The long view: Our support to Nepal’s health sector over 25 years

When I was asked to reflect on our work in Nepal, I didn’t know where to begin – I’ve been working intermittently with the team for 20 years!

It started in 2003, when I moved with my family from India to Nepal to take up the Project Director role for Options’ UK aid-funded Nepal Safer Motherhood Project (NSMP). Having spent a decade working on primary health care in Odisha State, India, I was ready for a new challenge.

I joined an experienced 35-person team of maternal health, community engagement, health infrastructure and project management experts. Part of the team was based at the Department of Health Services at Teku, whilst a group of nurse-midwives supported service expansion and quality improvement at district hospitals in Western Region and Far Western Region, Nepal.

NSMP, which operated from 1997 to 2004, was one of the first large-scale projects focussing on access to emergency obstetric care. At the time, there was a high unmet need for life saving emergency obstetric care in Nepal. The country had a high maternal mortality ratio (MMR) of 539 per 100,000 live births, 89% of births were taking place at home and it had a population-level caesarean section rate of just 1%.

Over seven years, met-need for emergency obstetric care gradually increased from 5% to 14% in 1997 in project-supported districts. In terms of skill development, an impressive 70% of the emergency obstetric procedures in the project-supported districts were managed by nurses who had additional training through NSMP. In addition, the Ministry of Health and Population (MoHP) committed to increasing availability of comprehensive emergency obstetric neonatal care (CEONC) services in hospitals and the UK government continued its support through the five-year Support to the Safe Motherhood Programme (SSMP) which began in 2005. Options continued to lead this programme, which then took a more intentional approach to build government staff capacities and instituted a minimum package of essential maternity services by linking evidence-based policy development and health system strengthening.

I think that key to success was the highly active, lively and cohesive safe motherhood community, which was driven by passionate individuals from diverse organisations that worked in partnership with the Department of Health Services. Lessons, achievements, and setbacks from different projects were jointly owned. This spirit of collaboration, further enabled by a sector-wide approach to the health sector from 2004, was crucial to Nepal’s success in significantly reducing maternal mortality over the next decades. I was lucky enough to work with and learn from some of the amazing women and men from this community who passionately turned the technical evidence into implementable plans.

In the interim, new female public health leaders have emerged and Options has actively supported their careers. Milima Singh Dangol, now Options’ Equity Based Planning Lead for the Nepal Health Sector Support Programme (NHSSP), shared the defining experiences of her early career during a recent Options event on ‘Making health systems work for everyone in Nepal’, held in Kathmandu in September 2023:

“I began my public health career with Options in 2007. I had no idea about public health and maternal health. I got to know about our health system in 2008/09 while working as one of the district supervisors for the Maternal Mortality and Morbidity Study. I still remember each case of maternal death that occurred in the district I was assigned to. During this time, I saw a delivery room for the first time in my life and let me say that my experience was not very pleasant. The condition of the delivery room, the plight of mothers during pregnancy and delivery. It still feels heavy thinking of that time. Having worked in the health system for about 16 years now my understanding has improved, and a lot of things have changed for good. From merely 20% delivery by skilled personnel when I first started working, it has now increased to almost 80%. However, we still need to work for the remaining 20% who are not only in remote villages but also in the urban communities.”

Milima’s words bring us to the current Options-led Nepal Health Sector Support Programme (NHSSP), which provides health systems support to federal, province and local levels of government. Now, more than 100 public hospitals provide emergency obstetric care and the MMR decreased by 70% from 1996 to the current 151 per 100,000 live births.  However, targeted support is needed for women who still face barriers to access emergency obstetric care, with caesarean section rates lower than optimal among some groups of women. So as part of the devolution process, Options has been supporting transitioning responsibilities for monitoring the functionality and quality of CEONC services in the earlier district hospitals, from federal to provincial level.

During our event, the Mayor and Deputy Mayor from Lumbini and Madesh provinces highlighted recruitment and retention of skilled staff as a major bottleneck to meeting their responsibilities at local level. This took me back to lessons from our earlier programmes where deploying skilled health professionals became the main limit to sustaining services – and of course is a continuing challenge in low, middle and high-income countries. Nepal is taking steps to address these critical health HR issues and has made midwifery education the long-term human resource strategy for improving skilled birth attendance. The government also approved a 10-year National Nursing and Midwifery Strategy and Action Plan in 2022 and aims to produce and deploy professional midwives across the country.

Since starting to write this blog a few weeks ago, more than 150 people have sadly lost their lives in earthquakes in western Nepal. This is a hard reminder of the importance of the government’s seismic and functional retrofitting project that we, with UK aid support, have provided technical assistance on since the 2015 earthquakes. Our health infrastructure team has worked with two flagship hospitals to enable them to withstand earthquakes and other hazards such as floods and heat, and make them safe, energy-use and waste management efficient.  The team has also assessed nearly 200 health facility designs put forward from local governments for approval and funding to the Federal MoHP to ensure that they meet multi-hazard resilient and green building standards.

All this will help ensure that investments in buildings made now benefit patient care for the next 50 years.