National Health System Profile

1. TRENDS IN POLICY DEVELOPMENT

The national health policy was adopted in 1991 (FY 2048 BS) to bring about mprovement in the health conditions of the people of Nepal with emphasis on (i) preventive health services (ii) promotive health services (iii) curative health services (iv) basic primary health services with one health post each in the entire 205 electoral constituencies to be converted into primary health care centre (v) ayurvedic and other traditional health services (vi) community participation (vii) human resources for health development (viii) resource mobilisation (ix) decentralisation and regionalisation (x) drug supply, and (xi) health research.

The second long term health plan (SLTHP) 1997-2017 (FY 2054-2074) aims at guiding
health sector development for improving the health of the inhabitants, particularly those whose health needs are not often met. The main objectives of SLTHP are: To improve the health status of the most vulnerable groups, particularly those whose health needs often are not met - women and children, the rural population, the poor, the underprivileged, and the marginalized population To extend to all districts cost-effective public health measures and essential curative services for the appropriate treatment of common diseases and injuries To provide technically competent and socially responsible health personnel in appropriate numbers for quality health care throughout the country, particularly in under-served areas To improve the management and organization of the public health sector and to increase the efficiency and effectiveness of the health care system To develop appropriate roles for NGOs, and the public and private sectors in providing health services; and To improve inter-and intra-sectoral coordination and to provide the necessary support for effective decentralization of health care services with full community participation To increase total health expenditure to 10 percent of total government expenditure (Ministry of Health, Annual Report 2002/2003).

The national health policy aims at improvement in the health conditions of the people of Nepal through extension of primary health care system to the rural population with a view to provide the benefits of modern medical facilities through trained health care providers; active involvement of private sector and NGOs in health services; and adequate training and community participation.

The strategic analysis of health sector in 1999 resulted in the development of the medium five-year health plan (2002-07). This included essential, term strategic plan for the 10affordable and accessible health care services, promote a public-private NGO partnership, decentralize the health system and execute particular approaches at all levels, and to improve quality of health care through the public/private/NGO partnership by total quality management of human, financial and physical resources.

Considering the Local Self Governance Act (LSGA) of 1999 and the decentralized health management of the Health Sector Reform Strategy (HSRS), it is anticipated that more resources will be mobilized at the local level to ensure financial sustainability (Ministry of Health, Annual Report 2002/2003).

The Nepal government is committed to bring about tangible changes in the health-sector development process. It aims at providing an equitable, high quality health care system for all the Nepalese during tenth five-year plan (2002-07). The proportion of the government budget allocated to health will increase from the present 5 percent to 6.5 percent in 2006 and 7 percent in 2009 (Nepal health sector programme implementation plan, 2004-09).

2. TRENDS IN SOCIO-ECONOMIC DEVELOPMENT

2.1 Economic trends

In more than a decade, the GNP increased only by US $ 16. It was reported to be US $ 250 in 2000 but it declined to US $ 249 in 2002 due to socio-political instability and insecurity in the country. It has again gone up to US$300 in 2004/05 (as per Nepal Millennium Development Goals: Progress Report 2005) The GDP per capita has increased from US $ 227 in 1998/99 to US $ 237 in 2002/03. The average annual growth during 1990-2000 was 2.4 percent (Statistical Yearbook, 2003).

Nepal is a less indebted country, as the present value of debt is 193 percent of export of goods, services and income (The World Bank, World Development Indicators, 2005). In Nepal, the foreign aid increased from Rs. 16,188 million in 1998-99 to Rs. 16,974 million in 2002-03. The share of annual health expenditure as percentage of the national budget was 5.1 in 2001-03. Nepal’s rank in terms of the UNDP human development index (HDI) is 138 among 177 countries. The index increased from 0.291 in 1975 to 0.527 in 2004 (Nepal Annual Report DOHS, 2002-03, Human Development Report, 2006).

Nepal’s labour force increased from 8.8 million in 1990 to 11.7 million in 2003. The average annual growth rate for the period is 2.2 percent. The unemployed population aged 10+ is reported to be 5.1 percent while unemployment rate is 3.8 percent (Statistical

Yearbook, 2003 and Nepal Living Standard Survey 2003/04). However, the proportion of females in labour force has not increased much. It was 38.5 percent in 1990 and 39.5 percent in 2003 (World Development Indicators, 2005). In Nepal, 24.1 percent of the population earn less than an American dollar per day and 31 percent of the population is living below poverty line (Nepal Millennium Development Goals: Progress Report 2005).

2.2 Demographic trends

The population of the country increased from 11.6 million people in 1971 to 25.8 million
in 2006. However, the annual growth rate during the period did not decline; rather it increased from 2.1 percent in 1971 to 2.6 percent in 1981, and again decreased to 2.1 in 1991, but again increased to 2.25 in 2001. The CBR decreased from 35.4 per 1,000 population in 1996-97 to 33.5 population in 2001 to 28.4 per 1,000 population in 2006 (Nepal Demographic and Health Survey, 2006) while CDR decreased from 11.5 per 1,000 population in 1996-97 to 9.96 per 1,000 population in 2001. The average fertility estimate for 2006 is 3.1 (Nepal Demographic and Health Survey, 2006) and 2001 was 4.1 as against 5.1 during 1984-86. There is significant difference in TFR for urban and rural areas i.e. 2.1 and 3.3 , respectively (Nepal Demographic and Health Survey, 2006).

As per the census 2001, 39.3 percent of population was below 15 years and 6.5 percent was 60 years and above. About 54.2 percent of population was between 15-59 years (Computed from Population Census 2001, National Report).

The life expectancy at birth increased from 42.0 years for males and 40.0 years for females in 1971 to 55.0 years and 53.5 years for males and females, respectively, in 1991. However, it has shown slight increase in female life expectancy over the males since then. It was 61 years for females and 60 years for males as per 2001 report (Demographic and Health Survey, 2001).

Trends in infant mortality rate (IMR) show that it declined from 140 per 1,000 live births in 1976 to 103 in 1986, to 64 in 2001 (Demographic and Health Survey, 2001) and is estimated to be 61 in 2005 (Nepal Millennium Development Goals: Progress Report 2005) and according to NDHS survey tis 51 per 1,000 live births (Nepal Demographic and Health Survey, 2006)

The percentage of the urban population in 2001 was 14.2 and it was expected to increase 5.15 percent annually during the period (2000-03) (Statistical Yearbook, 2003).

Social trends

The literacy rate is showing a steep upward trend. It was 54 percent in 2001. The Ministry of Education pegs the latest rate at 57 percent. Enrolment ratio in the primary and secondary schools are 0.79 and 0.69, respectively. Gender inequality in the rate of literacy is, however, glaring. It was 42 percent for females and 65 percent for males (National Population Census, 2001). The Net Enrolment Rate in primary education in 2005 is 84 (Nepal Millennium Development Goals: Progress Report 2005)

2.4 Food supply and nutritional status

The proportion of newborns weighing less than 2,500 grams at birth was 23 percent in 1996/97 and 14.3 percent in 2006. The government has set a target to reduce it to 12 percent by 2017 (Health Information Bulletin 2001).

The demographic and health survey of 2001 reported that about 50.5 and Nepal Demographic and Health Survey, 2006 reported that about 49.3 percent children below 5 years were affected by stunting (short of their age), which can be a sign for early chromic under nutrition. The survey also found that 48.3 percent in 2001 and 38.6 in 2006 of the children were under weight. Also, in the year 2000, 55 percent of children below 5 years were stunted (Nepal Millennium Development Goals: Progress Report 2005), an indicator of acute malnutrition.

The Nepal Micronutrient Status Survey (NMSS) report 1998 revealed that the median urinary iodine level among women was 114.0 mg/I and among school-aged children it was 143.8 mg/I. According to the ‘between census household information monitoring evaluation survey 2000’, only 63 percent households were adequately covered with iodized salt. These reports show that the median urinary iodine level is higher than the WHO cut-off point but household coverage of adequately iodised salt is still lower than the WHO cut-off point. Therefore, IDD is still a public health problem in Nepal.

Iron deficiency anaemia is the most common nutritional problem in Nepal affecting approximately three-quarters of women. Anaemia is one of the underlying risk factors in pregnancy. Anaemia reduces work capacity of adults by 10-30 percent. Among women, there is distinct variation in the prevalence of anaemia according to the ecological zone with highest levels in the Terai followed by the mountainous regions. The most common cause of anaemia in Nepal is considered to be inadequate intake of iron from food followed by parasitic infection, as 71 percent pregnant women are not consuming adequate amount of iron from their daily diets. This is despite fact that antenatal iron supplementation is in place in Nepal since more than two decades. However, the coverage and compliance of antenatal iron supplementation is beyond satisfaction. There is a big gap between supply and demand of iron tablets.

A baseline study was carried out in the districts where Intensified Antenatal Iron Supplementation Programme (IAISP) was implemented. The findings in the programme areas revealed that 27 percent and 47 percent of pregnant women took iron tables in the second and third trimester, respectively. Similarly, drop-out rate was 19 percent during the second trimester and 25 percent in the third trimester. Lack of knowledge about the importance of iron tablets is stated to be the main reason for not taking iron supplementation. However, due to continuous effort by health workers to improve the coverage of iron tablets during pregnancy and postpartum, the coverage of iron tablets reached to 68 percent in the fiscal year 2002-03.

Breastfeeding is nearly universal in Nepal and the median duration of breastfeeding is long (34 months). Nearly one in three children is breastfed within one hour of birth, while two out of three babies are breastfed within one day of birth. This is an improvement over the last five years. However, contrary to the WHO recommendation, only two-thirds of children less than six months of age are exclusively breastfed. Only 53 percent of children under six months of age are exclusively breastfed. Bottle-feeding is not common in Nepal (Nepal Demographic and Health Survey, 2006)

It also reported that 40.9 percent of newborn receive pre-lacteal feed which needs to be reduced (Demographic and Health Survey, 2001).

2.5 Lifestyle and Risk Factors

Smoking is associated with increased risk of lung and heart diseases and is also closely related to other behaviours risky to health, such as alcohol and drug use.

Nearly three-fourths of men smoke cigarettes, bidis or other tobacco, two-thirds consume alcohol; more than one in two both smoke and consume alcohol. Smoking and alcohol consumption is much less common among men in the age group of 15-19. Smoking and alcohol consumption is also less common among divorced, separated, or widowed men and women living in the Terai ecological zone, western development region, and central Terai sub-region than in other regions. heart disease, diabetes and cancer are on the increase. That is why the government has taken several steps to create awareness among the public about the harmful effects of tobacco, alcohol and narcotic drugs. Besides, other measures such as increase in excise duty on tobacco and alcohol products, health tax on tobacco products, compulsory health warning on every cigarette package, ban on smoking in public places, ban on advertising and promotion of tobacco products, and import and export tax on tobacco products have been enforced to discourage use of tobacco and alcohol. The Smoking (Prohibition and Control Act, 2058) is awaiting the parliamentary approval. Under the national anti-tobacco programme, anti-tobacco communication campaign, a five-year action plan (2004-08) has been prepared by the health ministry (Update on the National Health System Profile Nepal, 2004).

3. HEALTH AND ENVIRONMENT

3.1 General protection of the environment

Air water pollution and deforestation are assuming alarming proportion. Water pollution is due to inadequate sewerage and sanitation, industrial wastes and pesticides from agricultural sources. On the other hand, vehicular and industrial emissions, combustion of fossil fuels and biomass are the main causes of air pollution. To address these problems, the Nepal environment policy and action plan was formulated in 1993 and in the same year the environment protection council was also established. The Ministry of Population and Environment was created in 1995. A ban on diesel driven three-wheelers in Kathmandu, regular check up of vehicle emission by the government and other designated agencies, a policy decision to keep the vehicles more than 20 years old off the road, are some of the important steps taken in recent years.

Lack of resources and trained human resources, inadequate infrastructure, weak coordination and lack of awareness on environmental issues, are some of the main problems in the implementation of environmental programme.


3.2 Water supply and sanitation

The piped water is considered as a safe source of water. According to the living standards survey report 2003/04, 14 percent households had access to piped water supply within their houses and 30 percent outside of their houses. The remaining 56 percent households depended on covered well (37 percent), open well (5 percent) and others (14 percent), including rivers, streams, ponds etc.

Urban areas have better access to safe drinking water (68 percent) as compared to rural areas (39 percent).The piped water facilities were available to 33 percent households in 1995/96 as compared to 44 percent in 2003/04.

The proportion of households with proper toilet facilities in their dwelling units was 39 percent in 2003/04 as compared to 22 percent in 1995/96. About 12 percent of households have access to sanitary (sewerage) system, but it is concentrated in urban areas (54 percent). Only eight percent households have disposal facilities for solid waste by public and private collector (Nepal Living Standard Survey 2003/04).

In Nepal 25 percent of the population have access to excreta disposal facility with coverage of 21 percent rural population and 53 percent of the urban population.

According to a joint study by the government, National Planning Commission (NPC) and UNICEF in 1996, the major reasons for not having a latrine among the households were: no perceived need (66 percent), resource constraint (31 percent), smell and privacy (three percent).

The Nepal Water Supply Corporation, a government agency, serves the major municipalities while the department of drinking water and sewerage serves rest of the country.

The government strategy is to integrate sanitation with water supply, promotion and utilisation of local knowledge, skills, resources and low-cost technology. Local bodies, user groups, NGOs are involved in the operation, repair and maintenance jobs. Small-scale drinking water projects are handed over to local communities and user groups. But the major constraints facing its better implementation are lack of resources, weak cost recovery, etc. Hence private investment is lacking. There is poor coordination among the stakeholders at local levels. Besides, rapid urbanisation, pollution of surface water, diminishing spring water sources and high leakage rate (38 percent) are some of the other problems. High content of arsenic in tube well water in the Terai region is posing a new problem.

4. HEALTH RESOURCES

4.1 Human resources for health

Human resource development has been an area of priority of health services delivery programme in Nepal. The integrated and community health programmes of 1974 introduced systematic training process with the aim to develop all health personnel on integrated health care, who were brought in to mainstream of the integrated public health services from vertical health projects. The revision of the health services structure in 1993 brought the institutional leadership in the area of health manpower training. The number of personnel trained at central and district level training centres during the 2000-01 and 2002-03, is given below:

Training performance over the three-year period
Sr. Training
Numbers of persons trained
No. 2000-01 2001-02 2002-03
1. Central level 4,961 7,745 2,440
2. District level 83,937 93,191 102,425
3. Training achievements 84 % 87 % 87 %
Source: Ministry of Health, Annual Report 2002/2003.

The above table shows that the training achievements increased from 84 percent in 2000-01 to 87 percent in 2002-03.

It may be seen from the table that health manpower has not increased, except for categories of doctors, FCHV/TBAs. The post of village health worker is a new creation According to the Central Bureau of Statistics, Nepal, 2003, there was one physician per 5,886 people.

4.2 Financial resources for health

A public expenditure review of the health sector was carried out during early 2003. The review brought out many important findings, some of which are given below.

i. Public funding in health care increased from US$ 3.5 to US$ 5.1 during 1999-2002.
ii. The contribution of external development partners (EDPs) in health sector through the ministry of finance was reduced to almost one-third during this period
iii. The share of recurrent budget is being spent more on wages
iv. The funding in health care to rural areas is decreasing. Health services are comparatively less utilised by the female population.

Resources available for health care during fiscal year 2003-04 (in rupees) are as follows:

A. Total outlay in health care
Fund from government 1,410 million (49.3percent)
Fund from external sources 1,450 million (50.7percent)

B. Breakdown of the fund
Physical infrastructure 300 million (10.5percent)
Salary and services 2,560 million (89.5percent)

C. Percentage outlay in health Percentage of national budget in helath 6.2
Percentage of the current five-year plan allocation in health: 6.0

About 10 percent of the expenditure on health care comes from the state-owned enterprises. Local bodies have been contributing more for the health sector in recent days. In absolute terms, the budget allocation for the whole nation and for the health sector has gradually been increasing over the last 30 years, but in percentage terms there has been no actual enhancement in the allocation for health. For example, in 1983-84 it was 4.6 percent, in 1993-94 it was 4.0 percent and in 2002-03 it was 4.9 percent. Unfortunately even the allocated budget for the health sector was hardly expended to the fullest. It is on an average 68 percent of the total allocation.

Financial resources in the health sector have been coming down noticeably during the last few years due to mounting concern for maintaining internal security. External donors have also reduced their contributions to the health sector. Funding from the external donors is increasingly going to the international and national NGOs.

Although the policy of the government, as per the 10th five- year plan, is to stress on giving priority to primary health care and to the poor in remote areas, in practice, distribution of funds is mainly urban-centric and more funds are being allocated for areas that already have better infrastructure, e.g., with better transportation and communication facilities.

Government Expenditure in Health Care by Level

Level of Care Fiscal year 1999/2000 2000-01 2001-02
Primary (percent) 62.8 55.1 59.5
Secondary (percent) 5.1 7.2 6.9
Tertiary (percent) 22.7 26.9 24.4

In Nepal, total health expenditure as percentage of GDP has been fluctuating since 1998. It was 5.1 percent in 1998 and 5.2 percent in 2002. Share of public expenditure in total health expenditure declined from 67.2 percent in 1998 to 65.6 percent in 2002, whereas the share of private expenditure increased from 32.8 percent in 1998 to 34.4 percent in 2002. On the other hand, the share of public expenditure increased nominally as it was 7 percent in 1998 and 7.5 percent in 2002 (World Health Report, 2005).

The per capita total expenditure on health has been increasing gradually as it was US $ 10 in 1998 and US $ 12 in 2002, whereas the per capita public expenditure on health stagnated since 1998 as it was constant at US $ 3 during 1998-2002 (World Health Report, 2005).

Main sources of funding are the royal government and external resources. In March 2004, the International Labour Organisation launched a national campaign on social security and coverage for the benefit of all Nepalese. It aims at providing access to health insurance and other benefits. It was initiated for the first time in Asia, particularly Nepal, where 95 percent of the people are not included in any form of social security.

4.3 Physical infrastructure for health

The lowest level of formal health care starts from Sub-Health Posts (SHPs) at the Village Development Committee (VDC) level to Health Posts (HPs), Primary Health Centres (PHCs) and hospitals at the district, zonal, sub-regional, regional and central levels. Basically all PHC services provided at various levels in the public sector are by the Department of Health Services (DHS) and the Department of Ayurvedic Medicine (DAM). The SLTHP, periodic plans and the general policy of the government emphasises in providing PHCs to people, particularly living in remote, rural and unserved areas and focusing on pregnant women and children.

Topography-wise the Distribution of the Health Care Facilities

Type of institution Total Mountain Hill Terai
Hospital 85 16 45 24
PHCC/HC 193 20 94 79
Health Post 701 152 379 170
Sub-Health Post 3,129 387 1,606 1,136
Ayurvedic Hospital 2 - 1 1
Dist. Ayurvedic HC 50 8 27 15
Ayurvedic Dispensary 211 28 125 58
Zonal Ayurvedic Dispensary 14 1 8 5
Homeopathic Dispensary 1 - 1 -
Unani Dispensary 1 - 1 -
Source: DHS Annual Report 2001-2002

Source: Ministry of Health 2001-2002*
* As per an exercise organised by the government, a total of 3,210 beds will be required for the district level alone by 2017.

In addition to the above-mentioned allopathic hospitals/health care facilities, there are two ayurvedic hospitals (one of which is a 100-bed hospital and the other one a regional hospital) and one regional ayurvedic dispensary. There are 14 zonal, 55 district and 216 general ayurvedic dispensaries throughout the country. Nepal also has a six-bedded homeopathic hospital and one Unani dispensary. All of these are run by the public sector.

Concern on equity, particularly in a country like Nepal, is louder than ever. The concern for the poor, marginalised and the unserved people has been the priority of the government in providing health services, education and employment in general and to the Dalits in particular. Similar provisions have also been made in the community drug programme. On the whole, the ministry spends about 51 percent of its funds in rural areas, 18 percent in semi-urban and 31 percent in urban areas. Each hospital allocates five percent of the contribution received from the government and five percent of their own income for the services of the poor.

The policy of Nepal Government as set out in the SLTH plan, health ministry has given low priority to the hospital based services. In practice, however, this policy could seldom be translated into reality. The policy, as set in the present five- year plan and in the medium-term expenditure framework (2002/03-2004/05), suggests that the private sector will be more involved in catering to hospital based services.

Due to the thinly scattered population profile in the hilly and mountainous regions, the accessibility to health facilities is still a problem in this Himalayan country.

4.4 Essential drugs and other supplies

The policy on medicine, which came into force in 1995, emphasises on establishment of coordination among the government, NGOs and private organisations involved in production, import, export, storage, supply, sale, distribution, quality assessment, regulation, rational use and information flow of medicines in the country.

The department of drug administration (DDA) was established in 1979 following the promulgation of the Drug Act the previous year. Since then, it has been implementing the following: Development of constitution and regulation for the drug consultative council and drug advisory committee Registration of medicine Maintaining of medicine standards Inspection of compliance of the regulations Promulgation and implementation of the codes for production of medicine Promulgation and implementation of the codes for sale and distribution of medicine Promulgation and implementation of the codes on advertisement of medicine.

It has developed and distributed books on the rational use of drugs, Standard Treatment Schedules (STS) for health posts and sub-health posts to encourage and enforce rational use of drugs. The drug administration has also developed and published training manuals for HPs and SHPs on drug quantification, prescribing and dispensing practice to be used for training health workers.

The drug administration also took 317 administrative actions and 33 legal actions during 2002-2003 for non-compliance of the Drug Act and other regulations. Similarly, 14 roducts from eight domestic and nine from four foreign companies were recalled from the market and import license of seven foreign companies was cancelled during the same period.

The Nepal Drug Research Laboratory is another principal body for testing and analysis of medicines. It works as the national drug control laboratory. Procurement and supply of drugs, equipment, insecticide, vaccine and medical consumables are organised for all the divisions of DHS by the Logistics Management Division (LMD) and a supply section in the department of ayurvedic medicines for ayurvedic medicines. Quality of medicine is overseen by the drug authority. .

While half of the procurements are still in the hand of the central office at the national level, half of the procurement is now done at five regional health service directorates for the peripheral units. Essential drug procurement is gradually being shifted to SHPs. This has however, raised questions on the quality of the medicine procured.

Since the establishment of the drug authority, Nepal has been producing medicines and meeting 65 percent of the domestic needs (39 percent allopathic and 26 percent Formatted: English (U.S.)traditional).

4.5 International partnership for health

The external development partners are generally involved in strengthening and expanding the health facilities and services in different parts of the country supporting preventive, promotional and curative services. In recent times, a health sector reform committee was formed under the chairmanship of the health minister and a core group was formed consisting of EDPs, international NGOs, national NGOs and private sector to plan and coordinate the use of resources available for health sector programmes from all stakeholders. The group is expected to mobilise bigger resources and also increase the fund absorption capacity of the government. Currently, Nepal is partnering with 21 international NGOs, four multi-lateral and six bi-lateral development partners.

The GFATM has provided US$7 million for the HIV/AIDS control programme and US$4 million for the malaria control programme.
DEVELOPMENT OF THE HEALTH SYSTEM

5.1 Health policies and strategies

After the world nations agreed to attain the goal of ‘Health For All’ (HFA) by the year 2000AD through primary health care approach, Nepal also stepped ahead to extend and strengthen the integrated approach to meet the national goals.

The ninth five-year plan (1997) had set a target to improve public health status by strengthening of the existing infrastructure for preventive, promotive, curative and rehabilitation services.

The second long-term health plan (1997-2017) aims at improving health status of the people, particularly those whose health needs are often not met; the most vulnerable groups, women and children, the rural population, the poor, the under-privileged and the marginalized. It emphasises on assuring equitable access by extending quality essential health care services with full community participation and gender sensitivity by technically competent and socially responsible health personnel throughout the country. In addition to essential health care, specialist services are also to be extended gradually on a cost-effective basis. The targets to be achieved by the second long- term health plan (SLTHP) by the end of the plan period of 1997-2017, are as follows:

i. IMR will be reduced to 34.4 per thousand live births from its present level ;
ii. Under- five mortality rate to be reduced to 62.5 per thousand live births from the its present level;
iii. TFR to be reduced to 3.05 from its present level;
iv. Increase life expectancy to 68.7 from its present level;
v. To reduce CBR to 26.6 per thousand population from the its present level;
vi. To reduce CDR to 6 per thousand population from its present level;
vii. To reduce maternal mortality ratio to 250 per 100,000 births from the its present level;
viii. To increase CPR to 58.2 percent of its present level;
ix. To reduce percentage of new born < 2,500 gm to 12, and
x. To provide essential health care services at district level to 90 percent of the
population living within 30 minutes of travel time

Millennium Development Goals (MDGs)The progress made towards achievement of health related MDGs is given at Annex-2.

5.2 Organisation of the health system

The overall purpose of the Department of Health Services is to deliver preventive, promotive and curative health services throughout the country. The Department of Health Services (DoHS) is one of three departments under the Ministry of Health. As seen in Figure 1, the organisational structure of the ministry MoH outlines how different levels of the health care system relate to each other in the form of a health care network under the DoHS.

According to the institutional framework of DoHS and MoH, the Sub-Health Posts (SHPs), from an institutional perspective, is the first contact point for basic health services. However, in reality, the SHPs are the referral centres of the volunteer cadres like TBAs and Female Community Health Volunteers (FCHVs) as well as a venue for community-based activities such as PHC outreach clinics and EPI clinics. Each level above the SHP is a referral point in a network from SHPs to HPs to PHCs, and to district, zonal and regional hospitals, and finally to the speciality tertiary care centres in Kathmandu. This referral hierarchy has been designed to ensure that the majority of population receives public health care facilities and minor treatment in places accessible to them and at a price they can afford. Inversely, the system works as a supporting mechanism for lower levels by providing logistical, financial, supervisory and technical support from the centre to the periphery.

QUESTIONS ON INTERCOUNTRY ADOPTION

WE CANNOT OVER-EMPHASIZE THE IMPORTANCE OF YOUR BEING INVOLVED WITH A PARENT-GROUP BEFORE, DURING, AND AFTER YOUR ADOPTION. PARENT-GROUPS PROVIDE EDUCATION AND SUPPORT THAT WILL GREATLY BENEFIT BOTH YOU AND YOUR CHILD.

QUESTIONS FOR PARENTS CONSIDERING INTERCOUNTRY ADOPTIONS

Trans-racial adoption is not for every family, just as adoption is not for every family. Some very nice people are not necessarily good parents at all. Many good parents cannot really excellent parents to a child of their own race, but not cut out to be good parents to a child of another race or background.

ADOPTING A CHILD OF A DIFFERENT RACE: WHAT IS INVOLVED FOR THE PARENT AND THE CHILD?

Your family will now be interracial for generations. It is not just a question of an appealing little baby. How do you think and feel about interracial marriage? How does your family think and feel when people assume that you are married to an Asian, a Spaniard, or a Black? How do you think and feel about getting some public attention positive and negative stares, comments? A possible problem could be that the adopted child gets your thoughts about race? What characteristics do you think people of other races have? Do you expect your child to have them? The children become mericanized. Do you raise him to have the same identity as you or your other children? Do you help him develop his own identity? Should he have a foreign name? What relationship will his name have to his sense of who he is? Imagine a child you know and love being sent to a foreign country to be adopted. How would you want him raised? As an American in a foreign country or as a native in that country? How can you learn how it is to be non-white or non-black, and growing up in a white to a Caucasian or Black, and will require more sensitivity to subtleties.

Pre-School years. The people he loves best look different from him. It will be natural for him to want to resemble those he loves, or else understand why he looks different, and learn that difference is not a bad thing. Latency stage. The child will need help in understanding his heritage and background so he can explain and feel comfortable about his status with his friends.

Teenage years. This is the time he tries to figure out who am I? Curiosity about his original parents or background may become stronger. Questions about dating arise, and you should look at your community. Try to guess how many of your friends and Neighbors would wholeheartedly accept their child dating yours. How would you feel if your child developed a special interest in his native country, and identified himself as a foreigner, involved himself with a group of Asian, Indian, and Latin American teens, wanted to visit his native land? Hopefully you and progress, and feel not in the least threatened by his wanting to identify himself with such others.

Moving into Adulthood. idea not that your child might marry a Caucasian, an Asian, a Mestizo, an Indian, a Black? Would you recommend for or against an interracial marriage for your child?

SUMMARY

In addition to your qualities, abilities, thoughts, and feelings as parents, it is important for you to understand your motive for this atus symbol, a conversation piece? On page 41 of her book, Adoptions Advisor (Information House, Hawthorn Books, 1975), Jan -important that your child, of if you feel that your primary orientation is to help this child become absorbed into your culture at the expense of his own, you might find Tran racial adoption difficult for both you and your child. It is important to keep in mind that children are removed from their own country ONLY because they essentially have no future in that country, and no possibility of being cared for by permanent, nurturing parents, either by adoptions within that country, or strong long-term foster care. Their only alternative to intercountry adoption would be institutionalization until they reach majority.


ADOPTION FORGES A LIFETIME LINKAGE


Once a child is place with his or her U.s Family, is it okay to forget about the child's county of birth? From my experiences in my professional work with adoptive and prospective families, as well as in my own life as an adoptive parent, I believe not. As we raise our kids to be part of a multicultural U.S. family in a multicultural nation, we need to help them understand and value their origins. While their national origin and adoption should not be the sole focus of their (or of our) lives, I believe that by
undertaking an international adoption, parents take on special responsibilities both to their child and to in certain countries and the negative effect it is having on the approval of international adoptions. While trying to counter these rumors by producing graphic documentation showing that children are happy and healthy in their new homes in the United States, facilitators for some international adoptions complained about the post-placement documentation requirements sending back photos and letters they must follow through the arduous and expensive adoption process, and that no further obligation to, or contact with, and to the officials who approved our adoptions, but also for our children, who can see how much we value parents to help support other kinds o
they felt I was being unrealistic in such an expectation of my fellow adoptive parents, and that the most American children.

Why, some of them asked me, do I think that adoptive parents should feel any more ties or obligation The denial of adults who describe adoption this way is a concern just as great as the issues of international understanding raised by such an analogy. Furthermore, the solid sense of entitlement that bonds adoptive parents and their children needs to be based on honestly addressing the core issues of adoption, We need to recognize the global interconnections that relate to each and every one of us. As parents f
inequalities between groups of people will deepen, both within the United States and between the United States and other nations. We need to show that we care, not just for selfish interests, but also because the future depends on us. We sink or swim together, whether at home or in the global sense. The alternative is a scary one indeed, and its ramifications extend far beyond the realm of adoption.

GRACIOUS ANSWERS TO AWKWARD QUESTIONS ABOUT OUR ADOPTED KIDS

When we adopt a child who looks different from us, we generally feel we can handle the stares and loss of privacy that go with the territory. We may find, however, that the frequent questions and comments of strangers and relatives sometimes annoy and worry us. At the heart of our anger and anxiety is the fear that our adopted child will be hurt by thoughtless questions, or that their older siblings, who look less exotic, will feel neglected, but this need not happen. It is reassuring to realize that even seemingly insensitive questions are nearly always well intentioned, and that they actually provide AN EXCELLENT OPPORTUNITY TO EXPRESS OUR DELIGHT AND PRIDE in our adopted children (as well as in their siblings who were born to us). The attention that our children receive is generally very positive, even when the inquirer's choice of words is not ideal. Our answers to questions about a foreign-born child should also include any bio-kids who are present:

Q: Where did you get this dear little one? Where is she from?
A: She was born in Korea, and her brother here was born in Albany. (Most people will pick up on your inclusion of the older child and start including him, too, if you furnish answers about both to EACH question asked about the adopted child.) We can start early to practice answers that will AFFIRM THE CHILDREN, preparing for the day when they will be old enough to understand:

Q: Isn't she a lucky little girl? What wonderful people you are!
A: We're the lucky ones, to have such a wonderful child!

Q: And do you also have children of your own?
A: Just these two. (This affirms adopted kids as our own.)

Q: Are they REAL brother and sister?
A: They are NOW! (This clarifies that adoption makes us a real family.)

Q: Where did he get that beautiful tan?
A: God gave it to him.

Q: How could the mother have given up such a lovely child?
A: It was very hard for the birthmother, but she just couldn't take care of ANY baby. (This reassures the child that there was nothing wrong with him or her.)

Q: What do you know about the real parents?
A: Well, we're his real parents, actually, since we're bringing him up.

Q: Oh, of course--I meant the natural parents.
A: We don't know very much about the birthparents. How have you been? How was your summer?
In nearly all cases, the questions reflect pleasure and delight in our families, and they can generally be answered very briefly and cheerfully, with a smile. If you are out shopping, it is fairly easy to avoid prolonging the discussion by saying, "Bye, now!" and moving from the peaches to the potatoes. If we are trapped into a longer conversation in a supermarket line or in a social situation (and the children are old enough to understand what is said), we have several options:

1) Give a constructive response, and then change the subject.
2) Answer with, "I'm glad you're interested in adoption. Let me give you my phone number and we can talk later. Can you call me tonight?
3) Give an oblique answer, rather than a direct one, if it seems a direct answer to a particular question would be awkward for the questioner, the children, or us:

Q: How much does an adoption cost these days?
A: It's about the same as giving birth in a hospital, if you don't have maternity coverage and allow for complications.

Q: Do you have any pictures of his parents?
A: Oh, yes, we've got albums of our whole family.

Responses such as the above can gently educate others, especially if said with a smile. BUT WE ARE ANSWERING PRIMARILY FOR OUR CHILDREN'S EARS. In the few seconds that we have to prepare our response, we need to make a quick decision as to what words will best support our child's self-esteem, protect the child's privacy about his origins, and/or clarify that adoption builds "real" families with their "own" children. (The right answers come more quickly with practice.) Until more people learn the modern vocabulary of "birthparents" and "children by birth" we're bound to be asked occasional seemingly insensitive questions about the child's "real parents" and our "own" children. I believe that the fault is really in our outdated language more than in the person asking an awkward question. True, some people are not as sensitive as they might be, but usually they have a genuine interest and we would rather not embarrass them (and risk making things worse). We can generally find a gracious answer that will affirm the child without sounding critical of the person asking the question.

The key to a successful response is one that we can say in a friendly, matter-of-fact voice, without showing impatience or anger. It is easier to avoid annoyance with questions and remarks if we remember that (1) we have chosen to build a family in a way that nevitably attracts attention but may help other children to be adopted, and (2) the children needn't be hurt by others' questions and remarks if we respond appropriately. An angry or rude retort on our part (even when it seems justified) is much more likely to cause our child distress and anxiety than anything a stranger, friend, or relative might say. It could signal to the child that there is something upsetting to us about him or his adoption. In a pinch, humor can save the day:

Q: Are you babysitting?
A: No time for that, now that I have these two of my own!

Q: Whose little darlings are these?
A: Ours! We adopted the big boys from Korea, and the two-year-old is homemade. (Some of us may find it helpful to volunteer all this information to forestall a subsequent question about whether the child who matches us is "our own".)

There are times when we may need to let a particular comment pass and help our child to understand it later. Recently my husband and I were entertaining one of his important clients, and our Colombian-born son was present. The client remarked that she had friends who had adopted two Korean children and later had had two children "of their own." It seemed best not to risk offending the woman by correcting her choice of words. The next day I asked our son it he had been bothered by the remark, explaining it as a problem in our language. He replied that he hadn't minded it at all. I felt reassured that whatever damage might be done by others is within my power to assess, and to repair if necessary.

This incident was also a reminder to me that our kids are often more resilient than we imagine when it comes to weathering an occasional unfortunate remark. In our early discussions with our children about birthparents, we can explain that "real parents" are actually people who are bringing up children who are THEIR OWN by birth or adoption, and that many people are confused about this. This point should ideally be made before kindergarten, where other children may question our children about their "real parents" when we're not there to explain that THAT'S WHO WE ARE! If we are upset by the frequency of well-intentioned friendly remarks, we can ask ourselves why this is so. Are we naturally rather private people who feel we weren't sufficiently warned by our agency or friends that a loss of anonymity is almost inevitable when our child is of a different race? Are we simply tired of explaining to new people, feeling that somehow they should know the answers that we've given to so many others? Is it painful to be reminded so often of our infertility by questions that focus on the fact our child is different? Our agencies stand ready to assist us with any post-finalization problems we may have, and our adoptive parent support group can help as well. Although we may not always feel comfortable about having our family the center of so much attention, the situation certainly does have its benefits. For one thing, the subject of adoption comes up naturally on many occasions, so we develop comfort in discussing adoption in our children's presence even before they understand the concept. Also, the encounters give us frequent opportunities to say positive, supportive things about our children (and about adoption) within their hearing. Some people have observed that adopted children who do not resemble their families often tend to feel more positive about their adoption
than those who match their adoptive parents. This is presumably because the fact of adoption is so obvious that the subject has necessarily been an open one from the time of the child's arrival. It is something the child has always known, rather than a subject to be broached someday with trepidation as a potentially shocking fact of life.

Adoption should always be the last resort!

Kathmandu, 10 March 2007: UNICEF hopes that the International Conference on Inter-Country Adoption being held in Kathmandu 11-13 March 2007 will lead to the ratification of the Hague Convention on Inter-Country Adoption and the adoption of national laws and mechanisms to regulate in-country and inter-country adoption.

"The Hague Convention is designed to put into action the principles regarding inter-country adoption which are contained the Convention on the Rights of the Child (CRC) which Nepal has ratified." said Ms. Gillian Mellsop, UNICEF's Representative in Nepal. "These principles include ensuring thatadoption is authorised only by competent authorities, and that inter-country adoption does not result in
improper financial gain for those involved in it."

According to UNICEF these provisions are meant first and foremost to protect children, and also have the positive effect of providing assurance to prospective adoptive parents that their child has not been the subject of illegal and etrimental practices.

Referring to the increasing trend of families from wealthy countries wanting to adopt children from other countries, Ms. Mellsop said, "Lack of education and oversight, particularly in the countries of origin, coupled with the potential for financial gain, has spurred the unfortunate growth of an industry around adoption. This means that profit, rather than the best interests of the children, takes centre
stage. Abuses include the sale and abduction of children, coercion of parents, and bribery, as well as trafficking to individuals whose intentions are to exploit rather than care for children"

"Adoption should always be the last resort for the child. The CRC, which guides UNICEF's work, states very clearly that every child has to the right to know and to be cared for by his or her own parents, whenever possible. UNCIEF believes that families needing support to care for their children should receive it, and that alternative means of caring for a child should only be considered when, despite this assistance, a child’s family is unavailable, unable or unwilling to care for her or him. "

"We therefore call upon the participants of the Inter Country Adoption Conference to seriously consider these issues and advocate for child adoption mechanisms that are transparent and in line with the Convention on the Rights of the Child and The Hague Convention."

NEPAL ADOPTION

Disclaimer: The following is intended as a very general guide to assist U.S. citizens who plan to adopt a child in Nepal and apply for an immigrant visa for the child to come to the United States. Two sets of laws are particularly relevant: 1) the laws of Nepal govern all activity in Nepal including the adoptability of individual children as well as the adoption of children in country. 2) U.S. Federal immigration law governs the immigration of the child to the United States. The information in this flier relating to the legal requirements of specific foreign countries is based on public sources and our current understanding. It does not necessarily reflect the actual state of the laws of Nepal and is provided for general information only. Moreover, U.S. immigration law, including regulations and interpretation, changes from time to time. This flyer reflects our current understanding of the law as of this date and is not legally authoritative. Questions involving foreign and U.S. immigration laws and legal interpretation should be addressed respectively to qualified foreign or U.S. legal counsel.

The Department of State has issued a Travel Warning for Nepal. Please review the latest information on travel to Nepal at http://travel.state.gov/ . All visitors to Nepal must obtain a visa. Visas can be obtained prior to departure from the Nepalese Embassy in Washington, DC or upon arrival at Tribhuvan International Airport in Kathmandu. It is preferable for travelers who plan to arrive overland from India to obtain a visa prior to arrival in Nepal. More information about visas for travel to Nepal can be found at http://www.immi.gov.np/touristvisa.php. U.S. citizens wishing to adopt a child in Nepal must meet both U.S. requirements and the requirements set by the Government of Nepal (GON). Procedures for foreign adoptions in Nepal are unpredictable and the Government of Nepal's requirements are not enforced in a uniform manner. The GON frequently changes requirements with little notice. Visa fraud of all types is at high levels in Nepal and is a significant problem facing potentially adoptive parents. As a result of high levels of visa fraud, the U.S. Embassy in Kathmandu must carefully investigate orphan visa cases to determine whether the child meets the definition of an orphan under U.S. immigration law. The need for investigations may result in delays in issuing the visa. If based on the investigation the Embassy determines that the child does not meet the definition of orphan under U.S. immigration law, the US Embassy in Kathmandu may be refer the case to the Department of Homeland Security for review and further action. Potential adoptive parents should be aware that under Nepalese law, single mothers or
married mothers who have been left by their husbands are faced with stringent requirements regarding the relinquishment of their children for adoption. Fathers have twelve years from the child's birth to claim the child and assert custody rights. Unless a mother identifies the father and he agrees in writing to the child's adoption, either willingly or through a court order, the child will not be eligible for adoption. This can result in uncertainties as to a whether a child is actually eligible for adoption and may result in further investigations.

PATTERNS OF IMMIGRATION OF ADOPTED ORPHANS TO THE U.S.:
Recent U.S. immigrant visa statistics reflect the following pattern for visa issuance to orphans
Fiscal Year Number of Immigrant Visas Issued
FY 2004 73
FY 2003 42
FY 2002 12
FY 2001 5
FY 2000 13

ADOPTION AUTHORITY IN NEPAL:
The Ministry of Women, Children and Social Welfare is the Nepalese Government office responsible for adoptions in Nepal. Officially, the Ministry has recognized the Nepal Children's Organization (NCO), also known as Bal Mandir, to process adoptions, although adoptions through orphanages other than NCO/ Bal Mandir are possible.

Ministry of Women, Children and Social Welfare,
Singha Durbar, Kathmandu
Telephone No. 4241465, 4240408, 4241728

ELIGIBILITY REQUIREMENTS FOR ADOPTIVE PARENTS:
Nepalese law sets out the following age and civil status requirements: The age difference between prospective parents and the adoptive child must be at least 30 years; The couple must have been married for at least 4 years prior to filing an application and be "infertile;" Single women between the age of 35 and 55 may also adopt.

Children (either male or female) under the age of 16 may be adopted. If the prospective adoptive parents already have a child of their own, GON regulations state they can adopt a Nepali child of the opposite sex of their first child. Siblings of the opposite sex can be adopted together if other qualifications are met. Families that already have two children may not adopt in Nepal, as the total number of children in a family after the adoption cannot exceed two. RESIDENTIAL REQUIREMENTS: There are no residency requirements for adopting an orphan from Nepal.

TIME FRAME: Most orphanages in Nepal will not assign a child to adoptive parents until there is evidence that the I-600A has been approved by USCIS. The process from the approval of the I-600A by USCIS to the approval of the adoption by the GON varies in length from 6 months to 2 years. Adoptive parents adopting children over the age of 3 years often find their cases are completed in 6 to 9 months. Adoptions in Nepal may be completed with one trip to Nepal; however, some adoptive parents elect to travel to Nepal twice. On the first visit, they meet the child and complete initial paperwork. They then return to Nepal when the adoption is approved by the GON to file the immigrant visa petition.

ADOPTION AGENCIES AND ATTORNEYS :
Most adopting families work with an adoption agency in the US to adopt from an orphanage in Nepal. Some orphanages have established relationships with specific adoption agencies in the US and only work with those US international adoption agencies. There are orphanages that will process an adoption directly with the adopting parent, without the assistance or work of a US adoption agency. The Government of Nepal does not require adopting parents to work with specific agencies in the US or in Nepal.

Prospective adoptive parents are advised to fully research any adoption agency or facilitator they plan to use for adoption services. For U.S.-based agencies, it is suggested that prospective adoptive parents contact the Better Business Bureau and licensing officeof the Department of Health and Family Services in the state where the agency is located. The U.S. Embassy in Nepal is currently compiling a list of agencies known to work in Nepal and a list of English-speaking Nepali attorneys that are available upon request. The Department of State does not assume any responsibility for the quality of services provided by these private adoption agencies, attorneys or their employees Please see Important Notice Regarding Adoption Agents and Facilitators at our Web site travel.state.gov.

ADOPTION FEES IN NEPAL:
The Ministry of Women, Children and Social Welfare has a fee of $300.00 for the adoption of an orphan from Nepal. Orphanages and local facilitators in Nepal often charge additional fees to process the adoption and care for the child once the child has been assigned to an adoptive parent but prior to the approval of the adoption by the GON. These fees vary widely. Adoptive parents have reported a wide variance in fees (between $3,000 – 17,000) charged by Nepalese orphanages, which are largely unregulated by the Government of Nepal. Many parents have reported that orphanages have charged them new and unexpected fees once the parents arrive in Nepal.

Prospective parents are advised to obtain detailed receipts for all fees and donations paid to orphanages, either by the parents directly or through their U.S. adoption agencies. ADOPTION PROCEDURES: Prospective parents may adopt through Nepal Children's Organization (Bal Mandir) or through a private agency. Adoptive parents in Nepal sign many documents in the process of completing an adoption. Many of these documents are in Nepali and English translations are not routinely provided. Parents are encouraged to have documents translated before they are signed. NCO will review your application and determine if you are eligible to adopt. The U.S. Embassy has no authority to challenge or change a decision by NCO to deny an application. Denial by NCO does not mean a definitive end to the process; parents may be still able to proceed with a private agency.

Adoption Guarantee Letter
The GON requires that all adoptive parents complete and sign a “Guarantee Letter”. This letter, which is made part of the dossier that is submitted to the Ministry of Women, Children and Social Welfare, serves to assure the GON that the adoptive parent(s) have been approved by the US Government to be adoptive parents and that, if legally qualified, the child will be a US Citizen. The letter must be signed by the adoptive parent(s) and by a consular officer at the US Embassy in Kathmandu. The letter must be accompanied by notarized copies of the adoptive parents' passport(s) with original signatures of the parent and the notary and photographs of the child and parent(s). This letter is completed after the child is assigned to the parents.

Government of Nepal: Next Steps Once the case has been reviewed by the NCO or another private agency, a 5-member committee at the Ministry of Women, Children and Social Welfare reviews each adoption file. The frequency of these meetings depends on the availability of the committee members. If the committee deems that everything is in order, they will recommend the case to the Legal Section of the Ministry for further processing. Once the Legal Section reviews the case and issues a positive recommendation, the Secretary of the Ministry of Women, Children and Social Welfare issues and signs the final adoption decree in English. Adoptive parents must be physically present in Nepal to take custody of the child once the final adoption is pronounced.
This step in the process varies in length. While some cases are processed in as little as three weeks, some take as long as six months, depending on the political situation and the Circumstances of an individual case. Further questions about the adoption process on the Nepalese side should be addressed to a foreign legal counsel.

Nepalese Travel Document
Once adoptive parents obtain the adoption decree, they will also need to obtain a travel document (passport) for the child through the Nepalese Ministry of Foreign Affairs. DOCUMENTS REQUIRED FOR ADOPTION IN NEPAL : If an adoption is processed through a private agency, in addition to the information listed above for NCO adoptions, the parent(s) must also obtain a favorable recommendation from the District Administration Office where the child resides; and a death certificate(s) and/or a affidavit(s) of consent and irrevocable release of the child of biological parent(s) for purposes of emigration. Once a child is identified, the adoption can be handled directly through the Ministry of Women, Children and Social Welfare. Many who choose the private adoption route find it useful to have an adoption lawyer or contact person in Nepal to help navigate the process.

AUTHENTICATING U.S. DOCUMENTS TO BE USED ABROAD:
Presently, the GON does not require all documents to be authenticated, although some documents may need to be. All U.S. documents submitted to the Nepalese government/court must be authenticated. Nepal is a party to the Hague Legalization Convention. Generally, U.S. civil records, such as birth, death, and marriage certificates, must bear the seal of the issuing office and an apostille affixed by the state's Secretary of State (an apostille is a special seal applied to a document to certify that a document is a true copy of an original). Documents must be apostilled in the state where they are issued. Tax returns, medical reports and police clearances should likewise be authenticated. Prospective adopting parents should contact the Secretary of State of the state where documents originated from for instructions and fees for authenticating documents. Documents issued by a federal agency must be authenticated by the U.S. Department of State Authentications Office, 518 23rd St., N.W., Washington, D.C. 20520, (202) 647-5002 Fee: $6.00. For additional information, call the Federal Information Center: 1-800-688-9889, and choose option 6 after you press 1 for touch tone phones. Walk-in service is available from 7:30 a.m. to 11:30 am Monday-Friday, except holidays and is limited to 15 documents per person per day (documents can be multiple pages). Processing time for authentication requests sent by mail is 5 working days or less. Please visit our Web site at travel.state.gov for additional information about authentication procedures.

Nepal Adoption Program

Background

Geographical: Nepal is located between China and India. Nepal is slightly larger than the state of Arkansas in the USA. The capital is Kathmandu.
Government: In May 2008 the reformed interim parliament declared Nepal a democratic federal republic. Mid-June 2008 the King of Nepal vacated the throne and parliament elected the country's first president in July 2008.
Religion: Nepal is the only official Hindu state in the world with approximately 80% of the population following that faith. The other religions followed include: Buddhist, Muslim, and Kirant.
Language: The primary language spoken is Nepali, followed by Maithali, Bhojpuri, Tharu, Tamang, Newar, Magar, Awadhi and others.

Children Available [Subject to Change].

Age: Children are available ages 10 months to 10 years.

Gender: Both boys and girls are available although only children of opposite gender to a biological child may be adopted.
Health: Children are generally healthy, but may have parasites and other treatable conditions caused due to living conditions. Children are tested at minimum -- for HIV/AIDS, TB, VDRL, Parasites and Hepatitis. Special needs children are available.

Adoptive Parents Requirements [Subject to Change]

Marriage: Single heterosexual women and married couples may apply. Couples must be married at least four years. Previous divorce is allowed. One parent must be a US Citizen.
Age: Between the ages of 30 and 55 may adopt.
Children: You may only adopt a child of the opposite gender to a biological child already in the home. The Nepalese government prefers no more than 2 children in the home including the adoptive child.
Travel: At least one parent must travel to Nepal. Travel is up to 14 days.
Time Frame: Depending on your state regulations and USCIS processing it will take 9-14 months to complete the adoption from submittal of the dossier to our agency. The timeframe will depend greatly on the age and sex of the child (ren) you are seeking to adopt.