How did Nepal implement?

Nepal’s success in reducing under-five mortality rate is a story with many interwoven elements. The national government pursued evidence-based interventions across all major causes of childhood deaths—often implementing several interventions and policies concurrently. 

Yet during the period of foremost interest for this report—the years 2000 to 2015—four themes have consistently appeared throughout Nepal’s campaign to reduce under-five mortality:

• An embrace of community-based approaches, sustaining and building upon a strong FCHV program
• The strengthening of the health facilities network 
• A consistent emphasis on neonatal health
• The use of data and local research

The remainder of this section of the report will discuss each of these themes in greater detail. The contextual factors that were critical to success, including women’s empowerment as a key driver of improvements in child and maternal health, are discussed in the section on Context.

Community-based care and the role of female community health volunteers

Given the difficulties of travel within Nepal and the inaccessibility of facility-based health care for large portions of the population, the country has long relied on community health workers to address its most pressing health challenges.

The primary community health worker cohort working to address under-five mortality is the Female Community Health Volunteer (FCHV) program, established in 1988. These volunteers give rural, isolated communities access to preventive health care, as well as basic treatment regimens and nutrition services.

Their numbers and scope of practice have expanded over time. In 1991 there were 20,000 FCHVs. By 2017 there were 52,000. When the program started, its main function was to promote family planning and distribute contraceptives. While this portfolio has broadened over the years, it has remained centered on reproductive, neonatal, and child health.¹ 

FCHVs have played a crucial role in several under-five mortality prevention and treatment interventions, including breastfeeding education; the provision of zinc and oral rehydration salts for treatment of diarrhea; the diagnosis, treatment, and referral of serious pneumonia cases; and counseling on birth preparedness.

Another important expansion of the FCHV role in the effort to reduce under-five mortality was centered on the Community Based Newborn Care Package (CB-NCP). This initiative, launched in 2007 in response to continued elevated levels of neonatal mortality, expanded the FCHVs’ role in providing immediate and essential care to newborns, including infants with dangerous conditions such as low birth weight and hypothermia.

The significance of these volunteers to Nepal’s efforts to reduce under-five mortality is almost universally recognized.^2,3 As one interviewee from the Ministry of Health (MOH) put it, “FCHVs were behind every major change and achievement in the health sector, and I consider them to be one of the main reasons behind the under-five mortality drop.”

Several interviewees singled out the FCHVs’ work in health education programs. As one official from a partner organization said, “FCHVs played a major role in creating awareness and promoting community participation.”

One of the most important vehicles for creating that awareness is the Mothers’ Group for Health. These are organized groups of village women who meet monthly to address local health issues. In a country as rural, poor, and geographically diffuse as Nepal, these ongoing interactions between FCHVs and local women are an important part of the national health infrastructure. FCHVs convene the monthly meetings, set the agendas, and share information that women can then share with their families and neighbors.

While FCHVs run the meetings, the Mothers’ Groups hold the FCHVs accountable. They select the FCHVs by internal consensus (candidates must be local married moms between 25 and 45 years of age; literacy is a plus),⁴ and evaluate their performance annually.

Yet it is not the Mothers’ Groups that officially supervise the FCHVs. That authority belongs to the auxiliary nurse midwives and auxiliary health workers of the local health facilities. These auxiliaries meet regularly with FCHVs in their catchment areas to discuss community health needs and the individual performance of FCHVs.

FCHVs do not receive a salary, though they do get free essential health care and some job-related items such as flashlights and bicycles. They also receive a retirement stipend worth about US$200 when they reach the age of 60. To boost financial incentives, in 2008 the MOH approved a special fund providing FCHVs access to microcredit accounts from which they can borrow for income-generating activities.⁵

Obviously, then, the primary motive for this difficult work is not financial. According to a 2014 survey, the most important motivating factor for FCHVs was the opportunity to help their communities.The role has also provided a level of public respect and recognition that might otherwise have been unattainable for rural women, many of whom are poor and illiterate. In the survey, 90 percent of FCHVs cited recognition as a “very important” factor in their work .⁶ 

Strengthened Health Systems

Even as it emphasized community-based approaches, Nepal made efforts to strengthen its health systems. This included bolstering its infrastructure and facility capacity, and also strengthening its leadership and governance in the health sector, ranging from the MoH to the community level.

Bolstering infrastructure, facility capacity, and number of health workers

Prior to 1997, Nepal did not have the health facilities and staff capacity to meet some fundamental under-five mortality challenges. Several districts lacked hospitals, basic procedures like cesarean sections were unavailable across much of the country, and many basic lifesaving services were not available.

Nepal began a pilot program in 1997 to assess facility-based Integrated Management of Childhood Illness (IMCI) in the Mahottari District. To broaden access further, a combined facility- and community-based IMCI program was then piloted in three more districts in 1999 and 2000. 

During the period of study for this Exemplar narrative (2000–2015), Nepal embarked on a substantial buildout of medical infrastructure, complemented by work to strengthen the capacity of existing facilities, expand outreach services, and improve the national road system—all of which gave more Nepalis access to health services. Indeed, the government increased the number of facilities from 975 in 2010 to 4,000 in 2015, and increased the number of birthing centers from 422 in 2007 to 1,121 in 2011.²

Strengthening Leadership and Governance in the Health Sector

After the Nepal government's 1990 political transformation resulted in the Ministry of Health becoming more prominent, the MoH gained support for policies fostering maternal health, including the Safe Motherhood Policy in 1998 and the National Safe Motherhood and Newborn Health Long-term Plan (2002–2017). This was accomplished by MoH officials who were able to influence higher-level leaders .¹⁶ In addition, the MoH prioritized strategic policy-making and implementation, through improved reporting and focusing more on local needs .¹⁶  

At the level where national policies were adapted to sub-national and district contexts, Nepal also focused on intersectoral partnerships and task shifting, through decentralizing policy development and service delivery. To mitigate some of the challenges of allocating resources to decentralized structures, the country developed intersectoral partnerships and lobbied these other ministries to help fund maternal health programs.¹⁶ From a health worker perspective, Nepal task-shifted some of their auxiliary nurse midwives (ANMs) to provide care in regions with shortages of health facility workers and community health workers. These ANMs helped provide immunization, family planning, ANC, and obstetric interventions .¹⁶

Lastly, at the local level, Nepal bolstered access to care through increasing the number of health workers and using a community-based model for care delivery. The country greatly improved health facility staffing; between 2004 and 2013, the number of doctors and nurses per 1,000 people increased from 0.7 to 2.4, more than doubling the size of the health workforce and meeting the WHO's original recommended threshold of 2.3 doctors, nurses, and midwives per 1,000 people. (Note: this recommendation was updated in 2016 to 4.45 doctors, nurses, and midwives per 1,000 people, as the minimum health workforce required to deliver essential maternal and child health services).^7,8,9,10 In addition, Nepal improved the efficiency of referral systems between communities and health facilities, and also incorporated delivery drugs into national essential drug lists. Lastly, the female community health volunteers played a critical role in expanding coverage, especially to hard-to-reach regions with shortages of health facility workers.¹⁶   

Consistent emphasis on neonatal health

Nepal has been a true exemplar in reducing under-five mortality. While some of the interventions needed to reduce neonatal mortality are relatively simple, others are more complex, making it a difficult area of under-five mortality to address. Even other Exemplars in reducing under-five mortality have encountered difficulties in achieving similar reductions in neonatal mortality rates. 

Nepal's efforts to reduce neonatal mortality drew from both the development of strong community health networks and the steady improvement of medical facilities. These factors were in many respects complementary, with FCHVs and other community volunteers augmenting the work of local health facilities, and the facilities providing a crucial treatment-and-referral resource for the community providers. Indeed, the interplay of these two factors demonstrated the value of community-based care in the crucial field of neonatal health.

In 1997, the country established a National Safe Motherhood Program to address some of the causes of neonatal deaths. Soon after the turn of the new century, however, two reports—the 2001 Demographic and Health Survey (DHS) and the 2002 State of the World for Newborns in Nepal—convinced the MOH that the country needed to address neonatal mortality more directly and with new urgency.^11,12

According to the 2001 DHS, the risk of mortality among neonates (39 deaths per 1,000 live births) was one-and-a-half times higher than for children in the post-neonatal phase (26 per 1,000 live births).¹³  

The reports also showed striking inequalities, with neonatal mortality rates of approximately 65 deaths per 1,000 live births in the far west and mountain regions, and particularly high rates among Nepal’s rural and most impoverished communities. Despite an increase in the number of health facilities, the 2001 DHS showed that only 9 percent of mothers in Nepal delivered at a health facility. Even in cities, fewer than half (45 percent) of all births occurred at a hospital or clinic. In rural areas, the figure was a mere 7 percent.

In 2002, the MOH formed the Newborn Working Group, which included experts in maternal and child health, neonatologists, public health leaders, and researchers.¹⁴ With the technical assistance from donors and experts, this working group developed the 2004 National Neonatal Health Strategy, which expresses a strong and wide-ranging commitment to improving outcomes for newborns.

Guided by this National Neonatal Health Strategy, Nepal has undertaken several evidence-based interventions, as well as health infrastructure improvements aimed at addressing care before, during, and after delivery.

Interventions and improvements have included measures devoted to increasing the availability of skilled birth attendants and convenient birthing facilities, as well as strengthening the capacity of birth centers to address leading causes of neonatal death (such as birth asphyxia and neonatal sepsis), and expanding the scope of FCHVs’ duties to include a focus on neonatal mortality reduction.

(For more information on Nepal's efforts to increase access to convenient birthing facilities and skilled birth attendants, see the "Facility-based delivery: Maternity Incentive Scheme and Safe Delivery Incentive" section of What did Nepal do".)

Use of data and local research

In setting priorities and planning interventions, Nepal drew upon data sources such as the Health Management Information System (HMIS) and the Demographic and Health Survey (DHS). These were especially helpful in monitoring causes of under-five mortality, such as measles and malaria. In addition, Nepal emphasized local research to study effectiveness and feasibility of an intervention before rolling it out.

Health Management Information System

Nepal’s HMIS program was created in 1993 to establish coordinated and centralized feedback across all health programs. Every month, FCHVs and other care providers reported to health facilities, who passed the information to district health offices, who then entered their reports into HMIS to be sent to the central government.

This cascading flow of program monitoring data across the public health system has proved to be very useful to the reduction of under-five mortality. One former senior MOH official mentioned how it had helped in a local neonatal care situation:

“We identified [a] gap from the HMIS system, then found the reason and came across the most prevalent diseases that we have, the major causes of death in the mother and the child, especially neonates and under-five,” the official said. “Once you analyze the data you know the area to focus on, and then we have strategic development meetings where all the experts are there—for example, all the international NGOs and the stakeholders, they all come together and decide where we should intervene.”

Some officials and partner organizations expressed concerns about the reliability and utility of HMIS figures—including the timeliness of reporting, the accuracy of data, and the feasibility of comprehensive reporting from such a wide range of providers. In addition, publication of the HMIS annual report takes almost nine months, diminishing the usefulness of some findings. Despite these drawbacks, the HMIS was still a crucial source of centralized data that informed Nepal's decision-making on interventions.

Demographic and Health Survey

The first DHS in Nepal was performed in 1996 and like many countries, has occurred every five years since. It captures nationally representative household-level data, including information on families who may not have access to or choose not to use the health system. This data is used as an indicator of general progress, and as a means of identifying current gaps and future priorities.

The DHS has been instrumental in the establishment and assessment of under-five mortality policy. For example, the 1996 DHS showed that only 43 percent of children had been fully vaccinated. This data prompted the MOH to focus on increasing vaccination rates across the country and reaching communities that prior campaigns had missed.

Overall, both the HMIS and DHS provided the MoH with data to inform priorities and monitor progress. According to one official, the MOH is constantly “improving our programs learning from the evidence.” Another interviewee noted that “our first priority is based on [diseases with] high mortality rates like Japanese encephalitis and measles... so we choose on the basis of mortality that contributes to under-5, infant, and neonatal mortality, and our second priority is cases with high morbidity like whooping cough.”

Local Research

Interviewees from multiple sectors pointed to a unique feature in Nepal’s efforts to reduce under-five mortality—a strong emphasis on local (originating within Nepal) research prior to the adoption of an intervention. The objective of such granulated research is to identify factors that could advance or hinder progress in specific areas of the country.

This research, carried out by local researchers but often supplemented by partner organizations, has given Nepal a way to assess the potential suitability of global under-five mortality interventions across the country’s diverse communities.

Interviewees and published assessments¹⁵ have outlined the general steps that Nepal takes in carrying out and implementing this local research: 

With approval and monitoring from the Nepal Health Research Council (NHRC), the MOH and other researchers (both from Nepali institutions and outside partners) organize small-scale pilot studies to test effectiveness and explore feasibility. The NHRC then assesses the local research to determine next steps.

This process of completing and analyzing local research results typically lasts two to three years. Only then will the MOH prepare for a nationwide rollout of interventions. Although Nepal’s commitment to conducting local research before following the recommendations of international bodies delayed action on some important health care advances (see the Challenges section), these exhaustive inquiries nonetheless serve some important purposes.

Local research has evaluated and informed several evidence-based interventions, including vitamin A supplementation, IMCI, vaccines, adoption of chlorhexidine as a cord care treatment, and the community-based neonatal care package (CBNCP). This has helped national officials gain robust support for changes to health care protocols in a deeply traditional country where many rural medical providers harbor skepticism about global organizations and the applicability of their recommendations to Nepal’s unique circumstances.