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The history of psychiatry as a discipline in Nepal has been poorly studied. We have attempted to summarise historical landmarks to explore how it began and its evolution over time in relation to contemporary political events. Although Nepal has achieved several milestones, from establishing a psychiatric out-patient department with one psychiatrist in 1961 to having more than 500 psychiatric in-patient beds with 200 psychiatrists by 2020, the pace, commitment and dedication seem to be slower than necessary: the current national mental health policy dates back to 1996 and has not been updated since; there is no Mental Health Act; the number of psychiatric nurses and in-patient psychiatric beds has increased only slowly; and there is a dearth of professional supervision in rehabilitation centres. Thus, despite making significant progress, much more is required, at greater intensity and speed, and with wide collaboration and political commitment in order to improve the mental health of all Nepali citizens, including those living in rural areas and or in deprived conditions.
During the past three decades Nepal has gone through series of reforms to address the mental health needs of the Nepalese population by promulgation of an exclusive National Mental Health Policy and related Strategic Action Plan. Small but significant improvements have been achieved in Nepal with regard to mental health policies and plans. This article discusses the evolution of mental health policies in Nepal and analyses the challenges to be overcome for their effective implementation.
In 1996, the Communist Party of Nepal-Maoist launched an insurgency that lasted 10 years and killed an estimated 16,000 people. But the case of Nepal's Maoists is particularly fascinating for the way in which the conflict ended: with their decision to put down their arms and join with other political parties in a campaign civil resistance. Drawing on original field research, this chapter will make the argument that the Maoist change in strategy was the result of changes in their social ties that came about as a result of territorial gain through war and coalition with other political parties. These changes caused the Maoists to reassess the relative viability of armed and unarmed strategies of rebellion.
This chapter traces the strategic evolution of the Nepali Congress from its deliberation and rejection of nonviolence through a vote of party leaders in Calcutta in 1950 to its gradual return to an exclusively nonviolent platform by 1990. It illustrates that the movement's lack of social ties with other groups within Nepal limited its ability to generate mass mobilization, causing leaders to sour on the prospects of being able to achieve victory through civil resistance. But over the course of the following four decades, the Nepali Congress party was able to substantially enlarge its social base in ways that made it far better positioned for civil resistance. Interestingly, a challenger with a very different ideology, the Marxist-Leninists, underwent a very similar transition. After a failed effort at inciting revolution through the beheading of “class enemies” in the early 1970s, the Marxist-Leninists, like the Nepali Congress, engaged in a program of organization- and coalition-building that paved the way for the adoption of civil resistance.
From Eastern Europe to South Africa to the Arab Spring, campaigns of civil resistance have proven capable of overthrowing regimes and bringing about revolutionary political change using primarily nonviolent tactics. Recent research has suggested that nonviolent campaigns are more likely to achieve their self-stated goals, to produce democratic outcomes, and to yield an enduring peace. But if nonviolent strategies are so effective, why do so many groups still choose to take up arms? This book aims to explain the crucial early-stage strategic choices made by challengers to state power seeking the political goal of regime-change. Drawing on multiple cases each from Nepal and Syria, as well as global cross-national data, it details the processes through which revolutionary organizations come to attempt or reject civil resistance as a means of capturing state power. The book illustrates how the social ties that link a challenger organization with broader society inform the challenger’s expectations about the viability of nonviolent tactics and consequently its strategic behavior.
To provide a comprehensive seasonal analysis of pregnant mothers’ eating behaviour and maternal/newborn nutritional status in an undernourished population from lowland rural Nepal, where weather patterns, agricultural labour, food availability and disease prevalence vary seasonally.
Secondary analysis of cluster-randomised Low Birth Weight South Asia Trial data, applying cosinor analysis to predict seasonal patterns.
Maternal mid-upper arm circumference (MUAC), BMI, dietary diversity, meals per day, eating down and food aversion in pregnancy (≥31 weeks’ gestation) and neonatal z-scores of length-for-age (LAZ), weight-for-age (WAZ) and head circumference-for-age (HCAZ) and weight-for-length (WLZ).
Rural areas of Dhanusha and Mahottari districts in plains of Nepal.
2831 mothers aged 13–50 and 3330 neonates.
We found seasonal patterns in newborn anthropometry and pregnant mothers’ anthropometry, meal frequency, dietary diversity, food aversion and eating down. Seasonality in intake varied by food group. Offspring anthropometry broadly tracked mothers’. Annual amplitudes in mothers’ MUAC and BMI were 0·27 kg/m2 and 0·22 cm, with peaks post-harvest and nadirs in October when food insecurity peaked. Annual LAZ, WAZ and WLZ amplitudes were 0·125, 0·159 and 0·411 z-scores, respectively. Neonates were the shortest but least thin (higher WLZ) in winter (December/January). In the hot season, WLZ was the lowest (May/June) while LAZ was the highest (March and August). HCAZ did not vary significantly. Food aversion and eating down peaked pre-monsoon (April/May).
Our analyses revealed complex seasonal patterns in maternal nutrition and neonatal size. Seasonality should be accounted for when designing and evaluating public heath nutrition interventions.
Nepal’s transition from highly restrictive abortion laws and high maternal mortality to liberal laws and many fewer maternal deaths provides one of the world’s most impressive examples of the relationship of the two. Nepal’s expansion of access to abortion through an emphasis on self-determination for women and incorporation of abortion training into medical and nursing training are excellent implementation models for other nations where the constraint of women’s rights and abortion services lead to injustice and early death for women. That Nepal accomplished so much for women despite political instability and only modest economic growth supports the importance of the collaboration of ministries of health and education and non-government organizations (NGOs) to progressively expand abortion training to include a wide range of urban and rural practitioners at early and later stages of their training, set standards for education and performance, and systematically evaluate effects on abortion access and safety.
Rapidly growing coronavirus disease 2019 (COVID-19) pandemic has brought unprecedented challenges to the health system in Nepal. The main objective of this study was to explore the health system preparedness for COVID-19 and its impacts on frontline health-care workers in Nepal.
Semi-structured interviews were conducted among 32 health-care workers who were involved in clinical care of COVID-19 patients and four policy-makers who were responsible for COVID-19 control and management at central and provincial level. Interviews were conducted through telephone or Internet-based tools such as Zoom and Skype. All interviews were audio-recorded, transcribed into English, and coded using inductive and deductive approaches.
Both health-care workers and policy-makers reported failure to initiate pre-emptive control measures at the early stages of the outbreak as the pivot in pandemic control. Although several measures were rolled out when cases started to appear, the overall health system preparedness was low. The poor governance, and coordination between three tiers of government was compounded by the inadequate personal protective equipment for health-care workers, insufficient isolation beds for patients, and poor engagement of the private sector. Frontline health-care workers experienced various degrees of stigma because of their profession and yet were able to maintain their motivation to continue serving patients.
Preparedness for COVID-19 was affected by the poor coordination between three tiers of governance. Specifically, the lack of human resources, inadequate logistic chain management and laboratory facilities for testing COVID-19 appeared to have jeopardized the health system preparedness and escalated the pandemic in Nepal. Despite the poor preparedness, and health and safety concerns, health-care workers maintained their motivation. There is an urgent need for an effective coordination mechanism between various tiers of health structure (including private sector) in addition to incentivizing the health-care workers for the current and future pandemics.
Chapter 6 focuses on the afterlives of Maoist propaganda outside China following the death of Mao Zedong in 1976, which soon led the end of Cultural Revolution policies. The relatively peaceful post-Mao transition in China contrasts with Maoism outside China. The outbreak of the millenarian “Shining Path” revolution in Peru, led by former philosophy professor Abimael Reinoso Guzmán, better known as Chairman Gonzalo, claimed an estimated 69,000 lives and uprooted those of 600,000 more. In the context of global Maoist ideas of continuous revolution and political militancy, Guzmán’s path to becoming a left-wing revolutionary makes sense, especially his time spent in China and his horror at poverty, systemic racism, and government corruption witnessed in urban Peru. The Sino-Soviet split provided a lasting impetus for Guzmán’s embrace of Maoist revolutionary violence, along with the supply of weapons and training for Latin American leftists. The chapter concludes with a discussion of the development of the Shining Path under the tutelage of Guzmán from an intellectual movement of urban professors and rural students to Maoist military insurrection, indiscriminate state brutality and scorched-earth policies, before turning to the movement’s more moderate legacy in Nepal, where it continues to the present day.
This chapter examines the peace process undertaken by the Government of Nepal and the Community Party of Nepal-Maoist (CPN-M). Nepal’s Comprehensive Peace Agreement (CPA), negotiated in the presence of United Nations officials and signed in 2006, does not include an amnesty provision but a commitment to accountability for human rights violations and an agreement to end impunity for such crimes. Yet, as this chapter demonstrates, agreement to include anti-impunity measures in the CPA was driven, not by a commitment to end impunity for human rights violations, but by a desire to avoid criticism from the international actors present during the negotiations. This lack of intention to comply with the human rights terms of the CPA was evident in the negotiating process and has been born out in the post-conflict period, with several successive governments attempting to legislate in favour of introducing amnesty laws. At the same time, a lack of capacity within those local institutions committed to ending impunity for human rights violations, exacerbated by the withdrawal of UN support for their processes, has hampered efforts to combat these impunity measures.
In the past two decades, peace negotiators around the world have increasingly accepted that granting amnesties for human rights violations is no longer an acceptable bargaining tool or incentive, even when the signing of a peace agreement is at stake. While many states that previously saw sweeping amnesties as integral to their peace processes now avoid amnesties for human rights violations, this anti-amnesty turn has been conspicuously absent in Asia. In Negotiating Peace: Amnesties, Justice and Human Rights Renée Jeffery examines why peace negotiators in Asia have resisted global anti-impunity measures more fervently and successfully than their counterparts around the world. Drawing on a new global dataset of 146 peace agreements (1980–2015) and with in-depth analysis of four key cases - Timor-Leste, Aceh Indonesia, Nepal and the Philippines - Jeffery uncovers the legal, political, economic and cultural reasons for the persistent popularity of amnesties in Asian peace processes.
This study assesses the prevalence of childhood undernutrition from 2001 to 2016 and estimate projections of undernutrition for 2016–2030 in Nepal.
The study used data from four rounds of a cross-sectional survey of Nepal Demographic and Health Survey (NDHS) conducted in 2001, 2006, 2011 and 2016. Descriptive analyses were conducted to calculate prevalence, binary logistic regression was used to test the significance of trends over time and autoregressive integrated moving average model was used to forecast the prevalence of childhood undernutrition.
The children and household member datasets from four NDHS were merged to assess the trends of childhood undernutrition in Nepal.
A total of 16 613 children (8399 male and 8214 female) under 5 years of age were selected for anthropometric measurements using a stratified cluster random sampling method.
Overall results show a decline in prevalence of stunting from 57·2 % to 35·8 % (P < 0·001), underweight from 42·7 % to 27 % (P < 0·001) and wasting from 11·2 % to 9·7 % (P < 0·05) from 2001 to 2016. However, different population subgroups have a higher prevalence of undernutrition than national average. Further, the analyses show that the prevalence of stunting will decline to 14·3 % and wasting to 8·4 % by 2030.
A remarkable decrease in the prevalence of stunting and underweight has been observed over the last 15 years. Nepal is likely to achieve the nutritional targets for stunting but not for wasting by 2030. Given large subpopulation variations, further improvement in undernutrition require more specific, targeted and localised programmes.
In the aftermath of the devastating 2015 earthquakes in Nepal, three non-governmental organizations collaborated to develop a program responding to the immediate mental health and psychosocial support (MHPSS) needs in three severely affected districts: Dhading, Gorkha, and Sindhuli. The program was implemented between April 2015 and February 2017 and aimed to (i) strengthen health worker capacity to provide integrated MHPSS services; and (ii) increase access to mental health services. This paper describes the program's implementation and the results of a pragmatic evaluation of the program's overall reach, effectiveness, and lessons learned.
The mixed-methods evaluation used routine program data, quantitative data from pre- and post-tests conducted with trainees and service users, and qualitative data from stakeholder interviews and focus group discussions.
A total of 1041 health workers received MHPSS training and supervision. Participants demonstrated significant improvements in skills, knowledge, and self-rated perceived competency. Trainees went on to provide MHPSS services to 3422 people. The most commonly identified presenting problems were epilepsy (29%) and depression (26%). A total of 67% of service users reported being ‘completely satisfied’ with the services received and 83% of those experiencing severe functional impairments on enrollment demonstrated improvement after receiving services.
Despite operational challenges, the program successfully engaged both laypeople and health workers to provide MHPSS in the aftermath of the crisis. Lessons learned can inform the planning and implementation of future training and integration programs to provide large-scale MHPSS efforts in humanitarian settings.
Nepali widows have a high prevalence of mental disorders, including prolonged grief disorder (PGD). Despite the considerable needs that Nepali widows have for mental health services, resources for mental health in Nepal are limited, amplifying the importance of accurate screening and diagnosis. The objective of this study was to explore the feasibility of implementing a culturally adapted Prolonged Grief Scale (PG-12/17-N) and provide actionable recommendations for its implementation.
Twenty-five mental health service providers in Kathmandu and Chitwan, Nepal were interviewed using a semi-structured guide based on selected constructs from the Consolidated Framework for Implementation Research. Qualitative data were inductively and deductively coded and analyzed to identify prominent themes.
Providers reported that the main advantages of the scale were the need to identify widows at risk, cultural relevance, easy language, and inclusion of detailed and specific symptoms. Perceived weaknesses included the complexity in response options and scoring, length, item redundancy, overlap with depression symptoms, and lack of somatic symptoms. Providers discussed the need for training, supervision, and a referral and detection system required to implement the scale in Nepal. Further development of a brief version of the scale as a routine screener may facilitate detection and referral to care.
Based on the results showing need to address PGD in Nepali widows, further efforts are needed to increase awareness about PGD and develop evidence-supported treatments for PGD, after which screening could be made routine for widows.
Although training in psychotherapy is an integral part of psychiatry training, standards in psychotherapy training have wide variation across and within countries. Post-graduate psychiatry training has been conducted in Nepal for over two decades, but little is known about its psychotherapy training provisions. An online survey was conducted with early career psychiatrists in Nepal. The findings show that the majority recognised psychotherapy training as important and were eager to pursue further training. However, two-thirds had no access to psychotherapy training opportunities. These results highlight the need to improve access to training in different psychotherapy modalities in Nepal.
This paper describes the current state of mental health services in Nepal and reflects on the significant changes over the past decade. The main challenges to overcome are proper implementation of community-based services, the high suicide rate, stigma of mental illness, financial constraints, lack of mental health legislation and proper utilisation of human resources.
Maize production is central to rural livelihoods in the hills of Nepal. Access to affordable improved maize seed has long been a barrier to productivity gains and livelihood improvement. This study evaluates the direct and indirect (spillover) impacts of a community-based seed production program in Nepal using a quasi-experimental method for selected outcome indicators. Our results show that community-based seed production provides a significant positive direct impact on maize income and female leadership opportunities. The impacts were particularly favorable for disadvantaged households (HHs) from lower castes and HHs that owned less land. There is also strong evidence of spillover impacts on improved seed adoption, yield, and household maize self-sufficiency. Community-based seed production thereby could help Nepal attain cereal self-sufficiency and nutritional security as envisioned in the national agricultural development strategy and seed vision.
The snow leopard Panthera uncia is the flagship species of the high mountains of the Himalayas. There is potentially continuous habitat for the snow leopard along the northern border of Nepal, but there is a gap in information about the snow leopard in Gaurishankar Conservation Area. Previous spatial analysis has suggested that the Lamabagar area in this Conservation Area could serve as a transboundary corridor for snow leopards, and that the area may connect local populations, creating a metapopulation. However, there has been no visual confirmation of the species in Lamabagar. We set 11 infrared camera traps for 7 months in Lapchi Village of Gaurishankar Conservation Area, where blue sheep Pseudois nayaur, musk deer Moschus leucogaster and Himalayan tahr Hemitragus jemlahicus, all snow leopard prey species, had been observed. In November 2018 at 4,100 m, 5 km south-west of Lapchi Village, one camera recorded three images of a snow leopard, the first photographic evidence of the species in the Conservation Area. Sixteen other species of mammals were also recorded. Camera-trap records and sightings indicated a high abundance of Himalayan tahr, blue sheep and musk deer. Lapchi Village may be a potentially important corridor for snow leopard movement between the east and west of Nepal and northwards to Quomolongma National Park in China. However, plans for development in the region present increasing threats to this corridor. We recommend development of a transboundary conservation strategy for snow leopard conservation in this region, with participation of Nepal, China and international agencies.
The objective of the paper is to analyse changes in food commodity prices and estimate the potential effects of food price change on nutrition security in Nepal in the context of COVID-19 contagion control measures. It presents a comparative intra-country observational study design looking at events before and during the pandemic (after implementation of contagion control measures). The study design includes three districts, enabling comparison between diverse agro-ecological zones and geographical contexts. The methodology consists of primary data collection, modelling and quantitative analysis. The analysis is based on actual school meal food baskets which represent culturally and nutritionally optimised food baskets, developed by the local community and notional typical household food baskets. End May/early June 2020 is the ‘Post-COVID-19’ reference point, the same time period in 2019 i.e. June 2019 is the ‘Pre-COVID-19’ reference point. The study finds a substantial increase in food commodity prices across food groups and districts with marked inter-district variation. For school meal basket, all micronutrients show large average declines ranging from 9⋅5 % for zinc to 11 % for vitamin-A. For household food baskets on average, vitamin-A reduced 37 % followed by iron at 19 %, reduction in zinc is low due to the high zinc content in whole grain cereals. COVID-19 control measures are likely to have contributed to substantial price inflation over the reference period with potentially damaging effects on nutrition security in Nepal with serious implications for vulnerable populations.
The catastrophic declines of three species of ‘Critically Endangered’ Gyps vultures in South Asia were caused by unintentional poisoning by the non-steroidal anti-inflammatory drug (NSAID) diclofenac. Despite a ban on its veterinary use in 2006 (India, Nepal, Pakistan) and 2010 (Bangladesh), residues of diclofenac have continued to be found in cattle carcasses and in dead wild vultures. Another NSAID, meloxicam, has been shown to be safe to vultures. From 2012 to 2018, we undertook covert surveys of pharmacies in India, Nepal and Bangladesh to investigate the availability and prevalence of NSAIDs for the treatment of livestock. The purpose of the study was to establish whether diclofenac continued to be sold for veterinary use, whether the availability of meloxicam had increased and to determine which other veterinary NSAIDs were available. The availability of diclofenac declined in all three countries, virtually disappearing from pharmacies in Nepal and Bangladesh, highlighting the advances made in these two countries to reduce this threat to vultures. In India, diclofenac still accounted for 10–46% of all NSAIDs offered for sale for livestock treatment in 2017, suggesting weak enforcement of existing regulations and a continued high risk to vultures. Availability of meloxicam increased in all countries and was the most common veterinary NSAID in Nepal (89.9% in 2017). Although the most widely available NSAID in India in 2017, meloxicam accounted for only 32% of products offered for sale. In Bangladesh, meloxicam was less commonly available than the vulture-toxic NSAID ketoprofen (28% and 66%, respectively, in 2018), despite the partial government ban on ketoprofen in 2016. Eleven different NSAIDs were recorded, several of which are known or suspected to be toxic to vultures. Conservation priorities should include awareness raising, stricter implementation of current bans, bans on other vulture-toxic veterinary NSAIDs, especially aceclofenac and nimesulide, and safety-testing of other NSAIDs on Gyps vultures to identify safe and toxic drugs.