Building back better: How to strengthen health systems after a disaster

In April and May 2015, two devastating earthquakes hit Nepal, claiming the lives of more than 9,000 people and leaving more than 21,000 people injured. Fourteen districts were severely affected, covering a population of more than 5.6m. Over 900 health facilities were damaged or destroyed and the health system was unable to cope with the subsequent health care needs of those injured. Vulnerable populations living in remote areas struggled to access the services they needed.

With a history of working in Nepal since 1997, Options’ team of experts were well positioned to respond swiftly to the emerging needs in the aftermath of the disaster. As well as addressing the immediate humanitarian needs by supporting the government to coordinate the influx of international organisations, we started looking at the longer term damage and how we could enable the country to build back its health system stronger, better and more resilient.

Guided by the Government-led principle of ‘build back better’, we worked at both national and district level to support the rebuilding of services through damage assessment and planning, as well as direct training of health care professionals to address the immediate needs of the population.

Options’ health infrastructure team worked with the Ministry of Health and the Department of Urban Development and Building Construction to support the enormous task of assessing damage, and planning and managing the rehabilitation and reconstruction of facilities across the 14 affected districts.

“The urgent need to rebuild medical centres and resume services as normal following the disaster was immediately obvious,” explains Sunil Kadka, Senior Infrastructure Planning and Procurement Advisor for our programme, the Nepal Health Sector Support Programme (NHSSP). “Not only did the earthquake claim thousands of lives at the time of the event, but the longer we went without reconstructing hospitals and clinics across the country, the more people were in danger.”

We helped to design new specifications for health facilities that are in line with international guidelines for an earthquake prone area, whilst ensuring that standards are even higher than before. We worked with the Ministry of Health to ensure that facilities are located where people need them most and designed to support provision of high quality services that people want to use. We are using online and digital monitoring of major and minor repair work to 355 health facilities across 15 districts to track progress to completion of restoration.

Back in 2004-2010, our NHSSP team helped to design and implement a flagship maternal health programme, known locally as Aama. The programme supports women in accessing antenatal care and free, institutional delivery including transport to and from a facility. It gives women the chance to take advantage of medical services across Nepal and means they can give birth safely, whatever their location, situation or caste. It also offers financial incentives for the facilities to provide quality care.

Due to the destruction of health facilities, women were suddenly forced to deliver at home. We supported the Ministry of Health to secure and implement the funding needed to help women return to using medical facilities. Since its implementation in 2005, Aama has led to significant increases in institutional deliveries, from 18% in 2006 to 55% in 2014. As of 2017, it has benefitted two million women across Nepal.

A mother from Dolakha who delivered in a facility said: “Nowadays women have more benefits than ever before…we receive incentives for transport, free delivery care, clothes for babies…there were no such provisions in my mother’s/mother in law’s time! I also received transport incentive and free care after the devastating earthquakes.”

At district level, we worked with local health workers to build their skills in emergency response.  We introduced new Comprehensive Emergency Obstetric and Neonatal Care services in Ramechhap and Dolakha, providing accessible emergency obstetric care to mothers experiencing difficulties in labour.

“We realised that many women – especially in rural, earthquake-affected Nepal – were finding it tough to afford to get to hospital if their labour wasn’t straightforward,” explains Parbati KC, NHSSP’s District Health Coordinator for Ramecchap. “So we launched a free-referral scheme here, and in Dolakha, which guarantees any women experiencing obstetric complications which cannot be managed at her local health facility, gets a full refund for her journey to the nearest referral hospital.” Our team worked with the District Health Office, facilities and transporters to design and implement free-referral ensuring women in labour have quick access to the right level and quality of care when needed.

One of the major effects of the earthquakes was the number of people who had been injured and therefore needed psychosocial support as well as rehabilitation for lifelong injuries and disabilities.

We worked with Handicap International, the Spinal Injury Rehabilitation Centre (SIRC) and Transcultural Psychosocial Organisation to provide specific earthquake-related services in the affected districts.

Following the disaster, SIRC needed to urgently increase its capacity from 51 beds to 150 beds. Increased numbers of patients required an increase in staff numbers. We provided hands-on spinal cord injury-specific training to 148 health workers, while neuro-training was given to 50 nurses, and targeted training camps were provided to 129 people with disabilities. All staff received training on disaster management.

To support the patients after leaving the centre, 400 home visits were made within the first year of recovery after the earthquake. Patients received vocational-skills training to ensure they could lead their own, independent rehabilitation.

Following on from this work, our Nepal team is now embarking on an exciting new UKAid-funded programme focused on enhancing capacity within the national health system. As Nepal transitions to a federal system, the challenge is to ensure the continuation of essential health services as a new administrative structure is put in place.  Working across five closely related workstreams (health policy and planning, procurement and public financial management, service delivery, evidence and accountability, and health infrastructure) our team will build on successes to date. Our focus for the next four years is to continue building a strong, resilient health system, able to deliver quality essential health care services with no one left behind.