From the point of view of the impact of the conflict, the data available from the two DHSs suggest more of a positive than of a negative impact on the health outcomes. The comparative data on 19 MDG-related indicators show that 16 out of 19 indicators had improved to such a level that MDG would be likely to be achieved by 2015. While two indicators-reductions in neonatal mortality and improvement in skilled attendance at birth had increased at a slower pace, hence the related MDGs are unlikely to be achieved. One indicator, the percentage of undernourished children under three years old worsened in 2006 compared to the reference year 1996. Most of these findings on the trend of progress are compatible to the trends of health indicators shown in the MDG Progress Report published by Nepal's National Planning Commission in 2010 [32]. According to this report "Nepal is likely to meet the targets on reducing under five mortality by two-thirds, reduce the maternal mortality ratio by three quarters, halt and reverse the spread of HIV/AIDS, halt and reverse the incidence of malaria and other major diseases and halve proportion of population without sustainable access to improved water source. It is potentially likely to meet the targets on achieving universal access to treatment for HIV/AIDS for all those who need it. However, the report reiterates that Nepal is unlikely to meet the targets of achieving universal access to reproductive health and halving proportion of population without sustainable access to improved sanitation"[32].
Contrary to evidence from other conflicts [8, 34–37] as well as from Nepal [38–40] of a negative impact of conflict on the health of populations, we found that in Nepal progress has been made in most health indicators. There does not appear much literature on what made it possible to achieve such progress despite a decade-long armed conflict. The discussion below explores the key drivers contributing to the better than expected changes in people's health status in a period of civil unrest and armed violence.
The first possible explanation is that Nepal's warring sides, in particular the former rebels, did not purposively disrupt the delivery of health services [41]. The health sector appeared to have been less susceptible to the violence. Besides few sporadic incidents, the overall political outlook of the rebels towards the health programmes and health workers was positive. Special national campaigns such as the National Immunisation Day for polio and measles immunisation, bi-annual vitamin supplementation and family planning camps were not much affected [16]. The key informant district health officers from Far-western districts expressed that the Maoist insurgents did not interrupt health activities in their districts.
Though the conflict had limited people's mobility for seeking our services particularly during transportation strikes (bandhs), they (Maoists) did not stop us from providing our services to the people (District Health Officer ID 5, Mid-western Region).
A second explanation is that the former rebels put pressure on the health care providers in their 'base areas' or the contested areas to attend regularly at clinics in order to ensure consistent drug supplies and treatment [42]. As a result, the government was under pressure to supply appropriate health staff and supplies. In spite of the security threat, 78% of staff positions in hospital, 75% in primary health care centres (PHCCs), 96% in health posts and 90% in sub-health posts were filled during the conflict [27].
Thirdly, conflict created an environment for improved coordination amongst the key actors: the MOHP, donors, civil society and the community representatives. One Local Development Officer's remark reflected this:
We have improved coordination between the district government and health representatives. We conduct regular meeting and discuss issues of local development, including those related to the health sector. (Key Informant ID 11)
The example of improved coordination despite the conflict in Nepal was also found during conflicts in East Timor [43] and Mozambique [37] where improved coordination amongst the key stakeholders helped increase utilisation of health services by the local population. In Nepal, it encouraged inclusive, people-based and transparent humanitarian programmes at the local level. Exemption of user fees to poor and disadvantaged populations and provision of citizen charters (agarics adapter) at service outlets could be taken as examples [27]. It also recognised the role of civil society and the local community groups in these health development activities.
Though the service guidelines have special provisions for poor and disadvantaged patients, there were problems however in defining them when it came to implementation [27, 44]. One participant in a focused group discussion (FGD) said:
The service guideline directs us to providing free health services to the DAG (disadvantaged groups) and poor people but there are no clear definitions who they are. The decision depends on the discretion of the doctor attending the patient. ( FGD 2, District ID 7)
Fourthly, building on the lessons from the protracted conflict, Nepal's public health system adopted a number of health improvement approaches and programmes. Some of the key policies focused on disadvantaged groups including dalits, women, disabled and elderly people, whilst helping to increase coverage of the health programmes in more remote and underserved areas. The policies also included the establishment of emergency funds and community drugs schemes and handing over the government ownership of the health facilities to the local communities [27].
Fifthly, Nepal strived to maintain a visible, sustained and adequate provision of health services at all levels from the centre to the community. There has been a substantial increase in the number of health care institutions, from 1,098 in 1991 to 4,552 in 2007/2008 [45]. The Government health facilities, such as health posts, sub-health posts, primary health care centres and outreach clinics provided basic community-based services, mostly free of charge. Nepal implemented many popular programmes such as the community-based integrated management of childhood diseases (CB-IMCI); community-based newborn care package(CB-NCB), community drug programme (CDP); direct observation treatment system (DOTS) for treatment of tuberculosis; HIV and AIDS prevention and control programmes; rural water supply and sanitation programme (RWSSP) and a food security programme. These initiatives helped increase access to and utilisation of the available health services [27, 32].
Sixthly, there was a functional community support system including the Health Facility Management Committees, mothers groups, Female Community Health Volunteers (FCHVs) and Traditional Birth Attendants (TBAs) for the mobilisation of local communities. One study showed that one-thirds of women were member of local women's groups, and that 43% members of the health facility management committees were from lower socio-economic groups such as Janajatis and dalits[27]. However, motivation and performance of these groups were often questionable in terms of their voluntariness as opposed to their desire for economic incentives, including the coping strategy in the context of the political conflict [46].
Seventhly, the UN (United Nations) and various international non-governmental organisations (INGOs) contributed for increasing the coverage and effectiveness of the health services in Nepal. They implemented conflict-sensitive development programmes whilst keeping a low profile [47]. Nonetheless, in the absence of clear government policy and elected representatives, coordination between the government, development partners and the community people appeared to be poor [27].
Eighthly, development of infrastructures such as road, health facilities, schools, electricity, and communication might have contributed to the positive changes. One study found that despite the frequent transportation blocks due to strikes, more women living near main roads sought care from maternal health services [44]. Additional evidence is that access to health services increased over the years, for example travel time fell 50 times between 1995/96 and 2003/4 [21]. The NHRC study shows 83% women and 71% of service users reported having access to a health facility within 30 minutes' walk, with a further 16% of women and 14% of service users had reached within one hour on foot. Similarly, of the total service-users interviewed 51% in the terai, 45% in the hill area and 4% in the mountain districts had access to a road. However, focus groups with women from a remote district highlighted a lack of access to health services still existed.
People from here should either travel on horseback for four days, or fly to Pokhara (regional headquarter) via aeroplane to get treatment in a hospital. (FGD 1, District ID 13)
Increase in access to education and communication could have supported positive changes in health outcomes. During the decade of 1996-2006, adult literacy increased from 34% in 1996 to 79% in 2006 [29, 30]. The primary school enrollment rate increased from 57% to 73%. In 1996, only 7% of all households had a radio and television, which increased to 28% in 2006 [33].
Ninthly, Nepal achieved a steady economic growth and substantial reduction in poverty. Between 1995/96 and 2005/6, the percentage of the population living below the poverty line (US$1/day) decreased from 42% to 31%, and the absolute poverty dropped by one percentage points per year over the past couple of years. This somehow seems to contradict the economic explanation on the causation of conflict that underdevelopment and poverty fuels conflict [48–50]. However, a 2005 regional poverty profile shows that Nepal has varying regional deprivation levels. During 2003-2004, Kathmandu had the lowest level of poverty (3%) while the other urban and rural areas had higher poverty levels i.e. 9.6% and 34.6% respectively [51]. The Nepal Living Standard Survey (NLSS II), 2003/2004 also reveals discrepancies in the distribution of poverty by development regions. It is lowest in the Central Development Region (27%) and highest in the Mid-western Development Region (45%), which is considered as the epicentre of the Maoist insurgency [52].
Economic inequality was reported between (a) the centre and the periphery; (b) the 'haves and have-nots; (c) different castes; and (e) people with different levels of education. For instance, in Kathmandu the average gross domestic product (GDP) was almost four times higher than that of some rural regions [52].
The increase in government's health sector budget, though only a small percentage change, might have helped towards achieving these health outcomes. The share of health sector budget increased from 5.99% in 1995/96 to 6.41% in 2005/2006 [32]. Moreover, the share of foreign aid of total government expenditure increased from 17.96% (2001/2002) to 19.88% in 2005/2006 and its contribution in Nepal's development expenditure increased from 58.07% to 74.45% [32]. Similarly, the share of foreign aid to GDP in the same period increased from 3.13% to 3.37% [32].These inputs would have contributed to the positive changes in the health indicators.