- Email: [email protected]
Improving immunization services under the armed conflict in rural Nepal
ARTICLE IN PRESS Public Health (2006) 120, 805–808
www.elsevierhealth.com/journals/pubh
SHORT COMMUNICATION
Improving immunization services under the armed conflict in rural Nepal Ram Chandra Silwala, Masamine Jimbab,, Amod K. Poudyalc, Krishna C. Poudelb, Susumu Wakaib a
Nepal Family Health Programme, Kathmandu, Nepal Department of International Community Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan c Institute of Medicine, Tribhuvan University, Kathmandu, Nepal b
Received 2 February 2005; received in revised form 12 April 2006; accepted 18 May 2006 Available online 1 August 2006
KEYWORDS Immunization; Conflict; Human resource for health; Nepal
Introduction Progress of the Expanded Programme on Immunization (EPI) has been hindered by armed conflicts in many countries, such as Nicaragua,1 Afghanistan,2,3 Sudan,2,4 Angola, Democratic Republic of the Congo, Liberia, Sierra Leone, Somalia and Tajikistan.2 It is reported that immunization coverage is very low in areas affected by armed conflicts.2 As a result, many children become victims of a warrelated upsurge in malnutrition and vaccine-preventable diseases. Since 1989, there have been more than 116 major armed conflicts in 78
Corresponding author. Tel.: +81 3 5841 3698;
fax: +81 3 5841 3422. E-mail address: [email protected] (M. Jimba).
countries, most of which have been civil wars in developing countries, including Nepal.5 The EPI is a priority programme in Nepal,6 and free, regular immunization services are available against tuberculosis (TB), diphtheria, pertussis, tetanus (DPT), poliomyelitis (polio) and measles. In 2003, UNICEF reported the immunization status of 1-year-old Nepalese children as follows: TB 91%; DPT3 third dose (DPT3) 78%; polio third dose (polio3) 76%; and measles 75%.7 The coverage is similar to that in 1997 and 1999 (TB 86%, DPT3 76%, polio3 70%, measles 73%).8 These data show that Nepal’s immunization coverage was not affected by the armed conflict, which escalated since 1996 due to the Maoist insurgency. However, during the period of conflict, health workers were traumatized by the Maoists and the government’s security forces.9 The Maoists
0033-3506/$ - see front matter & 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2006.05.019
ARTICLE IN PRESS 806 regarded health workers with suspicion, viewing them as supporters of other political parties or spies for the Government. Conversely, the government security forces suspected the healthcare workers of being Maoist supporters. Little is known regarding how the above mentioned high EPI coverage rates were achieved by the Nepalese health workers under such a conflict situation. This study aimed to analyse the immunization coverage in a hilly district of Nepal where the conflict was escalated between 2001 and 2004, and to explore how the coverage changed during this period.
Methods Study area and population The study was conducted in Dhading, one of the hilly districts of Nepal, which has 50 village development committees (VDCs; i.e. the lowest local government units of Nepal). The district is bordered with Tibet to the north, with a total population of 343 305.10 The district consists of three constituencies, each with a population of approximately 100 000. Constituency 1 is located in a remote area; vehicle access is limited and there is no electricity supply. More than half of the VDCs in Constituency 2 and all of the VDCs in Constituency 3 have road access. In Dhading, there are 52 government health facilities [one hospital, two primary healthcare centres, 16 health posts and 33 subhealth posts (local medical clinics in Nepal)] that provide and supervise immunization services and report the results to the district health office (DHO). Twentyone of these health facilities are in Constituency 1, 16 are in Constituency 2 and 15 are in Constituency 3. In each VDC, a village health worker (VHW) is assigned who is responsible for providing immunization services. In VDCs with subhealth posts, maternal child health workers (MCHWs) are also assigned to work in the communities. Of the 21 health facilities in Constituency 1, there are two vaccine distribution subcentres, ‘Salyantar’ and ‘Darkha’. The DHO supplies vaccines to each subcentre every month from the district administrative centre. Each subcentre had a kerosene-operated refrigerator for the cold chain, so kerosene had to be transported with the vaccines to maintain the cold chain. VHWs from remote VDCs come to the subcentres to get the vaccines. They keep the vaccines in their carriers with ice packs, which can usually maintain the cold chain for 5–6 days. As such, they can operate
R.C. Silwal et al. mobile immunization services for 5–6 days per month. In 2000–2001, the DHO aimed to provide immunization services to 11 656 children aged 1 year; 3693, 3541 and 4422 from Constituencies 1, 2 and 3, respectively. However, the target number changes from year to year due to changes in the population.
Data collection and analysis In January 2004, qualitative data were collected during a half-day group discussion among VHWs and MCHWs regarding how the conflict has affected immunization services. In total, 17 VHWs and 12 MCHWs from Constituency 1 attended the discussion. The discussion was held at the government district administration centre, and the health workers had to walk for 3–18 h to attend. The discussion was conducted in the presence of DHO staff members and facilitators. Anonymity and confidentiality of participants’ information were assured. The facilitators noted all the points raised by the participants. One of the authors (RCS) discussed the influence of the conflicts on EPI, regulation of the EPI programme, and the initiatives taken by the DHO to seek a solution with the chief of the DHO. In March 2004, immunization coverage data from the DHO register were reviewed for the years 2000–2001 to 2003–2004. TB, DPT3/polio3 dose and measles coverage were used as indicators for yearly comparison. The immunization records of all health facilities were studied. A descriptive analysis was performed using SPSS 11.0 for Windows, and data from Constituency 1 were compared with data from the total district. Immunization coverage was calculated based on the target population for each respective year. For qualitative data, notes from the discussion group were examined, important themes were identified, and data were categorized under the appropriate themes. Finally, the issues raised by the participants in the group discussion were compared and discussed.
Results Immunization coverage Immunization coverage was low in Constituency 1 in 2000–2001 (TB 64%, DPT3/polio3 62% and measles 59%) compared with the district average (84%, 77% and 75%, respectively), and remained low
ARTICLE IN PRESS Improving immunization services under the armed conflict in rural Nepal Table 1
807
Immunization coverage by year in Constituency 1 and the district total.
Year
Target areas
2000–2001
Constituency District total Constituency District total Constituency District total Constituency District total
2001–2002 2002–2003 2003–2004
1 1 1 1
Target (n)
BCG
3693 11 656 3784 11 945 3877 12 239 3373 11 235
n 2368 9836 2616 11 171 3078 10 485 2691 9693
DPT % 64.12 84.39 69.13 93.52 79.39 85.67 79.78 86.28
n 2278 8962 2546 11 128 2822 9759 2679 9396
Measles % 61.68 76.89 67.28 93.16 72.79 79.74 79.42 83.63
n 2173 8709 2553 10 228 2827 9508 2492 8971
% 58.84 74.72 67.47 85.63 72.92 77.69 73.88 79.85
Total population ¼ 343 305, Constituency 1 population ¼ 100 120.
in 2001–2002 (TB 69%, DPT3/polio3 67% and measles 67%; district average 94%, 93% and 86%, respectively). Immunization coverage in Constituency 1 increased in 2002–2003 (TB 79%, DPT3/polio3 73% and measles 73%; district average 86%, 80% and 78%, respectively). Coverage in Constituency 1 increased further in 2003–2004 (TB 80%, DPT3/ polio3 79% and measles 74%; district average 86%, 84% and 80%, respectively) (Table 1).
Difficulties in performing immunization services During the discussion, the participants identified two types of problems leading to reduced immunization coverage in Constituency 1 in 2001: serviceprovider-related problems and service-consumerrelated problems.
Service-provider-related problems Various service-provider-related problems were identified, such as transportation of vaccines, personal safety and restriction of movement. After escalation of the conflict in 2001, the vaccine transporters felt that they were in danger when carrying the vaccines and became hesitant to carry them to the remote areas. The health workers were afraid of continuing their work for safety reasons as there was a possibility of confrontation with government security forces and the Maoists. The security forces arrested some health workers under suspicion of supporting the Maoists. The Maoists, on the other hand, asked the health workers for vaccine carriers, sterilizers, money, food and shelter. Finally, the Maoists restricted the movement of outsiders in their controlled areas, and local people were reluctant to provide shelter for health workers visiting for immunization services.
Service-consumer-related problems The participants identified three consumer-related problems: insecurity, irregular service and an external service provider. Village women did not feel safe when visiting immunization centres for vaccination of their babies, and worried about being caught into the crossfire during their 1–2-h journeys to such centres. Some women did not visit the immunization centre as it had not been run in the previous month. One health worker explained as follows. When I went to the subcentre to receive the vaccines, they were not available. One week later, I learned that a porter could not come to the subcentre because there was skirmishing on the way and he went back to the district centre. Next month, I went to the same subcentre with the vaccines, but I met no one there because mothers thought it would be cancelled again. In this way, the conflict hampered the immunization programme. Some women did not know their health workers because they were outsiders from urban areas. One health worker stated as follows. I was newly transferred as a VHW in my target location. Most of the mothers did not know who I was. I also did not know their local language. When I reached the immunization centre, the local people were afraid of seeing me. The mothers from the nearby villages did not come for immunization for this reason.
Action taken to improve immunization services Recruitment of local health workers for immunization To improve immunization coverage, the DHO recruited, on a temporary basis, two full-time and
ARTICLE IN PRESS 808 one part-time health workers from local villages in Constituency 1 in 2002. These health workers received 6 months of training from a community health service and in-service training on immunization, and were deployed to work in their villages. Once they mentioned that they were locally employed, the Maoists and the government security forces did not threaten them. Moreover, the locally employed health workers were well known by the villagers, which motivated the mothers to take their children for immunization. The immunization programme ran without any difficulties after hiring local people for the programme. Establishment of solar-powered cold chain In the same year, the DHO replaced the kerosene refrigerators in the vaccine distribution subcentres with solar-powered refrigerators. As a result, vaccines could be stored throughout the year. In addition, there was no need to transport kerosene as fuel for the refrigerators.
Discussion The results of this study suggest that immunization coverage can be improved during periods of armed conflict by employing trained indigenous health workers and by introducing solar-powered refrigerators. Compared with the district total, immunization coverage was low in a remote constituency during the period of conflict. However, the DHO improved immunization coverage by employing local health workers. A study in Sudan also recommended the recruitment of local health workers to improve immunization coverage in areas of armed conflict.4 This study has some limitations. Firstly, a causal relationship could not be established. For example, it cannot be concluded that the use of local health workers improved immunization coverage as there
R.C. Silwal et al. was no comparison group. Despite this limitation, these findings can be useful to improve or maintain immunization coverage in areas of armed conflict where such information is extremely limited. Secondly, average immunization rates varied from year to year, presumably because of the high rates of immigration and emigration that have reportedly increased with escalation of the conflict. In conclusion, this study suggests that use of indigenous health manpower is the key to improving immunization coverage in areas experiencing armed conflict.
References 1. Anonymous. Health effects of the war in two rural communities in Nicaragua. Nicaragua Health Study Collaborative at Harvard, CIES, and UNAN. Am J Public Health 1989;79:424–9. 2. Tangermann RH, Hull HF, Jafari H, Nkowane B, Everts H, Aylward RB. Eradication of poliomylitis in countries affected by conflict. Bull World Health Organ 2000;78:330–8. 3. Dadgar N, Ansari A, Naleo T, Brennan M, Salama P, Sadozai N, et al. Implementation of mass measles campaign in central Afghanistan, December 2001 to May 2002. J Infect Dis 2003;187:186–90. 4. ElZein HA, Birmingham ME, Karrar ZA, Elhassan AA, Omer A. Rehabilitation of the expanded programme on immunization in Sudan following a poliomyelitis outbreak. Bull World Health Organ 1998;76:335–41. 5. Eriksson M, Wallensteen P. Armed conflict, 1989–2003. J Peace Res 2004;41:625–36. 6. Nepalese Ministry of Health/Department of Health Service. Annual report of the Ministry of Health, 2059/60 (2002/ 2003). Kathmandu: Ministry of Health; 2004. 7. UNICEF. The state of the world’s children 2005. New York: UNICEF; 2005. 8. UNICEF. The state of the world’s children 2001. New York: UNICEF; 2001. 9. Poudyal AK, Jimba M, Wakai S. Difficulties of peace-building in Nepal. Can Med Assoc J 2005;172:1663. 10. Central Bureau of Statistics, Nepal. Population census report. Kathmandu: Central Bureau of Statistics, Nepal; 2001.
www.elsevierhealth.com/journals/pubh
SHORT COMMUNICATION
Improving immunization services under the armed conflict in rural Nepal Ram Chandra Silwala, Masamine Jimbab,, Amod K. Poudyalc, Krishna C. Poudelb, Susumu Wakaib a
Nepal Family Health Programme, Kathmandu, Nepal Department of International Community Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan c Institute of Medicine, Tribhuvan University, Kathmandu, Nepal b
Received 2 February 2005; received in revised form 12 April 2006; accepted 18 May 2006 Available online 1 August 2006
KEYWORDS Immunization; Conflict; Human resource for health; Nepal
Introduction Progress of the Expanded Programme on Immunization (EPI) has been hindered by armed conflicts in many countries, such as Nicaragua,1 Afghanistan,2,3 Sudan,2,4 Angola, Democratic Republic of the Congo, Liberia, Sierra Leone, Somalia and Tajikistan.2 It is reported that immunization coverage is very low in areas affected by armed conflicts.2 As a result, many children become victims of a warrelated upsurge in malnutrition and vaccine-preventable diseases. Since 1989, there have been more than 116 major armed conflicts in 78
Corresponding author. Tel.: +81 3 5841 3698;
fax: +81 3 5841 3422. E-mail address: [email protected] (M. Jimba).
countries, most of which have been civil wars in developing countries, including Nepal.5 The EPI is a priority programme in Nepal,6 and free, regular immunization services are available against tuberculosis (TB), diphtheria, pertussis, tetanus (DPT), poliomyelitis (polio) and measles. In 2003, UNICEF reported the immunization status of 1-year-old Nepalese children as follows: TB 91%; DPT3 third dose (DPT3) 78%; polio third dose (polio3) 76%; and measles 75%.7 The coverage is similar to that in 1997 and 1999 (TB 86%, DPT3 76%, polio3 70%, measles 73%).8 These data show that Nepal’s immunization coverage was not affected by the armed conflict, which escalated since 1996 due to the Maoist insurgency. However, during the period of conflict, health workers were traumatized by the Maoists and the government’s security forces.9 The Maoists
0033-3506/$ - see front matter & 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2006.05.019
ARTICLE IN PRESS 806 regarded health workers with suspicion, viewing them as supporters of other political parties or spies for the Government. Conversely, the government security forces suspected the healthcare workers of being Maoist supporters. Little is known regarding how the above mentioned high EPI coverage rates were achieved by the Nepalese health workers under such a conflict situation. This study aimed to analyse the immunization coverage in a hilly district of Nepal where the conflict was escalated between 2001 and 2004, and to explore how the coverage changed during this period.
Methods Study area and population The study was conducted in Dhading, one of the hilly districts of Nepal, which has 50 village development committees (VDCs; i.e. the lowest local government units of Nepal). The district is bordered with Tibet to the north, with a total population of 343 305.10 The district consists of three constituencies, each with a population of approximately 100 000. Constituency 1 is located in a remote area; vehicle access is limited and there is no electricity supply. More than half of the VDCs in Constituency 2 and all of the VDCs in Constituency 3 have road access. In Dhading, there are 52 government health facilities [one hospital, two primary healthcare centres, 16 health posts and 33 subhealth posts (local medical clinics in Nepal)] that provide and supervise immunization services and report the results to the district health office (DHO). Twentyone of these health facilities are in Constituency 1, 16 are in Constituency 2 and 15 are in Constituency 3. In each VDC, a village health worker (VHW) is assigned who is responsible for providing immunization services. In VDCs with subhealth posts, maternal child health workers (MCHWs) are also assigned to work in the communities. Of the 21 health facilities in Constituency 1, there are two vaccine distribution subcentres, ‘Salyantar’ and ‘Darkha’. The DHO supplies vaccines to each subcentre every month from the district administrative centre. Each subcentre had a kerosene-operated refrigerator for the cold chain, so kerosene had to be transported with the vaccines to maintain the cold chain. VHWs from remote VDCs come to the subcentres to get the vaccines. They keep the vaccines in their carriers with ice packs, which can usually maintain the cold chain for 5–6 days. As such, they can operate
R.C. Silwal et al. mobile immunization services for 5–6 days per month. In 2000–2001, the DHO aimed to provide immunization services to 11 656 children aged 1 year; 3693, 3541 and 4422 from Constituencies 1, 2 and 3, respectively. However, the target number changes from year to year due to changes in the population.
Data collection and analysis In January 2004, qualitative data were collected during a half-day group discussion among VHWs and MCHWs regarding how the conflict has affected immunization services. In total, 17 VHWs and 12 MCHWs from Constituency 1 attended the discussion. The discussion was held at the government district administration centre, and the health workers had to walk for 3–18 h to attend. The discussion was conducted in the presence of DHO staff members and facilitators. Anonymity and confidentiality of participants’ information were assured. The facilitators noted all the points raised by the participants. One of the authors (RCS) discussed the influence of the conflicts on EPI, regulation of the EPI programme, and the initiatives taken by the DHO to seek a solution with the chief of the DHO. In March 2004, immunization coverage data from the DHO register were reviewed for the years 2000–2001 to 2003–2004. TB, DPT3/polio3 dose and measles coverage were used as indicators for yearly comparison. The immunization records of all health facilities were studied. A descriptive analysis was performed using SPSS 11.0 for Windows, and data from Constituency 1 were compared with data from the total district. Immunization coverage was calculated based on the target population for each respective year. For qualitative data, notes from the discussion group were examined, important themes were identified, and data were categorized under the appropriate themes. Finally, the issues raised by the participants in the group discussion were compared and discussed.
Results Immunization coverage Immunization coverage was low in Constituency 1 in 2000–2001 (TB 64%, DPT3/polio3 62% and measles 59%) compared with the district average (84%, 77% and 75%, respectively), and remained low
ARTICLE IN PRESS Improving immunization services under the armed conflict in rural Nepal Table 1
807
Immunization coverage by year in Constituency 1 and the district total.
Year
Target areas
2000–2001
Constituency District total Constituency District total Constituency District total Constituency District total
2001–2002 2002–2003 2003–2004
1 1 1 1
Target (n)
BCG
3693 11 656 3784 11 945 3877 12 239 3373 11 235
n 2368 9836 2616 11 171 3078 10 485 2691 9693
DPT % 64.12 84.39 69.13 93.52 79.39 85.67 79.78 86.28
n 2278 8962 2546 11 128 2822 9759 2679 9396
Measles % 61.68 76.89 67.28 93.16 72.79 79.74 79.42 83.63
n 2173 8709 2553 10 228 2827 9508 2492 8971
% 58.84 74.72 67.47 85.63 72.92 77.69 73.88 79.85
Total population ¼ 343 305, Constituency 1 population ¼ 100 120.
in 2001–2002 (TB 69%, DPT3/polio3 67% and measles 67%; district average 94%, 93% and 86%, respectively). Immunization coverage in Constituency 1 increased in 2002–2003 (TB 79%, DPT3/polio3 73% and measles 73%; district average 86%, 80% and 78%, respectively). Coverage in Constituency 1 increased further in 2003–2004 (TB 80%, DPT3/ polio3 79% and measles 74%; district average 86%, 84% and 80%, respectively) (Table 1).
Difficulties in performing immunization services During the discussion, the participants identified two types of problems leading to reduced immunization coverage in Constituency 1 in 2001: serviceprovider-related problems and service-consumerrelated problems.
Service-provider-related problems Various service-provider-related problems were identified, such as transportation of vaccines, personal safety and restriction of movement. After escalation of the conflict in 2001, the vaccine transporters felt that they were in danger when carrying the vaccines and became hesitant to carry them to the remote areas. The health workers were afraid of continuing their work for safety reasons as there was a possibility of confrontation with government security forces and the Maoists. The security forces arrested some health workers under suspicion of supporting the Maoists. The Maoists, on the other hand, asked the health workers for vaccine carriers, sterilizers, money, food and shelter. Finally, the Maoists restricted the movement of outsiders in their controlled areas, and local people were reluctant to provide shelter for health workers visiting for immunization services.
Service-consumer-related problems The participants identified three consumer-related problems: insecurity, irregular service and an external service provider. Village women did not feel safe when visiting immunization centres for vaccination of their babies, and worried about being caught into the crossfire during their 1–2-h journeys to such centres. Some women did not visit the immunization centre as it had not been run in the previous month. One health worker explained as follows. When I went to the subcentre to receive the vaccines, they were not available. One week later, I learned that a porter could not come to the subcentre because there was skirmishing on the way and he went back to the district centre. Next month, I went to the same subcentre with the vaccines, but I met no one there because mothers thought it would be cancelled again. In this way, the conflict hampered the immunization programme. Some women did not know their health workers because they were outsiders from urban areas. One health worker stated as follows. I was newly transferred as a VHW in my target location. Most of the mothers did not know who I was. I also did not know their local language. When I reached the immunization centre, the local people were afraid of seeing me. The mothers from the nearby villages did not come for immunization for this reason.
Action taken to improve immunization services Recruitment of local health workers for immunization To improve immunization coverage, the DHO recruited, on a temporary basis, two full-time and
ARTICLE IN PRESS 808 one part-time health workers from local villages in Constituency 1 in 2002. These health workers received 6 months of training from a community health service and in-service training on immunization, and were deployed to work in their villages. Once they mentioned that they were locally employed, the Maoists and the government security forces did not threaten them. Moreover, the locally employed health workers were well known by the villagers, which motivated the mothers to take their children for immunization. The immunization programme ran without any difficulties after hiring local people for the programme. Establishment of solar-powered cold chain In the same year, the DHO replaced the kerosene refrigerators in the vaccine distribution subcentres with solar-powered refrigerators. As a result, vaccines could be stored throughout the year. In addition, there was no need to transport kerosene as fuel for the refrigerators.
Discussion The results of this study suggest that immunization coverage can be improved during periods of armed conflict by employing trained indigenous health workers and by introducing solar-powered refrigerators. Compared with the district total, immunization coverage was low in a remote constituency during the period of conflict. However, the DHO improved immunization coverage by employing local health workers. A study in Sudan also recommended the recruitment of local health workers to improve immunization coverage in areas of armed conflict.4 This study has some limitations. Firstly, a causal relationship could not be established. For example, it cannot be concluded that the use of local health workers improved immunization coverage as there
R.C. Silwal et al. was no comparison group. Despite this limitation, these findings can be useful to improve or maintain immunization coverage in areas of armed conflict where such information is extremely limited. Secondly, average immunization rates varied from year to year, presumably because of the high rates of immigration and emigration that have reportedly increased with escalation of the conflict. In conclusion, this study suggests that use of indigenous health manpower is the key to improving immunization coverage in areas experiencing armed conflict.
References 1. Anonymous. Health effects of the war in two rural communities in Nicaragua. Nicaragua Health Study Collaborative at Harvard, CIES, and UNAN. Am J Public Health 1989;79:424–9. 2. Tangermann RH, Hull HF, Jafari H, Nkowane B, Everts H, Aylward RB. Eradication of poliomylitis in countries affected by conflict. Bull World Health Organ 2000;78:330–8. 3. Dadgar N, Ansari A, Naleo T, Brennan M, Salama P, Sadozai N, et al. Implementation of mass measles campaign in central Afghanistan, December 2001 to May 2002. J Infect Dis 2003;187:186–90. 4. ElZein HA, Birmingham ME, Karrar ZA, Elhassan AA, Omer A. Rehabilitation of the expanded programme on immunization in Sudan following a poliomyelitis outbreak. Bull World Health Organ 1998;76:335–41. 5. Eriksson M, Wallensteen P. Armed conflict, 1989–2003. J Peace Res 2004;41:625–36. 6. Nepalese Ministry of Health/Department of Health Service. Annual report of the Ministry of Health, 2059/60 (2002/ 2003). Kathmandu: Ministry of Health; 2004. 7. UNICEF. The state of the world’s children 2005. New York: UNICEF; 2005. 8. UNICEF. The state of the world’s children 2001. New York: UNICEF; 2001. 9. Poudyal AK, Jimba M, Wakai S. Difficulties of peace-building in Nepal. Can Med Assoc J 2005;172:1663. 10. Central Bureau of Statistics, Nepal. Population census report. Kathmandu: Central Bureau of Statistics, Nepal; 2001.