Lessons from the field: progress towards the sustainable development goals in Nepal in federal transition of the state

Kc, Ashish; Bhandari, Amit

doi:10.1136/archdischild-2019-318505

Cited by 3 publications

(2 citation statements)

References 3 publications

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“…Similarly, our findings imply that local governments have a limited level of understanding of health, although they have primary responsibility for local service delivery. As a result, there is a need for capacity building at the lower levels of government: a recent study, which aligns with our findings, indicated that local governments require additional support from the federal government to plan, budget, manage and monitor health programmes [ 50 ].…”

Section: Discussionsupporting

confidence: 76%

Overcoming the challenges facing Nepal’s health system during federalisation: an analysis of health system building blocks

Wasti,

van Teijlingen,

Rushton

et al. 2023

Health Res Policy Sys

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Introduction Nepal’s move to a federal system was a major constitutional and political change, with significant devolution of power and resources from the central government to seven newly created provinces and 753 local governments. Nepal’s health system is in the process of adapting to federalism, which is a challenging, yet potentially rewarding, task. This research is a part of broader study that aims to explore the opportunities and challenges facing Nepal’s health system as it adapts to federalisation. Methods This exploratory qualitative study was conducted across the three tiers of government (federal, provincial, and local) in Nepal. We employed two methods: key informant interviews and participatory policy analysis workshops, to offer an in-depth understanding of stakeholders’ practical learnings, experiences, and opinions. Participants included policymakers, health service providers, local elected members, and other local stakeholders. All interviews were audio-recorded, transcribed, translated into English, and analysed thematically using the six WHO (World Health Organization) health system building blocks as a theoretical framework. Results Participants noted both opportunities and challenges around each building block. Identified opportunities were: (a) tailored local health policies and plans, (b) improved health governance at the municipality level, (c) improved health infrastructure and service capacity, (d) improved outreach services, (e) increased resources (health budgets, staffing, and supplies), and (f) improved real-time data reporting from health facilities. At the same time, several challenges were identified including: (a) poor coordination between the tiers of government, (b) delayed release of funds, (c) maldistribution of staff, (d) problems over procurement, and (e) limited monitoring and supervision of the quality of service delivery and data reporting. Conclusion Our findings suggest that since federalisation, Nepal’s health system performance is improving, although much remains to be accomplished. For Nepal to succeed in its federalisation process, understanding the challenges and opportunities is vital to improving each level of the health system in terms of (a) leadership and governance, (b) service delivery, (c) health financing, (d) health workforce, (e) access to essential medicines and technologies and (f) health information system.

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Section: Discussionsupporting

confidence: 76%

Overcoming the challenges facing Nepal’s health system during federalisation: an analysis of health system building blocks

Wasti,

van Teijlingen,

Rushton

et al. 2023

Health Res Policy Sys

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“…More recent UN data show that all six countries have continued to decrease U5M, and between 2015 and 2020 have done so with a greater percentage change than global averages [67,68]. While these trends suggest ongoing progress, research focusing on country progress towards achieving Sustainable Development Goal U5M targets has reflected on the unequal progress on U5M subnationally in countries, suggesting that more work will be necessary to maintain this progress for all populations [69][70][71][72].…”

Section: Discussionmentioning

confidence: 99%

Cross-country analysis of contextual factors and implementation strategies in under-5 mortality reduction in six low- and middle-income countries 2000–2015

Binagwaho,

VanderZanden,

Garcia

et al. 2024

BMC Pediatr

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Background The Exemplars in Under-5 Mortality (U5M) was a multiple cases study of how six low- and middle-income countries (LMICs), Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal, implemented health system-delivered evidence-based interventions (EBIs) to reduce U5M between 2000 and 2015 more effectively than others in their regions or with similar economic growth. Using implementation research, we conducted a cross-country analysis to compare decision-making pathways for how these countries chose, implemented, and adapted strategies for health system-delivered EBIs that mitigated or leveraged contextual factors to improve implementation outcomes in reducing amenable U5M. Methods The cross-country analysis was based on the hybrid mixed methods implementation research framework used to inform the country case studies. The framework included a common pathway of Exploration, Preparation, Implementation, Adaptation, and Sustainment (EPIAS). From the existing case studies, we extracted contextual factors which were barriers, facilitators, or determinants of strategic decisions; strategies to implement EBIs; and implementation outcomes including acceptability and coverage. We identified common factors and strategies shared by countries, and individual approaches used by countries reflecting differences in contextual factors and goals. Results We found the six countries implemented many of the same EBIs, often using similar strategies with adaptations to local context and disease burden. Common implementation strategies included use of data by decision-makers to identify problems and prioritize EBIs, determine implementation strategies and their adaptation, and measure outcomes; leveraging existing primary healthcare systems; and community and stakeholder engagement. We also found common facilitators included culture of donor and partner coordination and culture and capacity of data use, while common barriers included geography and culture and beliefs. We found evidence for achieving implementation outcomes in many countries and EBIs including acceptability, coverage, equity, and sustainability. Discussion We found all six countries used a common pathway to implementation with a number of strategies common across EBIs and countries which contributed to progress, either despite contextual barriers or by leveraging facilitators. The transferable knowledge from this cross-country study can be used by other countries to more effectively implement EBIs known to reduce amenable U5M and contribute to strengthening health system delivery now and in the future.

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Implementing quality improvement intervention to improve intrapartum fetal heart rate monitoring during COVID-19 pandemic- observational study

et al. 2022

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Introduction Adherence to intrapartum fetal heart rate monitoring (FHRM) for early decision making in high-risk pregnancies remains a global health challenge. COVID-19 has led to disruption of routine intrapartum care in all income settings. This study aims to evaluate the implementation of quality improvement (QI) intervention to improve intrapartum FHRM and birth outcome before and during pandemic. Method and materials We conducted an observational study among 10,715 pregnant women in a hospital of Nepal, over 25 months. The hospital implemented QI intervention i.e facilitated plan-do-study-act (PDSA) meetings before and during pandemic. We assessed the change in intrapartum FHRM, timely action in high-risk deliveries and fetal outcomes before and during pandemic. Results The number of facilitated PDSA meetings increased from an average of one PDSA meeting every 2 months before pandemic to an average of one PDSA meeting per month during the pandemic. Monitoring and documentation of intrapartum FHRM at an interval of less than 30 minutes increased from 47% during pre-pandemic to 73.3% during the pandemic (p<0.0001). The median time interval from admission to abnormal heart rate detection decreased from 160 minutes to 70 minutes during the pandemic (p = 0.020). The median time interval from abnormal FHR detection to the time of delivery increased from 122 minutes to 177 minutes during the pandemic (p = 0.019). There was a rise in abnormal FHR detection during the time of admission (1.8% vs 4.7%; p<0.001) and NICU admissions (2.9% vs 6.5%; p<0.0001) during the pandemic. Conclusion Despite implementation of QI intervention during the pandemic, the constrains in human resource to manage high risk women has led to poorer neonatal outcome. Increasing human resources to manage high risk women will be key to timely action among high-risk women and prevent stillbirth.

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Lessons from the field: progress towards the sustainable development goals in Nepal in federal transition of the state

Cited by 3 publications

References 3 publications

Overcoming the challenges facing Nepal’s health system during federalisation: an analysis of health system building blocks

Overcoming the challenges facing Nepal’s health system during federalisation: an analysis of health system building blocks

Cross-country analysis of contextual factors and implementation strategies in under-5 mortality reduction in six low- and middle-income countries 2000–2015

Implementing quality improvement intervention to improve intrapartum fetal heart rate monitoring during COVID-19 pandemic- observational study

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