Impact of investment case on equitable access to maternal and child health services in Nepal: a quasi-experimental study.

BACKGROUND: Disparities in the use of maternal, neonatal and child health (MNCH) services remain a concern in Low- and Middle-Income countries such as Nepal. Commonly observed disparities exist in education, income, ethnic groups, administrative regions and province-level in Nepal. In order to improve equitable outcomes for MNCH and to scale-up quality services, an Investment Case (IC) approach was lunched in the Asia Pacific region. The study assessed the impact of the IC intervention package in maternal and child health outcomes in Nepal. METHODS: The study used a quasi-experimental design extracting data from the Nepal Demographic Health Surveys - 2011 (pre-assessment) and 2016 (post-assessment) for 16 intervention and 24 control districts. A Difference in Difference (DiD) analysis was conducted to assess the impact of the intervention on maternal and child health outcomes. The linear regression method was used to calculate the DiD, adjusting for potential covariates. The final models were arrived by stepwise backward method including the confounding variables significant at p < 0.05. RESULTS: The results of the DiD analyses showed at least four antenatal care visits (ANC) decreased in the intervention area (DiD% = - 4.8), while the delivery conducted by skilled birth attendants increased (DiD% = 6.6) compared to control area. However, the adjusted regression coefficient showed that these differences were not significant, indicating a null effect of the intervention. Regarding the child health outcomes, children with underweight (DiD% = 6.3), and wasting (DiD% = 5.4) increased, and stunting (DiD% = - 6.3) decreased in the intervention area compared to control area. The adjusted regression coefficient showed that the difference was significant only for wasting (ß = 0.019, p = 0.002), indicating the prevalence of wasting increased in the intervention group compared to the control group. CONCLUSION: The IC approach implemented in Nepal did not show improvements in maternal and child health outcomes compared to control districts. The use of the IC approach to improve MCH in Nepal should be discussed and, if further used, the process of implementation should be strictly monitored and evaluated.

Investment case approach for equitable access to maternal neonatal and child health services: Stakeholders' perspective in Nepal.

BACKGROUND: Investment Case is a participatory approach that has been used over the years for better strategic actions and planning in the health sector. Based on this approach, a District Investment Case (DIC) program was launched to improve maternal, neonatal and child health services in partnership with government, non-government sectors and UNICEF Nepal. In the meantime, this study aimed to explore perceptions and experiences of local stakeholders regarding health planning and budgeting and explore the role of the DIC program in ensuring equity in access to maternal and child health services. METHODS: This study adopted an exploratory phenomenography design with a purposive sampling technique for data collection. Three DIC implemented districts and three comparison districts were selected and total 30 key informant interviews with district level stakeholders and six focus groups with community stakeholders were carried out. A deductive approach was used to explore the perception of local stakeholders of health planning and budgeting of the health care expenses on the local level. RESULTS: Investment Case approach helped stakeholders in planning systematically based on evidence through collaborative and participatory approach while in comparison areas previous year plan was mainly primarily considered as reference. Resource constraints and geographical difficulty were key barriers in executing the desired plan in both intervention and comparison districts. Positive changes were observed in coverage of maternal and child health services in both groups. A few participants reported no difference due to the DIC program. The participants specified the improvement in access to information, access and utilization of health services by women. This has influenced the positive health care seeking behavior. CONCLUSIONS: The decentralized planning and management approach at the district level helps to ensure equity in access to maternal, newborn and child health care. However, quality evidence, inclusiveness, functional feedback and support system and local resource utilization should be the key consideration.

Status of Maternal and Child Health Seeking Behavior among Women Aged 15-45 Years during Earthquake of 2015 in Nepal: A Mixed Method Study.

BACKGROUND: Delivery of the maternal and child health services are generally affected during the time of disaster. This study aims to assess the maternal and child health service utilization in areas in Nepal affected by the 2015 earthquake. METHODS: A mixed method study was carried in 29 Village Development Committees from nine earthquake-affected districts in Nepal. Quantitative data on maternal, neonatal and child health indicators before and after the earthquake were collected from the Health Management Information System. Focus group discussions and key informant interviews with different stakeholders were conducted to collect qualitative data. Quantitative data was analyzed using Microsoft Excel 2013. Qualitative data was analyzed manually using thematic analysis technique. RESULTS: Most of the indicators were comparable before and after the earthquake. Indicators such as Bacille Calmette-Guerin vs. Measles-Rubella vaccine drop-out rate, 1st antenatal care visit, delivery by skilled birth attendant and 1st postnatal care visit within 24 hours of delivery improved after the earthquake. Though most of the health facilities were damaged, health services resumed under tents or in open spaces. Some of the common problems among pregnant women included stomachache, headache, malnutrition, diarrhea, and mental stress. CONCLUSIONS: There was not much effect in the delivery of maternal neonatal and child health services. This reflects the coordinated efforts from government as well as non-government organizations and civil societies during and after the earthquake in Nepal.