Nepal’s remarkable progress to improve the health of its people has been uneven—caste, ethnicity, gender, education, location, and economic status all affect an individual’s access to health care.
For example, marginalized and disadvantaged women, such as Dalits, are less likely to attend pre- and post-natal checkups and use family planning services. Similarly, although increasing numbers of women are delivering at health facilities in Nepal, disparities persist between castes and ethnicities. Infant and child mortality is also an issue: children from the poorest households are at the greatest risk of dying before age five.
Stronger Systems and Healthier Lives through the Health for Life Project
To strengthen Nepal’s health systems and increase access to health services for marginalized and disadvantaged people, in 2013 the U.S. Agency for International Development (USAID) launched a five-year project known as Health for Life.
RTI implemented Health for Life, adopting an equity-based approach to help strengthen the government’s capacity to plan, manage, and deliver high-quality and equitable family planning, maternal, newborn, and child health services (FP/MNCH). Our activities directly addressed key health system constraints in local health systems governance, data for decision making and evidence-based policy development, human resources management, quality improvement systems, and knowledge and behavior change.
We coordinated with the Government of Nepal’s Ministry of Health (MOH) to support the testing and roll-out of national-level policies, guidelines, and programs. Our project team worked in 28 districts—including 10 districts that were heavily impacted by devastating earthquakes in early 2015—to strengthen district and village health systems and help identify and implement best practices.
In addition to the MOH, we partnered with a range of key local stakeholders, including
- Ministry of Federal Affairs and Local Development (MoFALD)
- District (public) health offices
- Village Development Committees, Health Facility Operations and Management Committees, and other local health committees
- USAID and other external development partners and implementers
- Academic and research institutions
- Training centers
- Media outlets
- Civil society organizations.
Strengthening Health Governance
One of Health for Life’s hallmark achievements was its support for the development of a Collaborative Framework for Local Health Governance between the MOH and the Ministry of Federal Affairs and Local Development.
In 2013 Nepal’s ongoing government decentralization process was not providing the resources needed to improve health service quality at the local level. The framework helped to overcome this challenge by clarifying the increased responsibility and decision-making power of local authorities regarding health.
The framework outlines the roles and responsibilities of village-level health committees—called Health Facility Operations and Management Committees (HFOMCs). These committees are intended to represent all community members and are mandated to work with local governments to identify health service gaps, oversee health planning, and mobilize funds and resources.
To support the revitalization of these committees in Health for Life districts, we went beyond training and provided frequent follow-up visits and supportive supervision. About 96 percent of village health committees in the 141 high-priority areas the project supports met key functionality criteria — most were nonfunctional at the start of Health for Life support.
As a result, village health committees prepared annual health plans, filled vacant health worker positions, and many have expanded health services or upgraded service quality. Further, almost all of the 620 communities across the project’s 14 core districts mobilized additional local resources for their health facilities. In 141 of the most disadvantaged communities in targeted districts, village health committees raised about US$288,000 to fund local health plans for fiscal year 2016.
Improving Service Quality at Health Facilities
In pilot districts, our team helped the government scale up a facility-based quality improvement system to ensure that health facilities achieve standards for FP/MNCH services.
We conducted quality assurance assessments in health facilities so that key stakeholders, including HFOMCs, health facility quality teams, and District Quality Assurance Working Committees, could address them. This empowered the HFOMCs to maintain a budget to improve compliance at health facilities and to monitor the availability of health workers. This approach was fully integrated into the local annual planning and budgeting process.
We also supported health facility staff to monitor quality and provision of health services, particularly those related to FP/MNCH.
Another exciting innovation in service delivery was introducing a mobile tracking system to remind pregnant women to visit a health facility for check-ups, delivery, and family planning counselling. Unlike many other mhealth initiatives, our approach supplements local health workers’ efforts rather than replacing them. As a result, from mid 2015 to November 2016,
- 8,675 pregnant women—an estimated 75% of all pregnant women in 39 targeted sites—registered
- 78% of all registered pregnant women, including Dalits, delivered at health facilities
- 65% of all pregnant women, and 60% of pregnant Dalit women, attended all four recommended check-ups before their delivery.
Improving the Health-Seeking Behaviors of Adolescents, Youth, and Pregnant Women
In addition to improving service quality, Health for Life supported a variety of innovative methods to increase demand for quality health services. To improve the health-seeking behavior of adolescents and youth, the project’s Radio Bahas initiative, together with district health offices, sponsored public health messaging on 28 local radio stations and led more than 300 public hearings in Village Development Committees to improve access to and use of maternal, newborn, and child health/family planning services.
With technical assistance from our team, the government launched a new mhealth program to reach adolescents and youth with messages about sexual and reproductive health. Users are prompted to contact a hotline operated by health workers who can answer their questions. To date, nearly 200,000 adolescents and youth sent about 2.7 million text messages and received 4.9 million responses from the program.
Rebuilding Systems and Services in the Aftermath of Natural Disaster
Health for Life is also helping communities and local governments recover and rebuild health systems and services in 10 of the 14 districts most heavily affected by Nepal’s devastating 2015 earthquakes.
Collaborating closely with partners, we helped the MOH coordinate technical assistance and reconstruction to support the government in its effort to “build back better.” We supported community efforts to directly address key health system constraints and improve local health governance, using many of the tactics proven successful in Health for Life core districts—including revitalizing village-level health committees and forming quality improvement teams to conduct self-assessments of health facility services.
In earthquake-affected areas and beyond, Health for Life strengthened health systems in Nepal, improving access to quality health services for Nepal’s most vulnerable and disadvantaged communities.