The delivery of health services and their utilisation are likely to depend on a varieties of factors such as the nature of the health problem, the quality of health care services, the need and demand for the services, and the availability of the alternatives. A single study such as this cannot incorporate and discuss all possible aspects of the health care delivery and utilisation in a society. This is partly because of limited time and resources and partly because of the unavailability of the information. Thus the following sections of this chapter will mainly focus on the health care delivery system and its utilisation with focus on children’s health in Nepal.
Despite the progress in the modem health care system, the majority of the population living in the rural parts of the country have very little access to it. Most children do not receive treatment when they are sick or in need. This is attributed to the lack of knowledge, inaccessibility or lack of medical facility as well as lack of confidence in
modern medicine (UNICEF, 1992: 16). Prevailing poor nutritional status, low haemoglobin levels, anaemia, vitamin A deficiency, iodine deficiency disorder, infectious and parasitic diseases, diarrhoeal diseases and other preventable diseases such as measles, whooping cough, tuberculosis and acute respiratory infections among children are some of the major health problems in the country (UNICEF, 1992: 17-74; Tribhuvan University (TU) and HMG, 1985: 4-5). Diarrhoeal disease alone kills 44,000 children under five years of age every year. This accounts for about 45 per cent of the total child deaths in a year. Acute respiratory infection is estimated to kill another 30,000 to 40,000 children of this age group (MOH, 1989-90: 1). In this respect, UNICEF (1992: 70) noted that although the vast majority of women in the country recognise the symptoms of pneumonia, the antibiotics are far away.
The modem health care service (western medical technology) in Nepal is known as allopathic. The modem health care service delivery in the context of Nepal can be classified into three broad components: preventive, curative and promotive. Control of malaria, tuberculosis, leprosy, and immunisation of infants and children, are categorised as preventive services. Such services are generally provided by various projects under the Ministry of Health. On the other hand, curative care is delivered through hospitals, health centres and health posts that are distributed throughout the country (Pant and Acharya, 1988: 147-148). Health posts are the primary units of the health services supported by district hospitals and a number of vertical projects (TU and HMG, 1985: 1). The Sixth Development Plan of the country set an objective to reach rural people with a package of curative, preventive and promotive health services through health posts (Pant and Acharya, 1988: 148). In addition, child immunisations in most part of the country were also carried out by mobile teams of vaccinators employed under the expanded programme for immunisation. However, the coverage of immunisation until 1985 was limited to a small proportion of eligible people, often at district headquarters or nearby health institutions (UNICEF, 1992: 62).
The ayurvedic treatment service is delivered through either ayurvedic hospitals or
148) noted that ayurvedic centres in rural Nepal provide traditional herbal treatment to their
patients. In some instances, ayurvedic treatment is more widely accepted than modem
medical services. For example, Durkin (1988) noted that the majority of the people in
Nepal, even in Kathmandu, the capital city of the country, preferred to take ayurvedic
treatment over modem medical services for the problem of viral hepatitis, despite the fact that the modem health care service in this area is highly developed and more easily accessible than in other parts of the country.
Another health care service is delivered by the local healers known as faith healers, spiritual healers and astrologers. A recent study in Nepal (Shrestha and Lediard, 1990, cited in UNICEF, 1992: 123) estimated the number of various traditional health care providers to be between 400,000 and 800,000. The type of health services delivered by each of these traditional healers largely depends on what the health seekers believe to be the type and cause of the illness. Many people in rural Nepal believe that sickness and death are often caused by ghosts, demons, evil sprits, planetary influences or displeasure of ancestors. To protect against these dangers a variety of precautions such as 'wearing of charms, the avoidance of certain food or sights during pregnancy, and or propitiation of ghosts and gods with sacrificial gifts' are taken (Harris et al., 1973: 85-86). In this context, Stone (1976: 75) noted that the question of which specialist is consulted is a function of illness itself. Stone further noted that minor discomfort, wounds and sores are treated with herbs; for more serious injuries the hospital is usually used; and fits of trembling will
inevitably bring forth a god-invoking janne manche (traditional or faith healer). The
significant roles of traditional functionaries of health care such as jhankri (faith healers),
dhami (magic healers) and sudini (traditional birth attendants) in meeting the health care needs of the people of Nepal is also noted by Pandey (1980: 113), Blustain (1976: 84), Okada (1976: 107) and Wake (1976: 118-119). UNICEF (1992: 123) noted that the majority of the rural people in Nepal eventually visiting the health post had first consulted a traditional healer. A study in the central-east region of the country also found that the majority of the women in the study area were using the services of the traditional birth attendants (Reissland and Burghart, 1989: 44). In addition, Reissland and Burghart also
noted that women in this region prefer to deliver a baby at home. Pandey (1980: 112) estimated that over 75 per cent of the people in Nepal receive treatment in their village
from vaidya or traditional healers.
Overall the traditional healing system in Nepal constitutes an integral part of the health service delivery and utilisation. The discussion so far also suggests that the prevailing modern health care services in the country are inadequate. In such a situation, identification of the high risk groups of children as well as factors underlying the higher level of mortality can prove to be important for policy formulation and for better understanding of the existing child survival situation in the society.