Understanding health system resilience in responding to COVID-19 pandemic: experiences and lessons from an evolving context of federalization in Nepal.

INTRODUCTION: The COVID-19 pandemic has tested the resilience capacities of health systems worldwide and highlighted the need to understand the concept, pathways, and elements of resilience in different country contexts. In this study, we assessed the health system response to COVID-19 in Nepal and examined the processes of policy formulation, communication, and implementation at the three tiers of government, including the dynamic interactions between tiers. Nepal was experiencing the early stages of federalization reform when COVID-19 pandemic hit the country, and clarity in roles and capacity to implement functions were the prevailing challenges, especially among the subnational governments. METHODS: We adopted a cross-sectional exploratory design, using mixed methods. We conducted a desk-based review of all policy documents introduced in response to COVID-19 from January to December 2020, and collected qualitative data through 22 key informant interviews at three tiers of government, during January-March 2021. Two municipalities were purposively selected for data collection in Lumbini province. Our analysis is based on a resilience framework that has been developed by our research project, ReBUILD for Resilience, which helps to understand pathways to health system resilience through absorption, adaptation and transformation. RESULTS: In the newly established federal structure, the existing emergency response structure and plans were utilized, which were yet to be tested in the decentralized system. The federal government effectively led the policy formulation process, but with minimal engagement of sub-national governments. Local governments could not demonstrate resilience capacities due to the novelty of the federal system and their consequent lack of experience, confusion on roles, insufficient management capacity and governance structures at local level, which was further aggravated by the limited availability of human, technical and financial resources. CONCLUSIONS: The study findings emphasize the importance of strong and flexible governance structures and strengthened capacity of subnational governments to effectively manage pandemics. The study elaborates on the key areas and pathways that contribute to the resilience capacities of health systems from the experience of Nepal. We draw out lessons that can be applied to other fragile and shock-prone settings.

Improving health workforce governance: the role of multi-stakeholder coordination mechanisms and human resources for health units in ministries of health.

BACKGROUND: A cohesive and strategic governance approach is needed to improve the health workforce (HW). To achieve this, the WHO Global Strategy on Human Resources for Health (HRH) promotes mechanisms to coordinate HRH stakeholders, HRH structures and capacity within the health sector to support the development and implementation of a comprehensive HW agenda and regular reporting through WHO's National Health Workforce Accounts (NHWA). METHODS: Using an adapted HRH governance framework for guidance and analysis, we explored the existence and operation of HRH coordination mechanisms and HRH structures in Malawi, Nepal, Sudan and additionally from a global perspective through 28 key informant interviews and a review of 165 documents. RESULTS: A unified approach is needed for the coordination of stakeholders who support the timely development and oversight of an appropriate costed HRH strategy subsequently implemented and monitored by an HRH unit. Multiple HRH stakeholder coordination mechanisms co-exist, but the broader, embedded mechanisms seemed more likely to support and sustain a comprehensive intersectoral HW agenda. Including all stakeholders is challenging and the private sector and civil society were noted for their absence. The credibility of coordination mechanisms increases participation. Factors contributing to credibility included: high-level leadership, organisational support and the generation and availability of timely HRH data and clear ownership by the ministry of health. HRH units were identified in two study countries and were reported to exist in many countries, but were not necessarily functional. There is a lack of specialist knowledge needed for the planning and management of the HW amongst staff in HRH units or equivalent structures, coupled with high turnover in many countries. Donor support has helped with provision of technical expertise and HRH data systems, though the benefits may not be sustained. CONCLUSION: While is it important to monitor the existence of HRH coordination mechanisms and HRH structure through the NHWA, improved 'health workforce literacy' for both stakeholders and operational HRH staff and a deeper understanding of the operation of these functions is needed to strengthen their contribution to HW governance and ultimately, wider health goals.

Scaling up tobacco cessation within TB programmes: findings from a multi-country, mixed-methods implementation study.

BACKGROUND: Brief behavioural support can effectively help tuberculosis (TB) patients quit smoking and improve their outcomes. In collaboration with TB programmes in Bangladesh, Nepal and Pakistan, we evaluated the implementation and scale-up of cessation support using four strategies: (1) brief tobacco cessation intervention, (2) integration of tobacco cessation within routine training, (3) inclusion of tobacco indicators in routine records and (4) embedding research within TB programmes. METHODS: We used mixed methods of observation, interviews, questionnaires and routine data. We aimed to understand the extent and facilitators of vertical scale-up (institutionalization) within 59 health facility learning sites in Pakistan, 18 in Nepal and 15 in Bangladesh, and horizontal scale-up (increased coverage beyond learning sites). We observed training and surveyed all 169 TB health workers who were trained, in order to measure changes in their confidence in delivering cessation support. Routine TB data from the learning sites were analysed to assess intervention delivery and use of TB forms revised to report smoking status and cessation support provided. A purposive sample of TB health workers, managers and policy-makers were interviewed (Bangladesh n = 12; Nepal n = 13; Pakistan n = 19). Costs of scale-up were estimated using activity-based cost analysis. RESULTS: Routine data indicated that health workers in learning sites asked all TB patients about tobacco use and offered them cessation support. Qualitative data showed use of intervention materials, often with adaptation and partial implementation in busy clinics. Short (1-2 hours) training integrated within existing programmes increased mean confidence in delivering cessation support by 17% (95% CI: 14-20%). A focus on health system changes (reporting, training, supervision) facilitated vertical scale-up. Dissemination of materials beyond learning sites and changes to national reporting forms and training indicated a degree of horizontal scale-up. Embedding research within TB health systems was crucial for horizontal scale-up and required the dynamic use of tactics including alliance-building, engagement in the wider policy process, use of insider researchers and a deep understanding of health system actors and processes. CONCLUSIONS: System-level changes within TB programmes may facilitate routine delivery of cessation support to TB patients. These strategies are inexpensive, and with concerted efforts from TB programmes and donors, tobacco cessation can be institutionalized at scale.

Using qualitative evaluation components to help understand context: case study of a family planning intervention with female community health volunteers (FCHVs) in Nepal.

BACKGROUND: Evaluations of health interventions are increasingly concerned with measuring or accounting for 'context'. How to do this is still subject to debate and testing, and is particularly important in the case of family planning where outcomes will inevitably be influenced by contextual factors as well as any intervention effects. We conducted an evaluation of an intervention where female community health volunteers (FCHVs) in Nepal were trained to provide better interpersonal communication on family planning. We included a context-orientated qualitative component to the evaluation. Here, we discuss the evaluation findings, specifically focusing on what was added by attending to the context. We explore and illustrate important dimensions of context that may also be relevant in future evaluation work. METHODS: The evaluation used a mixed methods approach, with a qualitative component which included in-depth interviews with women of reproductive age, FCHVs, and family planning service providers. We conducted iterative, thematic analysis. RESULTS: The life-history fertility and contraception narratives generated from the in-depth interviews contextualised the intervention, yielding nuanced data on contraceptive choices, needs, and areas for future action. For instance, it highlighted how women generally knew about effective contraceptive methods and were willing to use them: information was not a major barrier. Barriers instead included reports of providers refusing service when women were not in the fifth day of their menstrual cycle when this was unnecessary. Privacy and secrecy were important to some women, and risked being undermined by information sharing between FCHVs and health services. The qualitative component also revealed unanticipated positive effects of our own evaluation strategies: using referral slips seemed to make it easier for women to access contraception. CONCLUSIONS: Life history narratives collected via in-depth interviews helped us understand pathways from intervention to effect from the user point of view without narrowly focusing only on the intervention, highlighting possible areas for action that would otherwise have been missed. By attending to context in a nuanced way in evaluations, we can build a body of evidence that not only informs future interventions within that context, but also builds better knowledge of contextual factors likely to be important elsewhere.

Road map to scaling-up: translating operations research study's results into actions for expanding medical abortion services in rural health facilities in Nepal.

BACKGROUND: Identifying unsafe abortion among the major causes of maternal deaths and respecting the rights to health of women, in 2002, the Nepali parliament liberalized abortion up to 12 weeks of pregnancy on request. However, enhancing women's awareness on and access to safe and legal abortion services, particularly in rural areas, remains a challenge in Nepal despite a decade of the initiation of safe abortion services. METHODS: Between January 2011 and December 2012, an operations research study was carried out using quasi-experimental design to determine the effectiveness of engaging female community health volunteers, auxiliary nurse midwives, and nurses to provide medical abortion services from outreach health facilities to increase the accessibility and acceptability of women to medical abortion. This paper describes key components of the operations research study, key research findings, and follow-up actions that contributed to create a conducive environment and evidence in scaling up medical abortion services in rural areas of Nepal. RESULTS: It was found that careful planning and implementation, continuous advocacy, and engagement of key stakeholders, including key government officials, from the planning stage of study is not only crucial for successful completion of the project but also instrumental for translating research results into action and policy change. While challenges remained at different levels, medical abortion services delivered by nurses and auxiliary nurse midwives working at rural outreach health facilities without oversight of physicians was perceived to be accessible, effective, and of good quality by the service providers and the women who received medical abortion services from these rural health facilities. CONCLUSIONS: This research provided further evidence and a road-map for expanding medical abortion services to rural areas by mid-level service providers in minimum clinical settings without the oversight of physicians, thus reducing complications and deaths due to unsafe abortion.

Unmet need for family planning and associated factors among currently married women in Nepal: A further analysis of Nepal Demographic and Health Survey-2022.

INTRODUCTION: Family planning (FP) is crucial for improving maternal and newborn health outcomes, promoting gender equality, and reducing poverty. Unmet FP needs persist globally, especially in South Asia and Sub-Saharan Africa leading to unintended pregnancies, unsafe abortions, and maternal fatalities. This study aims to identify the determinants of unmet needs for FP from a nationally representative survey. METHODS: We analyzed the data of 11,180 currently married women from nationally representative Nepal Health Demographic Survey 2022. We conducted weighted analysis in R statistical software to account complex survey design and non-response rate. We conducted univariate and multivariable binary and multinomial logistic regression to assess association of unmet need for FP with independent variables including place of residence, province, ecological belt, ethnicity, religion, current age, participant's and husband's education, occupation, wealth quintile, parity, desire for child, and media exposure. RESULTS: The total unmet FP need was 20.8% (95%CI: 19.7, 21.9) accounting 13.4% (95%CI: 12.5, 14.4) for unmet need for limiting and 7.4% (95%CI: 6.8, 8.0) for unmet for spacing. Lower odds of total unmet need for FP were present in 20-34 years and 35-49 years compared to <20 years, women belonging to Madhesi ethnic group (AOR: 0.78; 95%CI: 0.64, 0.95) compared to Brahmin/Chhetri, women from richest (AOR: 0.69; 95%CI: 0.56, 0.84), richer (AOR: 0.82; 95%CI: 0.68, 0.97) and middle wealth quintile (AOR: 0.82; 95%CI:0.70, 0.98) groups compared poorest wealth quintile group and women belonging to rural area (AOR: 0.89; 95%CI: 0.80, 0.99) compared to urban area. Higher odds of unmet need for FP were present among women with basic (AOR: 1.34; 95%CI: 1.17, 1.54), and secondary level (AOR: 1.32; 95%CI: 1.12, 1.56) education compared to women without education, among women from Madhesh (AOR: 1.56; 95%CI: 1.22, 1.98), Gandaki (AOR: 2.11; 95%CI: 1.66, 2.68), Lumbini (AOR: 1.97; 95%CI: 1.61, 2.42) and Sudurpashchim province (AOR: 1.64; 95%CI: 1.27, 2.10) compared to Koshi province and among women whose husband education was basic level (AOR:1.37; 95%CI: 1.15, 1.63), or secondary level (AOR: 1.32; 95%CI: 1.09, 1.60) education. CONCLUSION: Nepal faces relatively high unmet FP needs across various socio-demographic strata. Addressing these needs requires targeted interventions focusing on age, ethnicity, religion, education, and socio-economic factors to ensure universal access to FP services.

Service availability and readiness for basic emergency obstetric and newborn care: Analysis from Nepal Health Facility Survey 2021.

BACKGROUND: Although there has been a significant focus on improving maternal and newborn health and expanding services in Nepal, the expected positive impact on the health of mothers and newborns has not been achieved to the desired extent. Nepal not only needs to focus on improving access to and coverage of services but also the quality to achieve Sustainable Development Goals (SDG) by 2030. In this context, we aimed to analyze Basic Emergency Obstetric and Neonatal Care (BEmONC) service availability and readiness in Health Facilities (HFs) of Nepal. METHODS: We analyzed data from nationally representative Nepal Health Facility Survey (NHFS), 2021. BEmONC service availability and readiness in HFs was measured based on the "Service Availability and Readiness" manual of World Health Organization (WHO). We measured service availability by seven BEmONC signal functions. The readiness score was calculated for three domains- guidelines and staff training, essential equipment/supplies, and essential medicines on a scale of 100, and the average score for the three domains was the overall readiness score. We performed weighted descriptive and inferential analysis to account complex survey design of NHFS 2021. We summarized continuous variables with descriptive statistics like mean, standard deviation, median and interquartile range whereas categorical variables with percent and 95% confidence interval (CI). We applied simple, and multivariate linear regression to determine factors associated with the readiness of HFs for BEmONC services, and results were presented as beta (ß) coefficients and 95% CI. RESULTS: Of total 804 HFs offering normal vaginal delivery services, 3.1%, 89.2%, 7.7% were federal/provincial hospitals, local HFs, and private hospitals respectively. A total of 45.0% (95% CI: 34.9, 55.6) federal/provincial hospitals, 0.3% (95% CI: 0.2, 0.6), local HFs (district hospital, primary health care centers, health posts, urban health centers) and 10.5% (95% CI: 6.6, 16.4) private hospitals, had all seven BEmONC signal functions. The overall readiness of federal/provincial hospitals, local HFs, and private hospitals were 72.9±13.6, 54.2±12.8, 53.1±15.1 respectively. In multivariate linear regression, local HFs (ß = -12.64, 95% CI: -18.31, -6.96) and private hospitals had lower readiness score (ß = -18.08, 95% CI: -24.08, -12.08) compared to federal/provincial level hospitals. HFs in rural settings (ß = 2.60, 95% CI: 0.62, 4.58), mountain belts (ß = 4.18, 95% CI: 1.65, 6.71), and HFs with external supervision (ß = 2.99, 95% CI:1.08, 4.89), and quality assurance activities (ß = 3.59, 95% CI:1.64, 5.54) had better readiness scores. CONCLUSION: The availability of all seven BEmONC signal functions and readiness of HFs for BEmONC services are relatively low in local HFs and private hospitals. Accelerating capacity development through training centers at the federal/provincial level, onsite coaching, and mentoring, improving procurement and supply of medicines through federal/provincial logistic management centers, and regular supportive supervision could improve the BEmONC service availability and readiness in facilities across the country.

Readiness of health facilities to provide services related to non-communicable diseases in Nepal: evidence from nationally representative Nepal Health Facility Survey 2021.

OBJECTIVE: To assess the readiness of public and private health facilities (HFs) in delivering services related to non-communicable diseases (NCDs) in Nepal. METHODS: We analysed data from nationally representative Nepal Health Facility Survey 2021 to determine the readiness of HFs for cardiovascular diseases (CVDs), diabetes mellitus (DM), chronic respiratory diseases (CRDs) and mental health (MH)-related services using Service Availability and Readiness Assessment Manual of the WHO. Readiness score was measured as the average availability of tracer items in per cent, and HFs were considered 'ready' for NCDs management if they scored ≥70 (out of 100). We performed weighted univariate and multivariable logistic regression to determine the association of HFs readiness with province, type of HFs, ecological region, quality assurance activities, external supervision, client's opinion review and frequency of meetings in HFs. RESULTS: The overall mean readiness score of HFs offering CRDs, CVDs, DM and MH-related services was 32.6, 38.0, 38.4 and 24.0, respectively. Guidelines and staff training domain had the lowest readiness score, whereas essential equipment and supplies domain had the highest readiness score for each of the NCD-related services. A total of 2.3%, 3.8%, 3.6% and 3.3% HFs were ready to deliver CRDs, CVDs, DM and MH-related services, respectively. HFs managed by local level were less likely to be ready to provide all NCD-related services compared with federal/provincial hospitals. HFs with external supervision were more likely to be ready to provide CRDs and DM-related services and HFs reviewing client's opinions were more likely to be ready to provide CRDs, CVDs and DM-related services. CONCLUSION: Readiness of the HFs managed by local level to provide CVDs, DM, CRDs and MH-related services was relatively poor compared with federal/provincial hospitals. Prioritisation of policies to reduce the gaps in readiness and capacity strengthening of the local HFs is essential for improving their overall readiness to provide NCD-related services.

Health systems resilience in fragile and shock-prone settings through the prism of gender equity and justice: implications for research, policy and practice.

Fragile and shock-prone settings (FASP) present a critical development challenge, eroding efforts to build healthy, sustainable and equitable societies. Power relations and inequities experienced by people because of social markers, e.g., gender, age, education, ethnicity, and race, intersect leading to poverty and associated health challenges. Concurrent to the growing body of literature exploring the impact of these intersecting axes of inequity in FASP settings, there is a need to identify actions promoting gender, equity, and justice (GEJ). Gender norms that emphasise toxic masculinity, patriarchy, societal control over women and lack of justice are unfortunately common throughout the world and are exacerbated in FASP settings. It is critical that health policies in FASP settings consider GEJ and include strategies that promote progressive changes in power relationships. ReBUILD for Resilience (ReBUILD) focuses on health systems resilience in FASP settings and is underpinned by a conceptual framework that is grounded in a broader view of health systems as complex adaptive systems. The framework identifies links between different capacities and enables identification of feedback loops which can drive or inhibit the emergence and implementation of resilient approaches. We applied the framework to four different country case studies (Lebanon, Myanmar, Nepal and Sierra Leone) to illustrate how it can be inclusive of GEJ concerns, to inform future research and support context responsive recommendations to build equitable and inclusive health systems in FASP settings.

Is evidence-informed urban health planning a myth or reality? Lessons from a qualitative assessment in three Asian cities.

City governments are well-positioned to effectively address urban health challenges in the context of rapid urbanization in Asia. They require good quality and timely evidence to inform their planning decisions. In this article, we report our analyses of degree of data-informed urban health planning from three Asian cities: Dhaka, Hanoi and Pokhara. Our theoretical framework stems from conceptualizations of evidence-informed policymaking, health planning and policy analysis, and includes: (1) key actors, (2) approaches to developing and implementing urban health plans, (3) characteristics of the data itself. We collected qualitative data between August 2017 and October 2018 using: in-depth interviews with key actors, document review and observations of planning events. Framework approach guided the data analysis. Health is one of competing priorities with multiple plans being produced within each city, using combinations of top-down, bottom-up and fragmented planning approaches. Mostly data from government information systems are used, which were perceived as good quality though often omits the urban poor and migrants. Key common influences on data use include constrained resources and limitations of current planning approaches, alongside data duplication and limited co-ordination within Dhaka's pluralistic system, limited opportunities for data use in Hanoi and inadequate and incomplete data in Pokhara. City governments have the potential to act as a hub for multi-sectoral planning. Our results highlight the tensions this brings, with health receiving less attention than other sector priorities. A key emerging issue is that data on the most marginalized urban poor and migrants are largely unavailable. Feasible improvements to evidence-informed urban health planning include increasing availability and quality of data particularly on the urban poor, aligning different planning processes, introducing clearer mechanisms for data use, working within the current systemic opportunities and enhancing participation of local communities in urban health planning.