enrollment in primary schools by 1993, and non-formal education to achieve functional literacy for women and provide technical skills to improve their potential for gainful employment. The strategy would thus provide a broad mix of contraceptive services, motivate demand, and incorporate the important interactions between fertility, education, and income noted in the preceding sections. B. Current Programs 4.02 The strategy provides a good basis for program formulation but so far has only partly been implemented. The most notable activity included in the strategy has been the expansion of the sterilization program. Among the current (1986) contracepting couples, 862 are using sterilization, 62 pills, 31 injectables or implantables, and 52 are using other methods. 4.03 Permanent Methods. From FY82 the number of sterilizations increased from 31,000 to a peak of 68,000 in F784. Subsequently the number of sterilizations fell to 62,000 in FY85 and then 49,000 in FY86. Although the number has fallen, the continuing level of performance remains high. It is also notable that the sterilization program involves a fairly equal balance of the clinical contraceptive method between men and women. Among current users of permanent methods 522 are female and 48Z are male. 4.04 The results of Nepal's sterilization program have been well recorded. They are evidence of the motivation of the central government. However, the country remains at an early stage of its population transition, impeded by tremendous geographic as well as social obstacles in its efforts to achieve fertility reduction. The sterilization program has been largely built on the use of mobile camps, with static facilities in larger urban centers. This has effectively used scarce managerial and technical personnel to extend services to areas where there are (almost) no health facilities. The reliance, so far, of the Nepal family planning program on sterilizations is not atypical of Asian population programs; what is different in Nepal is that the program hr3 been relatively effective in reaching its sterilization goals. Program performance is - 57 - higher than in neighboring countries -- in 1985 it was proportionately double the magnitude achieved in Bangladesh or Uttar Pradesh in India. Given that health services are very weak in Nepal and that there is only a very limited infrastructure for delivering temporary methods, the Government perhaps has had little choice in strategy (although the link between the infrastructure that does exist and sterilization camps remains poorly developed). Donor support for the sterilization program, in order to prevent any weakening of the program in the future, will specifically need to address the issues of linking health infrastructure (including e.g. female health manpower) to the sterilization campaigns, and of identifying the 'opportunity cost' of such campaigns in terms of interruptions of other health programs and in terms of trade-offs with the potential to build-up family planning service delivery capacity for temporary methods. 4.05 Temporary Methods. The Nepal family planning program has been weak in the delivery of services other than sterilization. Distribution and acceptance of temporary methods have remained low since adoption of the population strategy, and discontinuation rates are so high as to render the fertility effect of acceptance minimal. Temporary methods are needed to bring the benefits of child spacing to younger, lower parity women, and there is a need to build a greater balance between temporary and permanent methods. It is, however, much more difficult to deliver temporary rather than permanent family planning services. Expansion in the number of users of temporary methods and lengthening of continuation rates would require strong and sustained user support in the provision of services, as well as the need for proper counselling of prospective clients of temporary methods, including measures to counter fears of side-effects of such methods. An extensive health infrastructure is required to provide the program outreach and quality of support needed, but the government program has not been able to develop the required primary health services in rural areas. The current program's weaknesses are discussed in Part II of this paper. In addition, a recent UNFPA report provides a comprehensive examination of program needs. 12/ Issues include weak organizational structure, a scarcity and poor geographic distribution of managerial and technical staff, insufficient training and inappropriate curricula, poor logistics, communications and supervision. C. Institutional Arrangements 4.06 The preponderance of family planning services in Nepal are delivered by two ma4or agencies within the Ministry of Health (MOH): the Family Planning/Maternal Child Health (PP/MCH) project, and the integrated program in the Department of Public Health. Although all services have recently been integrated the FP/MCH project has been a free standing, quasi-vertical program that delivers a package of family planning and maternal child health services. The Department of Public Health project is intended to integrate a number of programs within the MOH, including family planning and maternal and child health programs. The FP/MCH project, together with a non-governmental organization, the Family Planning 12/ UNFPA, NEPAL: Report of the Second Mission on Needs Assessment for Population Assistance, Report Number 89, New York, September 1987. _ 58 - Association of Nepal (FPAN), has been the agency largely responsible for the success of the sterilization program. The FP/MCH project, however, has been weaker in the delivery of temporary methods and other maternal and child health services. The Department of Public Health program has been stronger in the delivery of selected MCH services, especially those (like the immunization program) that require less sustained user support, but has been weaker in the delivery of family planning services. Neither agency has yet developed a delivery system that can be used effectively to deliver a number of primary care health interventions. 4.07 The two government agencies in the past sometimes duplicated administrative, supervisory and support servicts in a number of districts. It is currently the intention of the MOH to ultimately merge the two programs. It is too early to discern the organizational nature of the merger, and in one sense the issue of integrating the programs is moot because the problems of service delivery cannot be solved merely by reorganization. This point is enlarged upon below in the discussion of a possible strategy and in the subsequent sections on institutional arrangements in MOH (see Chapter 9). 4.08 The question of organizational structure of the national program would be of less importance if there was a strong central coordinating agency. The National Commission on Population (NCP) was created to coordinate and evaluate population policies and programs, but does not have operational control over population programs. At present, the NCP is relatively inactive in operational population policy, and if it is to be effective it would probably need greater integration with functional programs, as well as institutional strengthening. - 59 - Chapter V - POPULATION PROJECTIONS AND THE BASIC NEEDS PROGRAM 5.01 A strong population program is assumed in the Basic Needs Strategy outlined by the government, and is implied in the two population projections used in the formulation of the Basic Needs targets. The most ambitious of the two projections is used as an objective for the population program. The more moderate projection is used to calculate the required growth in social service and basic needs indicators. Unfortunately the projection used for the population targets cannot be reconciled with achievable contraceptive performance objectives. To achieve the low population growth target would require reaching a CPR of over 602 in only eleven years, that is, by the year 2000. Even the more moderate projection, which would reduce the population growth rate to 1.91 by the year 2000, would require a CPR of almost 401, relative to a current level of only 15X. Significantly, the government's mcderate projection is coincident with the Bank's very low projection that would require a full execution of the government strategy. 5.02 It is recommended that several alternative plausible scenarios be used as a basis for setting population strategy and for calculation of Basic Needs requirements. Use of only a single (or two), very ambitious projection(s) may distort planning and could misdirect the allocation of scarce public resources allocated to basic needs programs. Rational planning would require as tealistic an assessment of attainable basic needs as possible, based on periodic and regularly updated alternative scenarios. 5.03 Population growth affects the attainment of basic needs targets in two ways. First, growth in population dilutes production achievements (for example in agriculture, housing and clothing) and increases the cost of providing essential health, education and other social services. Second, as a factor of production, a larger labor force allows a greater output. Since these two elements in basic needs attainment act in opposing directions it is necessary to know their relative magnitudes to predict the net effect of population growth on welfare. However, in Nepal, the low availability of complementary non-human resources, the low productivity of labor, and the high rates of underemployment in agriculture and larger urban areas all suggest that the first element prevails and population growth is associated with diminishing attainment of basic needs goals. Accordingly, the first priority of the basic needs program should be the development of a vigorous program to contain population growth. - 60 - Chapter VI - PROGRAM IMPLEMENTATION STRATEGY 6.01 Continued building of a national consensus on population policies is required to expand the existing program. The problem in mounting an expanded program does not seem to be a simple one of political will at the center, but one of developing jupport and service provision at the local level. Nor is the problem in mounting an expanded program to be solved by changing the existing strategy; the 1983 statement of population strategy contains the important elements of a strong family planning program, but implementation has been weak. What is needed are not new elements in the existing strategy, but specific and practical steps for carrying it out. 6.02 The next steps for proceeding with the existing strategy of HMG would be: (i) to maintain the existing sterilization program; (ii) to build the base for the expansion of temporary methods; (iii) to concentrate resources in cost-effective areas; and, (iv) to exploit the links between fertility, education and infant mortality. Each of these is discussed below. 6.03 Maintaining Permanent Methods. The government and various donors have been discussing the current imbalance in family planning services. In the attempt to expand temporary methods and other services, there is a risk that the support for permanent family planning methods will be reduced and the annual number of sterilizations will fall below the current level of 40,000 to 45,000 per year. The dialogue between the government and donors needs stress the importance of maintaining the sterilization program at its current level, while development of the needed support services for increased coverage with temporary methods is being formulated and implemented over a number of years. Apart from the recognized need to immediately strengthen the capacity for temporary methods, there is a growing number of women, generated by population growth, who are over 30 and who have completed their desired family size. It is important that the government continue to meet their need for permanent contraception. 6.04 Building the Base for Temporary Methods. Regularly accessible user support at the periphery of the health system is necessary to expand the use of temporary methods. The low continuation rates in Nepal are largely attributable to the lack of sustained contact between clients and trained field staff, in combination with low education. Problems in inconsistent use of contraceptives due to low literacy of clients and intermittent supply may be reduced in the future through greater reliance on injectables and, to a lesser extent, on implantable contraceptives, and these could potentially become the focus of the temporary method part of the program. Injectables could perhaps be delivered at rural health posts. Implantables, which require trained medical staff for their placement, could possibly be delivered as a complement to sterilization by mobile teams and in static facilities with sterilization capacity. However, both methods would require the back-up of credible health services at health posts and in outreach visits to clients. Adequate population coverage would also require expansion of the number of health posts, and at a minimum increasing the effectiveness with which existing health posts function. - 61 - 6.05 Details of the development of credible services have been noted in other World Bank, UNFPA and Government documents. Service development will require training programs for physicians, nurses and paramedics, and retraining of rural extension workers and health post field staff. Some investment in physical facilities is needed, because well located and functional buildings are required as a base for program delivery. Housing for health workers is also a problem and is a factor in the poor geographic distribution of technical personnel. Supervision and management needs to be strengthened and this is to be done through decentralizing management responsibilities, development of improved monitoring procedures and encouraging field visits by supervisory staff. The current regionalization strategy of the government would provide a good basis for improved monitoring if carried out (para. 10.13). 6.06. A possible organizational structure that might be considered is the Indonesian model that is built around a strong coordinating agency, the BKKBN. In Indonesia the health posts and health centers are a shell with a basic staff that is used to deliver a number of quasi-vertical programs, of which family planning is one of the strongest. The family planning program has its own motivators and supervisory staff. The advantage of this arrangement is that it allows a concentration of resources and supervision on a high priority program. Addressing the organizational weaknesses of the government health and family planning programs and the need for a strong central coordinating agency should be a major issue in the consideration of reform of the existing program. 6.07 Locational Questions. The cost of delivering services per birth averted in remote areas, for example in the hill areas of the far west and the mountains in all regions, is over two to three times the cost per birth averted in the densely populated districts of the terai and hills in the central regions. The most efficient use of resources for the expansion of the family planning program would be to concentrate, at least initially, in the terai and densely populated hill areas. 6.08 Intersectoral Linkages. As discussed previously, the intersectoral links between population growth, education, health and general development are very strong, and need to be fully exploited as provided for in the government strategy. The fall in infant mortality over the last ten years is important in changing the impetus for high fertility. Continued emphasis on the delivery of effective child health services is needed to sustain this decline and reach the lower levels of infant mortality associated with spontan us falls in fertility that have been observed elsewhere. Similarly, an increase in female literacy and the percentage of women completing primary school is a prerequisite for fertility decline. 6.09 The links between these sectors are strong enough that projects designed for either would be most effective if they were coordinated and carried out jointly. Given the priority for containing the population problem, one suggested strategy would be to concentrate educational resources on activities needed for family planning support. Another possibility would be the development of joint education and population projects in the hill regions of highest density and in the terai. Possible priority areas for support are discussed in the final chapter of this volume, and in the main report. - 62 - PART II.B - HEALTH, FAMILY PLANNING AND NUTRITION Chapter VII - CURRENT HEALTH STATUS 13/ A. Introduction 7.01 Over the ldst two decades mortality rates in Nepal have been declining slowly but steadily. Fertility has remained fairly constant, resulting in an increasing rate of population growth (about 1.62 on average 1960-1965 to 2.6Z in 1988). The crud& birth rate varies between 38-44 per 1,000 population, with the total fertility rate (TFR) currently ranging from around 7.1 in the hills to 5.8 in the Terai. Nepal is one of the fairly few countries in the world showing higher female than male mortality at all ages. Life expectancy at birth is estimated at 54 years for males and only 51 years for females, with indications that this gap is widening. B. Mortality 7.02 Infant mortality is estimated to occur at the rate of around 110 deaths per 1,000 live births (1987). Combined infant (below 1 year of age) and child (1-5 years of age) mortality probably varies between 160 and 220 for each 1,000 population under 5 years of age. Selected poor hill districts sometimes display infant mortality rates of 180 and over, and child mortality rates in excess of 300/1,000 (1-5 years of age) population. It should be noted that perinatal mortality and abortions - spontaneous and induced - go unrecorded, as they do not constitute live births but still births, or are not considered (or remembered) as births at all. If incorporated as a constituent part of infant mortality (infant and foetal mortality), IMR estimates would possibly vary between 190 to 250 per 1,000 pregnancies in Nepal. 7.03 A similar situation exists with regard to maternal mortality which, while less studied, also appears to be exceptionally high. The female age-groups younger than 18 years and older than 30 years are at particular risk of death. Compared to, for example, ratios of around 5 maternal deaths per 100,000 deliveries in North-West Europe and 350-400 maternal deaths per 100,000 in Indonesia, maternal mortality rates in Nepal are estimated to range from 1,500 to 2,000 per 100,000 deliveries. 13/ No functional institutional data system for indicators of death, birth, disease, fertility, contraceptive behavior or nutritional status exists in Nepal; figures represent almost without exception estimates of key variables from often widely varying data, depending on their source. They should be treated with the utmost care. - 63 - Table 7.1: Ranoos ot Maternal. Infant and Fatal Mortallty Negal. 1987 Maternal Mort.alty/ Infant Mortality/ Infant A Fetal Mortality 100,000 live births 1000 lve births Eatimateo/1.000 oreananclas N.W. Europe 6-7 7-15 10-16 Indonela 850-400 70-110 160-200 Banglades 600-1000 100-160 160-220 Nepal 1,600-2,000 95-160 190-250 7.04 Low birth weight, prematurity, complications during delivery, neonatal tetanus, sepsis and other infections due to hazardous delivery practices, birth trauma and serious nutritional problems probably account for most of neonatal deaths, which in turn cover 502 or more of infant mortality. Post-neonatal mortality seems most closely associated with diarrhoeal disease, in particular bacillary dysentery, and lower respiratory tract infections (rather than upper respiratory tract ones). Measles figures prominently as a cause of death, especially in combination with malnutrition (e.g. insufficient levels of breastfeeding), but also as a cause of disease in view of its adverse effect on the immunological potential of infants and children. C. Morbidity and Disability 7.05 Pertussis (whooping cough), diphtheria and poliomyelitis contribute significantly to infant and childhood mortality and morbidity, while tuberculosis is extremely prevalent throughout the country for all age-groups. This also holds for both the non-contagious and contagious types of leprosy. If not resulting in death, these, together with the grossly underreported prevalence of meningitis, encephalitis, chronic ophthalmological and ear, nose and throat pathologies (eg., chronic conjunctivitis and otitis media), and the high level of accidents, result in very significant numbers of disabilities. Micro-nutrient deficiencies - of iodine, vitamin A, iron, and folic acid - add to this disproportionately large pool of seriously disabled persons in Nepal, significantly affecting the country's economy, both in terms of direct costs (of health care to these persons) and in terms of lost productive potential (see note on nutrition para. 7.10). 7.06 Nepal's malaria situation has equally important economic consequences. Whereas the country suffered up to two million malaria cases a year during the 1950s, effectively preempting productive activity in the affected areas (mainly the terai), prevalence was reduced to only 2518 cases by 1970. Due to reasons of both epidemiological, entomological and service delivery nature, the malaria situation deteriorated and reached a high of 42,000 in 1985, decreasing to 37,000 in 1986 and 27,000 in 1987 (a figure to be qualified in that it may be too optimistic to indicate a trend, in view of the prolonged drought the country experienced in 1987). Longer term prospects are worrisome in view of the increasing numbers of indigenous cases of the malaria parasite Plasmodium Falciparum (up from 55? in 1985 to 932 in 1987), many of which now are resistant to chloroquine. In addition, resistancy levels of the anopheline vectors (the mosquitoes) appear to increase with insecticide applications (DDT, Ficom, Malathion and Actellic), implying the need for a very selective approach to insecticide use. Since malaria-control measures affect the prevalence of other vector- borne diseases as well, deterioration of the effectiveness of the malaria - 64 - program implies similar effects with regard to such diseases as dengue fever, visceral leishmaniasis (kala-azar), filariasis and Japanese encephalitis. The latter, for instance, showed a significant increase in number of both cases and deaths since 1983, with the case fatality rate in 1987 almost double that in 1983 (29.3Z and 15% respectively; the reported number of cases increased from 142 in 1984, 692 in 1985 and 1,195 in 1986). 7.07 Many of these statistics remain unreliable, and mortality and morbidity continue to be under- or misreported. Infectious and parasitic diseases are reported as the number one cause of health post attendance, and the number two cause of hospital admissions in Nepal. Dengue fever, for instance, which may well be a serious periodic and chronic health problem in the country, currently is often (mis)diagnosed as influenza or another respiratory infection, malaria, acute joint pain, measles, rubeola, or fevers or symptoms of an undefined nature 14/ Table 7.2: Maternal Morbidity - Five Leading Causes Among Hospital Admissions During the years 1980/1 and 1983/84 /a 1980/81 1983/84 Cause Group Percent Rank Percent Rank Complication of pregnancy, child birth and puerperium 25.1 1 47.5 1 Infectious and parasitic diseases 15.2 2 9.0 3 Injury and poisoning 10.3 3 7.4 4 Diseases of the digestive systems 8.4 4 - - Diseases of the respiratory systems 8.2 5 6.0 5 Symptoms, signs and ill-defined conditions - _ 12.3 2 Total 67.2 - 82.2 - Total number of admissions 28061 39095 a/ Which accounted for 67 and 82%, respectively, of the total number of admissions. 14/ "Other symptoms, signs and ill-defined conditions" constitute an increasingly important cause of attendance at health posts -ranked third in 1984/85-, indicating a serious weakness in the quality of service delivery; with regard to mortality, among the 10 leading causes of death reported by 15 health posts in Kaski District in 1984/85, such "Other symptoms and ill-defined conditions" figured as the number one cause of death. - 65 - D. Maternal Morbidity and Disability 7.08 There is a tendency, in reporting morbidity data on Nepal, not to take sufficient account of maternal morbidity. Diseases of the skin and subcutaneous tissue are very prevalent (e.g. scabies), intestinal parasitism (e.g. ascaris, ankylostoma, trichuris) may well infect around 0B of the total population, and diarrhoeas (parasitic and non-parasitic) and respiratory infections account for at least 20Z of total patient-load upon admission in the average health care facility in the country. However, pregnancy-related health problems probably outnumber these in terms of severity and frequency (See Table 7.2 and Annex II-3.2). While the chronic nature of the former disease categories puts a heavy strain on the country's manpower resources in terms of productivity losses and social costs, the importance of pregnancy-related health problems, which includes a combination of mortality and morbidity, is often underestimated. Traditionally, only maternal mortality is being reported, with maternal morbidity and maternal disability not figuring in the health picture at all. 7.09 In the absence of specific data, it can be estimated that maternal morbidity and disability occurs at the rate of 3 to 4 times maternal mortality. For each maternal death -and, as a proxy, for each infant death-, a substantial number of women suffer non-lethal but serious complications of fertility, pregnancy, birth and breast-feeding. These complications are either of a short-term recurrent or periodic nature, or longer-term afflictions becoming chronic and developing into periodic or permanent disability (both somatic and mental). A very large number of women are affected - every year there is a pool of approximately 800,000 pregnant women. The pathologies given in Table 7.3 are considered to be most common complications of pregnancy and childbirth. - 66 - Tablo 7.8: Maternal Mortality, Morbidity and Disability - Causs and Conso.uoncoos NagaI 1988 Cause Consecuence 1. Blodin 1 (o.g. onts-partuO hmorrhage - renal lnauffictency or failure dIu- 020pic pregnancy, placenta - pituitary failuro (shoshnn's syndrom; failure proevia or abruptio, post-partun to lactate my result In death of the Infnnt, hemorrhage due to retained placenta or snd, uterine rupture and bloeding due to - anomia; abortion) 2. Infection (e.g. abortion-rolated - abdominal pain, Infectlons, pelvic Inflamatory dlsease- - menstrual disorders PID, chronic PID, diarrhoea, urinary - ectopic pregnancy, tract Infection with subsequent sepsl, - Infertility; tetanus) . Hypertension (e.g. hypertensive dlase - eclaupla, of pri nsnjcy, pre-eclmpia) - brain damaes, - cerebro-voscular Occident; 4. Birth Trauma (e.g. cepholo-pelvic perineal damage disproportlon, ruptured uterus) - recto-vaginal fistula, vosico-vaginal fistula; S. Abortion - bleeding (se above), - - lnfection (se above;, trauma to genitall. 8. Violence and Suicido - full range of physical and mental Injurios and subsequent temporary or permanent disabilitios (breast injurio back and skull traumas bone mlforma"tons, hip fractures, blindness, etc.) 7. Maternal Goltre and other Nutritional - cretinism, Defl_ onc es *na/or Dop letlo MMadr - ul e cencesan ores on nrome - deaf-muti m, Iron deficiency anemia (during prognancy), blindnes, - stunting, - wasting, - PEM, - Irregular menstrual bloeding. 15/ Excluding chronic irregular menstrual bleeding among non-pregnant women due to, for instance, malnutrition and physical and mental stress. - 67 - E. Nutrition 7.10 For a number of reasons it was decided not to undertake a separate sub-sector review of nutrition in this report 16/ but rather to address questions of overall food availability in the context of agriculture and poverty (see Chapters 1, 2 and 5 of Volume I), and to review only the most important micro-nutrient deficiency problems and programs in the health sector review. (see also the section on iodine deficiencies (paras. 11.08-11.12)). A number of sample surveys in the mid-1970's and 1980's indicate that malnutrition is a serious problem in Nepal. The country falls within the Himalayan Goitre Belt and is considered to suffer the second-highest prevalence of iodine deficiency in the world, and consequently very high levels of goitre (see Table 7.4), with rates of up to 1OX of cretinism (arrested physical and mental development with dystrophy of bones and soft tissue) and deaf-mutism not being uncommon in remote areas. Iron deficiency anaemia, as noted earlier, affects most pregnant women (prevalence
Groupe de la Banque mondiale · Pre-2003 Economic or Sector Report
Nepal - Social sector strategy review (Vol. 2 of 2) : Sector reviews
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