Maternal and child health in nepal: scaling up priority health care services * A. Morgan,

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1 Maternal and child health in nepal: scaling up priority health care services * A. Morgan, Y. Prasai, E. Jimenez-Soto, Z. Dettrick, S. Firth, A. Byrne Aims: * The research that forms the basis of this report was funded by AusAID and the Bill and Melinda Gates Foundation. Opinions expressed in this document, however, are those of the authors and do not necessarily reflect those of AusAID, the Government of Australia, or the Bill and Melinda Gates Foundation. From the Nossal Institute for Global Health, University of Melbourne, Australia. From New ERA, Kathmandu, Nepal. From the School of Population Health, The University of Queensland, Australia. In each of several developing countries in the Asia-Pacific region, an Investment Case (IC) for Maternal and Child Health aims to provide information that would help government departments to devise plans and budgets for improving maternal, neonatal and child health (MNCH). In preparing these Investment Cases, we have used local evidence: to assess the degree of equity or inequity in maternal and child healtacross each study country to identify barriers that interfere with mothers or children receiving key health interventions to measure the impact on health and the costs that would be expected if alternative packages of strategies to increase the use or uptake of these interventions were adopted. In Nepal, the IC was piloted in a cluster of disadvantaged districts in each of the three distinct geographical (or ecological) zones, that is, the terai, hill, and mountain zones. For each cluster, three core scenarios (or packages of strategies) were costed and measured for their expected impact on maternal, neonatal and child health outcomes. Findings: We discovered that: 1. coverage of quality health care is low for almost all MNCH interventions. For health care services delivered at the community level and through outreach programs, a range of constraints limit the supply of services, yet those services that are available are significantly underutilised. Addressing the demand-side factors can realise an increase in MNCH coverage more effectively than focusing on supply-side factors alone; 2. clinical services were more constrained by supply-side factors, for example, many health worker posts were unfilled, sanctioned posts were not increasing in line with population growth, and infrastructure was often inadequate for the services provided or required;

2 3. there was a lack of support for, and supervision of, peripheral health care workers from supervisory staff, who were overburdened with Health Management Information System (HMIS) recording and reporting; 4. Specific strategies that addressed the local context have the potential to achieve a similar impact at less cost when compared with national strategies. Recommendations: In the light of these and related findings we recommend the following courses of action: 1. Plan the supply of health services based on current population figures, to ensure that every woman has access to essential obstetric services 2. Invest in community based initiatives to increase community demand for services 3. Ensure an enabling environment for health workers that includes continuing professional development, incentives for remote postings, addresses housing and security concerns and provides timely provision of medical supplies and equipment 4. Support policymakers and health planners to strengthen data quality, particularly in the difficult areas of cause of death and of vital registration systems. 5. Support district level planning to enable more context specific responses to better achieve national health targets Outcomes: 1 Government of Nepal, Ministry of Health and Population, Nepal Health Sector Programme Implementation Plan 2 (Kathmandu, 2010). Bearing in mind that the health services sector of Nepal is centrally planned and financed, and that the country is diverse, with key differences in health services, population density, and barriers to access and utilisation between its 75 districts, 3 geographic (or ecological) zones and 5 development regions, it is possible that national gains in MNCH health indicators may be masking sub-national inequalities. With input from staff of non-government organisations and various levels of the government at interactive workshops, the IC has been able to explore these differences and consider the impact and costs of various locally-relevant strategies as well as the national government s strategic health plans, in particular, the Nepal Health Sector Programme Implementation Plan 2 (NHSP-IP2).1 Mortality rates and ratios The maternal mortality rate (MMR) is the number of mothers who die per 100,000 live births during a given year. The neonatal mortality rate (NMR) is the number of children up to 28 days old who die per 1,000 live births during a given year. The under-five mortality rate (U5MR) is the number of children under 5 years of age who die per 1,000 live births during a given year. 2 Maternal and child health in Nepal: scaling up priority health care services

3 Recent progress in maternal, neonatal and child health Nepal has made impressive gains in maternal and child health since It is likely to achieve Millennium Development Goal (MDG) 4, which is that the under-five mortality rate (U5MR) would fall to approximately 54 deaths per 1,000 live births per year by However, the country may not achieve MDG 5, which is that the maternal mortality ratio (MMR) would fall to an estimated 134 deaths per 100,000 live births per year by Inequity in under-five mortality between sectors of Nepal s population based on wealth, setting (rural/urban) and geographic zone has declined. However inequity in health outcomes on a caste/ethnicity basis persists and inequality within the urban population in terms of access to, and utilisation of, health services, is increasing. 2 K. Nguyen, A. Morgan, E. Jimenez-Soto, and C. Morgan, Nepal: Developing an Investment Case for financing equitable progress towards MDGs 4 and 5 in the Asia-Pacific region: equity report (Brisbane: The University of Queensland, 2011). Unfortunately, the neonatal mortality rate (NMR) has not improved in line with the other mortality indicators, and, by 2015, it will make up 70% of the U5MR.2 Moreover, inequities in NMR and in MMR and IMR persist on the basis of wealth, caste/ethnicity, and region. The IC process To assist local health planners in prioritising strategies to reduce the MNCH mortality burden, we conducted a detailed analysis of the delivery of health care services by the local health system. We collated the best available and locally relevant information on factors which endanger health, on the effectiveness and uptake of health interventions, and on the causes of death. We conducted problem-solving workshops with local health officials and health care professionals. This led to consensus on the key barriers to scaling up MNCH services and on the priority list of strategies that would help overcome these barriers. We also estimated the expected impact on mortality and marginal costs of implementing these strategies. The main barriers to the uptake of MNCH interventions We discovered that there are several constraints on the uptake of MNCH interventions across all of the three study sites in Nepal. In our analysis of the available data, we focused on, among other things, the questions in the following box. Maternal and child health in Nepal: scaling up priority health care services 3

4 Identifying barriers to receiving health care In order to understand what are the barriers (or bottlenecks or constraints) that reduce the degree to which mothers or their children receive appropriate health care services, the ICs studied six different attributes of critical health services: Are health care personnel available? Are other important elements of services, such as medicines, available? Are people within reach of where a health service is offered? Are people using the health service? Do people return to use the health service? Is the health service of good quality? Across all three study sites, we discovered that: 1. coverage of quality health care is low for almost all MNCH interventions. For health care services delivered at the community level and through outreach programs, a range of constraints limit the supply of services, yet those services that are available are significantly underutilised. Addressing the demand-side factors can realise an increase in MNCH coverage more effectively than focusing on supply-side factors alone; 2. clinical services were constrained by supply-side factors, for example, many health worker posts were unfilled, sanctioned posts were not increasing in line with population growth, and infrastructure was often inadequate for the services provided or required; 3. there was a lack of support for, and supervision of, peripheral health care workers from supervisory staff, who were overburdened with Health Management Information System (HMIS) recording and reporting; 4. Specific strategies that addressed the local context have the potential to achieve a similar impact at less cost when compared with national strategies. In addition to these overarching constraints, the IC identified specific constraints in health service supply, demand and quality that differed between the study sites, as summarised below. In the terai (densely populated low-altitude plains bordering India [to the south] that have a warm climate), physical access to health facilities is often reasonably straightforward, but socioeconomic and cultural factors inhibit utilisation. The number of sanctioned government health posts has not changed since 1990 even though the population has increased by well over 50% in that period, leaving health workers without adequate time to provide quality care. Fortunately, some local village development committees recruit and fund additional staff at health posts and sub-health posts to address the shortfall in central government planning. 4 Maternal and child health in Nepal: scaling up priority health care services

5 3 Government of Nepal, Ministry of Health and Population, New ERA, Macro International Inc., Nepal Demographic and Health Survey 2011: preliminary report (2011). 4 Government of Nepal, Ministry of Health and Population, New ERA, Macro International Inc., Nepal Demographic and Health Survey 2011: preliminary report (2011). 5 Government of Nepal, Ministry of Health and Population, New ERA, Macro International Inc., Nepal Demographic and Health Survey 2006 (2007). The people of the terai face several key health issues: below national average coverage of full childhood immunisation; a high prevalence of malnutrition, with wasting in children; and maternal and childhood iron-deficiency anaemia, regardless of food availability; high numbers of low birth weight babies; and high levels of HIV risk behaviours.3 Nevertheless, in the terai, skilled birth attendance, facility-based deliveries,4 and contraceptive use are higher than the respective national averages.5 The terai-specific barriers to improving MNCH are listed in Table 1. Table 1: Barriers to improving MNCH: the terai lack of support and supervision of female community health volunteers, causing poor competency in integrated management of childhood illness and newborn care poor community understanding of hygiene practices use of private providers to manage childhood pneumonia due to poor service quality in the public sector cultural beliefs and unsound practices that adversely affect postnatal care mothers work obligations, restricting care for children poor complementary feeding practices due to lack of knowledge among carers and adverse influences from the surrounding culture insufficient staff trained to assist with family planning and antenatal care cultural taboos in regard to family planning lack of promotion of antenatal care by female community health volunteers low community demand for skilled birth attendance due to lack of awareness about it, dissatisfaction with its quality when it is taken up, and exclusion based on caste The cluster of districts selected from the hill ecological zone was situated in the remote Mid Western and Far Western Regions of Nepal areas most affected by recent conflict and characterised by difficult terrain and significant distances from major population centres. The hill cluster faced major challenges in maintaining facilities and staff, and in communicating with and providing services to distant remote villages; other barriers to improving MNCH are listed in Table 2. The hill zone frequently features as the middle performer compared to the terai and mountain zones for maternal and child health indicators. Maternal and child health in Nepal: scaling up priority health care services 5

6 Table 2: Barriers to improving MNCH: the HILL ZONE long distances to health care facilities food insecurity long distances to clean water supplies, limiting hygiene practices high use of private medicine providers work demands on mothers interfering with child feeding outreach services lacking integration negative health worker attitudes mismatch in health care facilities between the availability of family planning trained staff and the availability of contraceptive supplies inappropriate opening hours of facilities mobility of significant sectors of the population overlooked antenatal care not well understood or prioritised by communities 6 Government of Nepal, Ministry of Health and Population, New ERA, Macro International Inc., Nepal Demographic and Health Survey 2011: preliminary report (2011). The constraints (or barriers) identified in the mountain cluster were similar to those for the hill populations (see Table 3), but the mountain cluster has the most difficult terrain to traverse and correspondingly the most difficult access to services. Reaching referral centres requires expensive flights that are not readily available or else many days travel overland. The people of the mountains have the highest prevalence of stunted children and of childhood diarrhoea and pneumonia; and they use health care facilities to give birth, and take up skilled birth attendance the least.6 Table 3: Barriers to improving MNCH: the mountain ZONE long distances to facilities compounded by security concerns and cultural practices relating to travelling for both staff and clients food insecurity lack of a clean water supply no comprehensive obstetric care facilities prior to 2010 transport subsidies for maternal care are insufficient: they do not make up for distance and terrain barriers limited community awareness of health programs mismatch in health care facilities between the availability of family planning trained staff and the availability of contraceptive supplies inappropriate opening hours of facilities antenatal care not well understood or prioritised by communities 6 Maternal and child health in Nepal: scaling up priority health care services

7 Strategies for overcoming barriers to receiving care: comparisons among three scenarios After we identified the barriers to, or constraints on, the uptake of health care services that applied to the various study site clusters, we modelled three core scenarios for overcoming such barriers. Each scenario consisted of a variety of interventions or strategies: Scenario 1 comprised the strategies proposed at the regional workshops. Scenario 2 incorporated scenario 1 and another three MNCH interventions currently not implemented in Nepal. Scenario 3 consisted of the NHSP-IP2, but with particular modifications (see Table 4). Table 4: The common strategies in the core scenarios Scenario 1 1. increase health staff numbers and training, focusing on quality, supervision and logistics 2. provide private spaces in clinics 3. conduct community education in hygiene and sanitation measures, pneumonia, and antenatal care 4. provide for increased supervision and training of female community health volunteers 5. carry out active case finding for immunisations 6. make the minimum duration for each staff posting one year 7. focus more on implementing current plans 8. provide for the equipment register to be maintained by the district health office 9. provide district management support for the local recruitment of staff, supervision, and logistics 10. ensure coordination between the government and donors, particularly in relation to equipment supplies Scenario2: scenario 1 strategies plus: 1. carry out pneumococcal vaccinations 2. provide calcium supplementation in pregnancy 3. provide steroids for pre-term labour Scenario 3: NHSP-IP2, with modifications concerning: 1. provision of a newborn care package through female community health volunteers 2. provision of staffing based on population size 3. upgrading of selected health posts to primary health care centres 4. revitalisation of mothers groups; community mobilisation Maternal and child health in Nepal: scaling up priority health care services 7

8 In addition there were specific strategies that were relevant for each of the distinct geographic zones (see Tables 5 7). Table 5: Terai-specific strategies 1. revitalise mothers groups with female community health volunteers 2. implement a mass media based water and sanitation campaign 3. increase the number of staff trained to provide family planning assistance, and replace retired immunisation staff 4. use discretionary funds to replace equipment 5. upgrade selected health posts to primary health care centres Table 6: Hill region specific strategies 1. discuss cultural practices in the educational sessions that prepare women for giving birth 2. increase the frequency of visits carried out by health care worker supervisors, and reward supervisory work that motivates staff, identifies their weaknesses and improves their skills 3. strengthen men s groups, women s groups and savings groups 4. scale up kitchen garden activities 5. provide financial support to poor people to compensate them for the loss of income they incur when they seek health care 6. increase the number of outreach clinics targeting poor and vulnerable households 7. replace retired female community health volunteers and MNCH workers 8. provide additional auxiliary nurse midwives: two per health care facility Table 7: Mountain region specific strategies 1. educate the community about optimal complementary feeding practices 2. implement a national water and sanitation radio campaign 3. establish more kitchen gardens and promote them through health post management committees 4. provide training and supportive supervision for village health workers and maternal and child health workers 5. increase the number of outreach clinics targeting poor and vulnerable households 6. increase the number of workers trained to provide family planning assistance and antenatal care 7. improve the management of supplies of vaccines, antibiotics and family planning requisites 8. strengthen men s groups, women s groups and savings groups 9. provide financial support to poor people to compensate them for the loss of income they incur when they seek health care 10. provide additional auxiliary nurse midwives: two per health care facility 8 Maternal and child health in Nepal: scaling up priority health care services

9 Results of IC modelling The IC modelling shows the expected impact on key MNCH indicators and progress towards the achievement of MDGs 4 and 5, as well as the anticipated marginal capital and recurring costs for each scenario. Terai. The expected impact and costs of implementing the various strategies devised for the terai are laid out in the following table and bar chart: Scenario Impact: mortality rate reductions (%) Cost MMR NMR U5MR per capita (USD) Scenario Scenario Scenario Scenario 3 (the NHSP-IP2) would exert the greatest impact on maternal, Scenario neonatal and child deaths. This approach however would bear a relatively Scenario high cost of US$11.8 per capita, which would be due to the strategy of population-based Scenario 3 (the staffing. NHSP-IP2) The would number exert of primary the greatest health impact care on centres maternal, neonatal deaths. would This need approach to be increased however by would 76 in bear order a relatively to service high the large cost of population US$11.8 per capita, w due of to the the terai. strategy Scenarios of population-based 1 and 2 increase staffing. primary The health number care of centres primary by health 25 care cent to to be increase increased services by 76 in as order well, to but service at more the manageable large population costs. of the terai. Scenarios 1 and primary health care centres by 25 to increase services as well, but at more manageable co Impact (marginal effect) of strategies terai Reduction in maternal deaths* Reduction in MMR Reduction in NMR Reduction in U5MR 34.9% 37.1% 45.5% 22.7% 25.3% 31.3% 39.2% 41.9% 45.6% 17.7% 19.8% 20.3% Scenario 1: workshop strategies Scenario 2: workshop strategies + new interventions Scenario 3: NHSP-IP2 * This relates to women aged 15 to 49 years Maternal and child health in Nepal: scaling up priority health care services 9 Hill region. The expected impact and costs of implementing the various strategies devised region are laid out in the following table and bar chart:

10 Hill region. The expected impact and costs of implementing the various strategies devised for the hill region are laid out in the following table and bar chart: Scenario Impact: mortality rate reductions (%) Cost MMR NMR U5MR per capita (USD) Scenario Scenario Scenario Scenario 3 (the NHSP-IP2) would provide the greatest progress towards MDGs 4 and 5, a result of NHSP-IP2 s scale-up of obstetric care and the target of 40% facility-based deliveries, even though this target is very ambitious. This strategy would be the most expensive to implement; however, it is only US$1.2 per capita more than scenario 2. Scenario 1 would be only slightly less effective in reducing neonatal and child mortality but it would be substantially more affordable. Impact (marginal effect) of strategies hill Region Reduction in maternal deaths* Reduction in MMR Reduction in NMR Reduction in U5MR 37.6% 47.0% 49.0% 34.1% 37.4% 39.7% 57.2% 59.0% 61.6% 33.4% 35.3% 35.5% Scenario 1: workshop strategies Scenario 2: workshop strategies + new interventions Scenario 3: NHSP-IP2 * This relates to women aged 15 to 49 years 10 Maternal and child health in Nepal: scaling up priority health care services Mountain region. The expected impact and costs of implementing the various strategies devis mountain region are laid out in the following table and bar chart: Scenario Impact: mortality rate reductions (%) Costs MMR NMR U5MR per capita (US Scenario Scenario Scenario Scenario 3 (the NHSP-IP2) would avert the greatest number of deaths; however, this w due again to the high coverage outlined in the NHSP results framework, which may not be real mountain districts. The addition of waiting homes to workshop strategies (to form scenario 1a reduce both maternal and neonatal mortality rates at relatively little additional expense; howe not known how acceptable such homes would be. Providing helicopter removals for women w obstetric emergencies (in scenario 3a ) would reduce both maternal and neonatal mortality bu

11 The impact of the NHSP-IP2 scenario (scenario 3) in each region would often be Mountain region. The expected impact and costs of implementing the various strategies devised for the mountain region are laid out in the following table and bar chart: Scenario Impact: mortality rate reductions (%) Cost MMR NMR U5MR per capita (USD) Scenario Scenario Scenario Scenario 3 (the NHSP-IP2) would avert the greatest number of deaths; however, this would be due again to the high coverage outlined in the NHSP results framework, which may not be realistic in mountain districts. The addition of waiting homes to workshop strategies (to form scenario 1a ) would reduce both maternal and neonatal mortality rates at relatively little additional expense; however, it is not known how acceptable such homes would be. Providing helicopter removals for women with obstetric emergencies (in scenario 3a ) would reduce both maternal and neonatal mortality but at an extra cost of US$1.2 million per year. Air retrievals however are often impossible due to poor flying conditions. The provision of emergency obstetric care to people in mountain districts remains a challenge. Impact (marginal effect) of strategies mountain Region Reduction in maternal deaths* Reduction in MMR Reduction in NMR Reduction in U5MR 35.9% 39.8% 54.5% 25.5% 30.1% 40.3% 40.1% 47.7% 57.5% 23.6% 28.7% 31.2% Scenario 1: workshop strategies Scenario 2: workshop strategies + new interventions Scenario 3: NHSP-IP2 * This relates to women aged 15 to 49 years A comparison of the highest achieving scenarios in the three regions shows that the gre improvements in neonatal and under-five health would be achievable in the hill region, greatest improvements in maternal health would be achievable in the mountain region. maternal and child health in the terai sufficiently to meet MDGs 4 and 5, however, wou implementing scenario 3 since maternal and child health in this region lags behind that regions significantly. Yet implementing this scenario in this zone would incur high costs Maternal and child health in Nepal: scaling up priority health care services 11 substantial increases in staffing that would be needed to service the zone s large popula

12 A comparison of the highest achieving scenarios in the three regions shows that the greatest improvements in neonatal and under-five health would be achievable in the hill region, while the greatest improvements in maternal health would be achievable in the mountain region. Improving maternal and child health in the terai sufficiently to meet MDGs 4 and 5, however, would necessitate implementing scenario 3 since maternal and child health in this region lags behind that in the other regions significantly. Yet implementing this scenario in this zone would incur high costs due to the substantial increases in staffing that would be needed to service the zone s large population. The impact of the NHSP-IP2 scenario (scenario 3) in each region would often be the highest as it represents more ambitious coverage targets targets that had been set for national achievement rather than for severely disadvantaged districts to achieve. A comparison of the costs for the scenarios in each of the zones is presented in the following bar chart. Cost comparisons across study sites $11.8 $8.2 $8.2 US $ per capita $3.5 $4.5 $2.8 $4.9 $6.1 $5.8 Terai Hills Mountains Scenario 1 Scenario 2 Scenario 3 Recommendations: a synopsis 1. Employ a disaggregated analysis of health care services on the basis of quality of care; and use the fresh insights gained from such analysis to address context-specific constraints. 2. Use data of better quality than has been available in the past for such a data that reflects more specific categorisation of the causes of death, r categorise causes of death as other. 3. Supplement existing government plans that set potentially unachievab increased uptake of maternal, neonatal, and child health care interven disadvantaged districts with district-specific strategies devised using th analysis and scenario modelling. 4. In planning the provision of health care, either on a district or a broade approach to consider the evidence on maternal and child health and to for its improvement where it will have the greatest impact for those in Outcomes 12 Maternal and child health in Nepal: scaling up priority health care services Bearing in mind that the health services sector of Nepal is centrally planned and fin country is diverse, with key differences in health services, population density, and b utilisation between its 75 districts, 3 geographic (or ecological) zones and 5 develop possible that national gains in MNCH health indicators may be masking sub-nationa

13 Recommendations: a synopsis 1. Employ a disaggregated analysis of health care services on the basis of supply, demand and quality of care; and use the fresh insights gained from such analysis to develop plans that address contextspecific constraints. 2. Use data of better quality than has been available in the past for such analyses, for example, data that reflects more specific categorisation of the causes of death, reducing the need to categorise causes of death as other. 3. Supplement existing government plans that set potentially unachievable targets for the increased uptake of maternal, neonatal, and child health care interventions in particularly disadvantaged districts with district-specific strategies devised using the IC approach to data analysis and scenario modelling. 4. In planning the provision of health care, either on a district or a broader basis, use the IC approach to consider the evidence on maternal and child health and to allocate resources for its improvement where it will have the greatest impact for those in greatest need. Outcomes With input from staff of non-government organisations and various levels of the government at interactive workshops, the IC has been able to explore these differences and consider the impact and costs of various locally-relevant strategies as well as the national government s strategic health plans, in particular, the Nepal Health Sector Programme Implementation Plan 2 (NHSP-IP2). Further reading For full reports of IC activities and country findings, please send requests to: Alison Morgan, <apmorgan@unimelb.edu.au>. Supported by

14 Maternal and child health in Nepal: scaling up priority health care services