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Tant qu’on a la santé

Yvonne Preiswerk
Mary-Josée Burnier

Gender as a transversal component in a rural health development project in Nepal

Chet Nath Chaulagai et Albert Burki

Texte intégral

Gender in Nepal

1Nepalese people are deeply conservative with socially, traditionally, ethnically-constructed and assigned roles for men and women. There is social pressure to follow traditions and there is criticism and blame if someone dares to share or inter-change their expected role. Certain activities are traditionally carried out only by men and others only by women.

2Cooking, serving food and cleaning dishes, washing clothes, rearing of and caring for infants and children, grinding grains, cleaning and sweeping the house, planting paddy and millet, working as a nurse, weaving of mats and clothes is considered only women’s work. The reasons given for such assignments is that they demand less physical strength and that women being considered physically weaker than men should do the easier work.

3Ploughing, driving, boating, masonry work, wood-cutting, working in the police and army, preparing fields for the planting of crops, and slaughtering of animals is considered to be men’s work. The reasons given for such assignments is that these types of work need more physical strength, so men being considered physically stronger than women should do the “difficult” work.

4These divisions are well and good and should not be disturbed as long as it does not hurt either the men or women of any particular society. However, the general situation in Nepal and the situation revealed from a baseline survey carried out in Ramechhap and Dolakha districts show the people in these areas are definitely hurting: a high maternal mortality rate of 875/100’000 among women of reproductive age (15-49 y) as a consequence of the low level of accessibility to antenatal, natal and postnatal services, and a high infant and child mortality rate which is higher in females as a reflection of the economic, social, cultural, political and educational differences and inequities between men and women. Enrolment in school is significantly lower in girls than in boys. A similar gap exists between female and male literacy rates. This is of particular importance since many health parameters have shown to be distinctly worse for the illiterate. Awareness of family planning methods is significantly lower in illiterate people. Despite this, women are more aware of methods like male or female sterilisation and Norplant. Only 1/3 of the adult population is aware of AIDS with a highly significant difference in awareness between men and women (44% / 25%). There is also a difference in the awareness of the consequences of being infected by the HIV virus and of how to prevent infection. Women think that maintaining a single partner is the best way of avoiding AIDS, whereas men consider safer sex and the use of condoms as the best methods. This also points out to gender differences in sexual behaviour. Other health factors such as immunisation status for all vaccinations is higher in male children. Awareness of micro-nutrients, Vitamin-A and iodised salt is lower in women, who are solely responsible for preparing food.

5The standard of living and health status is very low in Nepal and it is even lower among women. Modern services are out of reach for many people due to the topographical difficulties. People have to work hard in order to earn little and have therefore only little time and money to spend on distant health services. Therefore people often do not get proper care. These shortcomings affect women and children more than men.

Background of the Rural Health Development Project (RHDP)

6This RHDP is the second phase continuation of the Primary Health Care, Mother-Child Health and Family Planning project (PHC-MCH/FP) of His Majesty’s Government of Nepal (HMG/N) and of the Swiss Agency for Development and Cooperation (SDC) which emerged in 1991 as an offspring of the Integrated Hill Development Project (IHDP, 1975-1990). Three projects started at that time as the hard core of SDC’s Rural Development Sector in Nepal: one covering the field of community forestry, another building upon experiences with leading farmers and the third, addressing community development and health in the districts of Ramechhap and Dolakha.

7Certain crucial experiences of IHDP strongly influenced the design of the project and the implementation of the first phase (1991-1996). Some of the recommendations applied were:

  • use a process approach and create programs for “direct community development” and not just have a stand alone project approach

  • for community formation, a motivator/facilitator is needed

  • work with user groups – do not use contractors

  • develop activities to empower the people, especially the women

  • allow time for the process and for mutual learning

  • handing over to the people is only possible with real decentralisation of power for making decisions

  • big inputs of money and infrastructure during implementation make a smooth handover very difficult

  • let villagers ideas prevail.

8These recommendations and their impact on design and implementation remain valid during the second phase (1997-2001) of the project. They are considered the strategic link with the first phase and the basis of continuity.


9The project area is situated within the Central Region of Nepal, north east of Kathmandu, in the Districts of Dolakha and Ramechhap. Both are remote districts in the hills of Nepal. Dolakha District is accessible by road, although most parts can only be reached by foot. Two days walking is needed to reach the northern parts. Swiss involvement in Dolakha district goes back 40 years, with 30 years of experience in the health sector. Ramechhap district, which lies to the south and east of Dolakha, remains the only district within the Central Region not to have road access. During 1999, the road has reached the district headquarters.

10Approximately 426’300 people live in the project area, 204’900 in Dolakha and 221’400 in Ramechhap. The population is concentrated in the central and southern parts of the districts, where the main groups are Brahmins and Chetris, with Magars and Sunuwars in smaller numbers. In the northern areas where the population is smaller, the dominant ethnic group is Sherpa. Within both districts, there is a sizeable Newari community. Tamangs are scattered throughout the area. The main socially deprived groups are the Thamis and the Jirels in Dolakha, and the Majhis, Hayus and Thamis in Ramechhap. Most residents are subsistence farmers living in small, scattered settlements. Seasonal migration of mainly male family members plays a considerable role in the economy of the area. Trafficking in girls for the sex trade occurs traditionally in specific locations, mainly in Dolakha district.

Orientation of the RHDP

11The RHDP aims at “contributing to a sustainable improvement of the local health system with emphasis on health at the periphery.” For this, the collaboration of the Community Health Coordinators is sought. Their main task is to support the promotive, preventive and curative health activities of the community organisations in both districts especially those concerning mother and child health.

12The project invests more in capitalisation of experience at both districts and national level. A proactive and selective participation in policy/donor dialogue is linked to the project’s objective. A monitoring and evaluation strategy with clear indicators and means of verification is implemented. Alliance building between the organisations in the rural communities is strengthened and promoted. Activities are co-ordinated with the Village Development Committee (VDC) and their health committees and where useful, with the District Development Committee (DDC) in a constant effort to build up linkages.

13A greater potential to build up links for better resource mobilisation and utilisation for the local level is arising as the “Decentralisation Act” is coming into effect. This is the legal background that supports an improvement in the local decision making process as well as in networking and co-operation between different line agencies, non-governmental organisations (NGOs), local political bodies and community organisations (COs). As decentralisation becomes a reality, strategies are oriented towards strengthening local capacities to make use of new resources and decisionmaking powers.

14The project looks for opportunities to channel its support to COs, to the capacity-building of health workers and to increase collaboration with those local NGOs that have similar objectives. They are supported to implement community initiatives in focus areas provided that they are ready to work within the guidelines and policy practices of the project.

RHDP planning process

15The foundation for the planning process of this phase was laid in June 1996 in a one-day workshop in which different donors involved in community health, SDC’s Co-ordination Office and a few representatives of the project participated. The experiences of the donors in community involvement and health were discussed and messages to SDC were formulated.

16After intensive, facilitated discussions between SDC and the project, an external review planning mission was called for. Its task was to analyse the field realities in Dolakha and to review the achievements and experiences of the first phase of the project in order to assess its potential and to develop a framework for the future involvement of SDC in the field of health.

17SDC headquarters in collaboration with the Co-ordination Office in Nepal, decided towards the end of 1996 to continue with the direct implementation of the project as part of SDC’s programme. This decision was based on the findings of the above-mentioned mission, on SDC’s sector policy for health and on a small proposal for the next phase drafted by the project. The desire to “remain in touch with the people’s reality”, expressed as an immediate fieldbased experience and SDC’s own interest in capitalisation and intraprogramme synergy, were two major decisive arguments for this. The main modifications to be undertaken in the second phase were identified as: a system orientation, more health at the periphery, capitalisation of experience, greater care for cost-effectiveness, shift of the management to the field and participation of the project in a policy/donor dialogue.

18The concrete planning process was carried out in a participatory manner in four planning workshops facilitated by a private local consultancy firm. The first one involved representatives of HMG/N, SDC and different NGOs who identified at a policy level the broad areas the project should direct its support to in this phase. Representatives of a number of COs and traditional healers then gathered in each district, in a community level workshop, to set their vision and analyse the health situation before the project’s intervention: how it had evolved, how they viewed the future and what their hopes were. The major factors hindering them in reaching their vision in the area of health were assessed and possible solutions identified. Furthermore, linkages were examined between the different actors and the roles they play in the communities’ development.

19The final district level workshop involved the DDC chairmen of both districts, the District Health Officers and Public Health Officers, the heads of different line agencies of Ramechhap district (Local Development Office, Women’s Development Office, Drinking Water Supply Office, District Education Office) and representatives of the main NGOs working in the two districts as well as of the two projects involved in SDC’s rural development sector. A log-frame methodology for planning was used to define the goals, purposes, outputs, major activity areas and the guiding principles for the project. A more suitable project name was suggested as Rural Health Development Project and the roles of different partners were defined.

Relationship with revised Country Programme Nepal 1998-2004

20The elaboration of the RHDP was done in parallel with the revision of the Country Programme of SDC for Nepal. The revised Country Programme (CP) 1998-2004 defines the priorities and strategies for SDC in Nepal. While “Health” is not considered a priority sector, it states that the positive results of this project warrant it to be continued under the category of projects belonging to the “consolidation project”. The CP defines two strategic thrusts: “functional division of tasks of various actors in the society” and “striving for a more equitable society”; both these thrusts are well represented in RHDP, a) by working with a multiplicity of partners who should be enabled to fulfil appropriate roles and b) by focusing on equity aspects; the significance of the latter is reflected in the two transversal issues of the CP: gender-balanced development and poverty-focus; both themes are of equally high importance in the RHDP. Another guideline contained in the CP is the gradual shift of SDC’s attention from Dolakha to other, more needy, districts. The project plans its withdrawal from Dolakha within this phase. The RHDP is the first attempt to translate many of the strategic guidelines of the CP into operational reality.

Gender Consideration in designin the RHDP

21The RHDP is designed in such a way that gender is considered to the maximum possible extent. The main mission of the gender consideration is to empower women and men to enhance their self-respect, to realise personal rights and to understand each other. In this regard, the project has defined the specific health needs of women, girls, boys and men as personal rights and explicitly mentions this in its goals and objectives.

RHDP’s Goals and Objectives

22The goal of the project is “to contribute to improve the health status of women, girls, boys and men through participatory development of a locally adapted and affordable health system”, whereas the objective of the project is “Women, girls, boys and men are empowered to enhance their health conditions and they have access to improved comprehensive health services at local level”.

Guiding Values and Principles

23The following guiding values and principles describe the fundamental concepts that determine and underpin the strategic choices and selection criteria of the project:

Sustainability and affordability

24Developing the capacity of women, girls, boys and men to manage their community actions for health is an essential contribution to sustainability as well as promoting local ownership, building on existing resources, developing resource mobilisation capacities and supporting local initiatives. Efforts are concentrated on developing accountability and the linkages between community-based organisations, locally-developed health services, VDCs, DDCs and the concerned district line agencies (particularly DHO, DEO, WDO, DWSO, LDO). As a key contribution to sustainable changes, the main focus of the support has been rooted in the value systems of women, girls, boys and men at community and family level, particularly where health is concerned. All project inputs with foreseeable adverse effects, primarily in terms of sustainability, are avoided. Special attention has been given to ensure that any development of the local health system is affordable.

Social equity

25To incorporate this principle, the specific problems of marginalised and deprived groups of women, girls, boys and men are identified and addressed with each CO. Particular attention is given to the issues of inequity and inequitable situations as the project aims to empower disadvantaged groups of society.

Gender equity

26As gender imbalances have serious repercussions on women’s health, the RHDP concentrates its efforts on fostering awareness on gender equity. Women and men have been involved in all steps of programming this project and also fully participate in its implementation and evaluation. Special arrangements such as child care facilities have been provided to enable women to participate in project events, training, etc.

Empowerment and participation

27The project’s major thrust continues to be orientated towards women, girls, boys and men at the local (peripheral, grass root) level enabling them to be involved in decision-making concerning their own development related to their health. They are encouraged to make choices and to take an active role at all stages of developing locally appropriate approaches to health and health-related matters. Working with women, girls, boys and men on health awareness, building up their knowledge about health related issues and facilitating their access to information helps to increase their sense of responsibility for their own development. The project also facilitates the promotion of knowledge about their basic rights, especially those related to health.

Respect for local standards, culture and sensitivity

28An essential principle when supporting and sustaining the development efforts of women and men is to respect their social and cultural norms and values. Perception of development and of health, illness and death varies greatly according to culture. To respect these differences is one of the basic conditions for sustainability. The acceptability of a particular measure to prevent or treat a disease or of a health service is often neglected. At the same time it is important to realise that diseases are neither the outcome of need assessments nor do they evolve out of a free choice made by a woman or a man. A disease is something “imposed” on a person or on a community, as in the case of an epidemic (for example AIDS). The free choice of a person occurs when it comes to preventing the disease, to treating it, and also to explaining its underlying cause. Here, traditional medicine predominates in people’s value system as it gives a “sense” to the illness. A choice is only free if it is an informed choice, leaving the person the freedom – and the resources – to opt for different solutions. Accordingly, awareness is raised among health workers and among women, girls, boys and men about the advantages and disadvantages of traditional and “modern” values as part of an empowerment process. At the same time, intercultural understanding and social know-how has been developed among project support staff.

Holistic health understanding

29At all levels, the project promotes a holistic understanding of health, linking it with SDC’s health development policy. It emphasises the multidimensional nature of health. Firstly, its human dimension which postulates that a favourable environment to health is crucial to ensure that health development interventions are effective and the initiated changes sustainable. Secondly, its intersectoral dimension which recognises the importance of knowledge, skills and technology of all sectors for health improvements and therefore the necessity for collaboration between the sectors. Thirdly, the sectoral dimension which encompasses the public health care system in its entirety with a popular, a folk and a professionally organised element. The holistic approach enables greater empowerment in several respects: it deals with health as a fundamental human right; there is considerable potential for developing self-reliance in terms of self-care and prevention of disease; quite a number of non-health factors (e. g. basic education) have an acknowledged influence on the health status of women, girls, boys and men and contribute at the same time to their empowerment.

System orientation

30This means working with existing organisations through strengthening their capacity rather than creating new and parallel systems. System orientation includes intersectoral co-operation between the health sector and other key development sectors. Regular synergy meetings are organised among project support staff of SDC projects working in the same districts to develop and share in interdisciplinary dialogue. At a local level, multi-sectoral programmes involving a variety of actors and affecting the health conditions and health status of the population are encouraged.

Choices of partners

31The main partners of the RHDP at ward, VDC and district level are defined in the project document. The term “community organisation” (CO) is used for any kind of existing organisation of the rural community: including groups, associations, committees, elected bodies, etc. The traditional forms of community organisations receive greatest attention. The selection criteria for phasing in to support any CO is summarised in the following table:

32The involvement of different actors and partners calls for a cooperative and complementary attitude. This requires that roles and responsibilities are well defined. One of the project’s roles is to facilitate this process of collaboration and to find opportunities to reinforce this approach of interaction.

Gender considerations in the implementation of RHDP activities

33RHDP has been trying in every effort to promote gender balance in all RHDP activities. Some of them are briefly highlighted:

Review of the project from a gender perspective

34At the start of implementation of the RHDP, a gender workshop was organised for the RHDP staff with the objective of fostering a better understanding of the differences between men and women, of inherent injustices and imbalances, and of reviewing all defined RHDP inputs from gender perspective.

35The workshop helped participants to define gender and to realise the extent of the problem in Nepal in general and in the project area in particular. Project staff were oriented on the latest concepts and approaches of “gender”. Essential elements of this workshop were discovering and analysing one’s perceptions and attitudes about gender relationships and realising one’s own role in both the private and in the project environment. It led to an improved understanding of gender and to changes in attitudes and behaviour of the RHDP staff. As an outcome of the workshop, all possible actions as explained in the table below were identified to integrate gender into the project activities:

Empowerment of women

36Women are disadvantaged when compared to men in many regards. The significantly higher number of illiterate women is probably one of the most striking examples of gender inequities, because its consequences on the health status of the mother and of the family is well proven to be negative. Gender imbalances are known to be further exacerbated with illiterate women. The use of antenatal services illustrates this in a dramatic way. Antenatal and natal care is strongly under-used in many places of Nepal including in the project’s districts. Out of 809 women who were pregnant in the last five years, only 29% received any kind of antenatal services during their latest pregnancy. Fifty-five percent of the literate were the recipients of these services whereas only 25% of the illiterate went to seek the services. The illiterate, socially and economically weak are at a significantly greater risk of not using the services with all the negative consequences this might have on maternal morbidity and mortality. Children of illiterate mothers have a significantly higher incidence of diarrhoea and of acute respiratory infections (ARI). The use of family planning methods is also much lower in the illiterate compared to the literate.

Towards more gender balance

37The above-mentionned situation compels the RHDP to make choices in terms of balancing male and female participation in workshops, trainings, study tours and scholarships as illustrated in the following table.

Type of training/workshop




VDC and community level training




PRA1 & management training to mother groups








Teachers’ training




Training to community clinic operators




Training/workshops to RHDP staff




Various training to health workers and volunteers




Study tours




Total participants in 21 months:




PRA: Participatory Rural Appraisal

  • 1 PRA: Participatory Rural Appraisal

38Balancing between male and female has different meanings. It should always be in favour of the deprived. When it comes to empowerment, it means giving more emphasis to a female participation in decision making of public affairs. Therefore, training at VDC and community level include a substantially higher amount of women and so do PRA1 exercises and management training that are oriented to mother groups. The quantitative male dominance of training to teachers or to clinic operators simply reflects the reality of these occupations which are mainly filled by men. In Nepal, only one out of ten teachers is a women.

Scholarships to women to promote gender equity

39There are ongoing adult literacy classes (ALC) in the villages provided by the adult literacy programmes of HMG. These ALCs are not sufficient in number to address the problems of female illiteracy. To remedy this situation the RHDP provides additional quotas for female adult literacy classes through the district education system to allow a bigger number of women to have the opportunity to become literate.

40To address the lower schooling level of women and the higher illiteracy rate amongst them, the RHDP is providing a number of scholarships for girls to be able to stay in school. This is intended for girls who drop out of school for financial reasons and because they have to participate in housework.

41The RHDP has realised that to increase the opportunities for girls to finish their regular schooling is a long term effort which can only succeed when the different decision makers at family and household level including the women themselves are repeatedly sensitised and constantly reminded of the importance of female education.

42In order to bring more women to the professional field the RHDP is providing a substantial number of scholarships to study different courses in the health professions.

Working with women’s groups

43Acknowledging women’s importance in care-taking care, prevention and promotion of health, His Majesty’s Government has institutionalised the formation of mother groups nation-wide. For each 250 members of the population living in the hill districts, a “mother group” is formed consisting of all women of reproductive age. Each mother group selects a Female Community Health Volunteer (FCHV) from amongst their members. The FCHV is trained, then given the responsibility to activate the mother group, to plan with them for health related activities and to provide health education.

44In order to empower rural women with the basic knowledge of Primary Health Care (PHC), to promote community participation and to increase awareness of public health issues the FCHV have been trained nation-wide in recognising and treating minor ailments, prevention of communicable diseases, immunisation, nutrition, family planning, sanitation and personal hygiene. After the training, each FCHV is provided with a first-aid kit containing a few basic medicines.

45Most of the time, neither the mother group nor the FCHV is functional. The necessary skills to lead and facilitate a group are usually missing. The RHDP therefore empowers both the mother group and the FCHV to manage the group in the following ways.

46Starting from the women’s own assessment of their needs, a planing exercise is carried out, where they define the activities they want to carry out to address these needs. During this exercise, they learn to identify the resources needed to carry out the planned activities and how to mobilise as much as possible locally available resources. Where a clear plan exists, RHDP supports the elaboration of a “community health initiative” with a contract between the group and the workforces involved. Action plans formulated by mother groups are related to literacy classes, building of smokeless stoves and toilets, repairing and maintaining drinking water schemes, health education campaigns to mention just a few examples. Such actions carried out together strengthen the management skills of the group.

47The mother groups are given “management training” aimed at enhancing their capacity to make decisions and mobilise local resources. FCHVs are also given additional training focusing on group dynamics, management and facilitation. As they participate in needs-identification, planning and formulating of an action plan they gradually acquire skills on how to facilitate the mother groups. In some groups where the FCHV was found by the mother group to be unmotivated and inactive, another FCHV has been selected.

48A number of mother groups have included some men in the group to give support for certain activities. This is seen as an improvement in the relationship between men and women which goes along with the empowerment of women.

49Wherever possible, the health workers (Village Health Worker and Mother Child Health Worker) of the nearby health post or sub health post have been included in the planning exercise. The aim is to motivate them to work with the community, to recognise women’s needs and to equip them with the tools to work with community people thus diminishing the gap between users and service providers. In many instances, the VHW and MCHW therefore participate in planning for community actions for health.

50In addition to the FCHVs, management training is given separately to traditional birth attendants (TBA) and faith healers who are important health care providers in the local health system. These training courses focus on developing management and facilitating skills. School teachers are also trained in rural health problems and on how to mobilise the students to identify and address health problems in their respective communities and households. Health workers and notably the ones working at the community level (VHWs, MCHWs) receive additional training with a strong emphasis on facilitating skills on how to deal with community groups.


51It is extremely difficult to achieve equity in terms of gender. There is not one single way nor one best way to act towards more gender equity. It can only be achieved by moving through a process rather than with dramatic changes in practice because any dramatic change may not help or may even have negative consequences on gender balance.

52The efforts to hire female staff for the project have remained futile as only a limited number of women are available in the job market. However, with the provision of reserved places for females, the RHDP will have a more balanced situation in future compared to the past.

53As there are only a few female teachers in the schools, the promotion of health awareness through teaching will remain essentially a male activity until more women are educated to become school teachers. ALC and scholarship programmes will contribute to the increase of the proportion of literate and educated women in the project area. By the end of the next phase of the project, a number of women, who will have successfully completed high-school, are expected to be trained to take more public positions including those of teachers and health workers.

54RHDP also has a number of shortcomings in ensuring gender equity in all its inputs. When using female community members who are already overburdened when compared to their male “counterparts” as volunteers to empower other women, we have to ask whether or not we are on the right track. Do we contribute to a greater “exploitation” of these women? Of course, we try to improve their capacity to deal with existing problems, to recognise needs, to make use of local resources and to mobilise them, to facilitate and develop all the skills among a group of women to make decisions. But are we really empowering them? Or are we simply putting a greater burden on these women?

55An increased number of local women trained as health workers will have a direct impact on the employment scenario of the local health system. Trained people who will not be able to obtain jobs in the public sector will start to run their own private businesses. With the increase of female providers, utilisation of services by females is also expected to increase.

56Formation of VDC Health Coordination Committees with the involvement of Mother Groups, FCHV and TBA will ensure women’s concerns will be reflected in the VDC Health Coordination Committee’s decisions. At the same time women and men will learn to work together in the local health system to mutually address each other’s problems.

57As a result of these multi-dimensional approaches, the degree of gender discrepancies is expected to decrease progressively.


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1 PRA: Participatory Rural Appraisal


Specialist in Public Health Management, Programme Manager of Rural Health Development Project, DDC, Nepal.

Médecin en santé publique, Conseiller santé de Rural Health Development Project, DDC, Nepal.


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