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President Obama's ambitious Global Health Initiative — announced to a receptive international community in 2009 — is faltering as budget constraints and shaky implementation limit the impact of the multibillion-dollar program.

GHI's missing piece in Nepal

U.S. law prevents Global Health Initiative funding for abortion.

The Obama administration chose Nepal to be one of its eight GHI focus countries as it redefines how American aid is delivered in developing nations. In Nepal, GHI seeks to strengthen the country’s health care system by boosting the local capacity of health care providers like nurse Bhusal and service locations like the Lamahi Primary Healthcare Center, say U.S. health officials here. GHI, they said, strives to support the government of Nepal’s health plan and promote country-ownership of health care services.

With a focus on gender equality and the inclusion of remote and disadvantaged groups, one of GHI’s main goals is to help Nepal improve its maternal health and thereby reduce the number of women dying during pregnancy or childbirth.

With the exception of abortion services, GHI in Nepal supports a broad range of maternal health services: It provides more access to contraception methods; trains community volunteers to counsel women on family planning and the need for antenatal check ups; collaborates with a private social marketing company to provide counseling and contraceptive services in local pharmacies; lends resources to beef up the number of skilled birth attendants in health centers; and encourages girls to stay in school and delay marriage and pregnancy.

Under GHI, USAID has also shifted its focus to target more remote and disadvantaged communities. For example, it now recruits and trains more community health volunteers who are living deep in Nepal’s mountainous region to provide better counseling on modern contraception as well as the need for antenatal checkups and giving birth at a hospital, primary healthcare center or health post that has a skilled birth attendant.

Abortion, however, has not been part of any overseas assistance since a 1973 amendment was made to the U.S. Foreign Assistance Act, known as the Helms Amendment. It prohibits U.S. funds from being used for abortion services overseas for the purpose of family planning.

Still, USAID officials in Nepal argue that it can help the country boost its maternal health without offering safe abortion services.

The USAID team in Kathmandu gave different reasons for why they do not need to provide awareness about safe abortion or access to such services. They stressed that abortion is not a safe method of family planning and that they can help with other interventions to prevent unwanted pregnancies. The team also said that USAID cannot do everything, and they coordinate with other donors who provide different services.

The government of Nepal and civil society actors say that it would help Nepal’s maternal health strategy if USAID supported the government plan in providing access to safe abortion, but they disagree over its impact.

“It would have been better if they were on board,” said Praveen Mishra, the population secretary at Nepal’s Ministry of Health and Population. But given that USAID legally cannot support safe abortions, he said, at least it can contribute to Nepal’s family planning programs and help manage complications resulting from unsafe practices. Furthermore, he said if USAID gave the government infrastructure for other health services, the government could also use those rooms or buildings to provide abortion services.

The case for family planning

A landlocked nation that has had a tumultuous political history, Nepal is one of the world’s poorest countries with severe social, economic and geographic disparities. Maoist rebels took on the cause of Nepal’s marginalized people and waged an armed conflict against the monarchy in 1996. By the time the civil war ended a decade later, about 13,000 people had died and much of the nation’s rural development had been disrupted. Nepal has spent the past five years trying to transition to a firmly established democratic republic, but an unstable government has struggled to complete the peace process and draft a new constitution.

Despite challenges related to its mountainous terrain, inequalities, corruption, lack of human resources in rural areas and political instability, Nepal has made great strides in improving its maternal health. It had a high maternal mortality ratio of 539 deaths per every 100,000 live births in 1995, but it has successfully brought the ratio down to 281 deaths per every 100,000 live births as of 2006.

USAID argues that the main reason for this drop has been their work convincing more women to use modern contraception and making various options available.

“To our minds it was very clear it was family planning,” Peniston said.

Only 29 percent of married women in Nepal used a modern method of contraception in 1995, but that number jumped to 48 percent in 2006, according to government statistics.

An increase in contraception usage decreases a nation’s maternal mortality because fewer pregnancies mean fewer chances a woman could die while pregnant or giving birth. Plus, spacing out births enables a woman’s body to fully recover from a past pregnancy and be in the best position to have a healthy delivery.

USAID says now they are trying to use GHI funds to target groups of women and girls who have been the hardest to reach with family planning messages, such as those married to migrant workers. With insufficient job opportunities at home, Nepal has seen a dramatic increase in the number of people working abroad. The wives back home benefit from the remittances, but their health can suffer. While the women might not need protection for most of the year, when their husbands come home to visit, they find themselves unprepared.

Sunita Thakur is one of those women. Thakur, who wears a line of red vermillion powder through her parted hair, says her husband works in Delhi and returns to their village in Terai region once every two to four months. Thakur, who estimates her age at about 18, dropped out of school when she was about 11 because she did not live near a secondary school and was already married. She had her first child around age 15 and her second, a little boy with disheveled hair sitting on her lap, nine months ago.

“Two is enough,” she said through a translator as she sat in a family planning clinic in Nepalgunj. USAID pamphlets explaining the various contraception methods available, including implants, intrauterine devices, Depo-Provera, birth control pills and condoms, sit on a nearby table. The young mother said she does not want more children because she wants to ensure she can afford to send her two to school. “I will educate them even if I have to sell my jewelry,” she said as she sat on a bench in the clinic, waiting to meet with a counselor. She hopes that if her daughter can become educated and wait until she is at least 18 to marry, she will have more opportunities than she has had.

“If I had completed my education, I would have a small job. I would be able to manage my home,” she said.

Thakur learned about using modern contraception from a friend, discussed it with her husband and mother-in-law and then accompanied her friend to this clinic, which received staff training as well as maintenance, repair and essential equipment from USAID.

Nepal, though, has a long way to go before all its adolescent girls and women know about and have access to modern contraception. One of the biggest challenges, say reproductive health specialists, is overcoming the myths and misconceptions surrounding modern contraception.