Challenges

Nepal’s efforts to reduce under-five mortality still faces notable challenges, despite the successes achieved so far. Some of those challenges relate to the very factors that have generated so much progress.

Key Points:

Sustainability of the FCHV program

High on the list of challenges is the future sustainability of the FCHV program. This system, fundamental to Nepal’s child survival gains, is under significant and growing stress. One reason for this is that the FCHV community is aging, even as its activities and responsibilities become more demanding.

This demographic issue is related to a trend in Nepali life, which is that women - particularly younger women - have more professional options than they used to, options that are more remunerative than the work of an FCHV. What this means for the future of the program remains an open question, and an important one.

In a study conducted by the MOH, an interviewee noted that “FCHVs have been shown to be effective providers of community-based care. However, over the years, they have been given more and more responsibility and have been asked to perform increasingly complex tasks. If this trend continues, there is a risk that we will ask too much of them. We must be careful not to overburden the FCHVs."¹

Increasingly complex neonatal health issues

Another pillar of Nepal’s past under-five mortality achievements is its emphasis on neonatal health, which also faces evolving circumstances. Prematurity and low birth weight have resulted in increased morbidity among newborns and a rising proportion of neonatal deaths.

There have been efforts to improve neonatal care, including a number of interventions within the 2008 Community-Based Newborn Care package (CB-NCP). Many of these interventions were provided by the Female Community Health Volunteers, and include identification of low birth weight by weighing, provision of kangaroo mother care and other home-based care, and recognition of asphyxia and subsequent resuscitation. However, there were limitations in implementation of some of these interventions, especially neonatal resuscitation; one key informant noted that FCHVs were hesitant to try resuscitating newborns, for fear of being blamed if the newborn died.¹⁹ As a result, this intervention was dropped from the CB-NCP.

Overall, addressing prematurity, low birth weight, and other causes of neonatal mortality will require costly and logistically complex interventions, such as the installation and expansion of neonatal intensive-care units (NICUs).

Drawbacks of local research

Nepal’s local research program has been critical to the effectiveness of several potential interventions, and has informed the specific strategies for their rollout. Yet this time-consuming process has also delayed the adoption of some potentially life-saving treatments.

The vaccination campaigns have demonstrated some of the challenges of Nepal’s emphasis on local research. While the effectiveness studies were important for capturing locally relevant information and generating popular acceptance, they also contributed to delays in the rollout of new vaccines.

Some interviewees - both from within the government and outside it - defended this tradeoff. According to a former MOH official, the delay is worthwhile because “we need our own evidence . . . and that took us some time.”

An interviewee from a partner organization concurred, saying “there is real value in things going slowly” if it leads to better implementation across complex systems. Nonetheless, such delays have made Nepal a relatively late adopter of proven vaccines, including effective vaccines for two major causes of under-five mortality: pneumonia and diarrhea.

The first example of delays was with a vaccine to address pneumococcal diseases. Starting in 2004, the South Asian Pneumococcal Alliance (SAPNA) studied pneumococcal disease prevalence, patterns of drug resistance, and serotype distributions, and confirmed the need for a vaccine to address pneumococcal disease .² Within a few years, the international policy and funding communities were beginning to rally behind a solution. Indeed, in 2006, WHO released a position paper recommending the use of PCV-7 (pneumococcal conjugate vaccine) for children in low-income and middle-income countries. Gavi kicked off its Advanced Market Commitment, which provided funding for countries to introduce PCV starting in 2010.³

However, Nepal performed its own local studies between 2005 and 2012 to assess the national need for this intervention, which delayed the national adoption of PCV. Also contributing to the delay was uncertainty about whether to deploy the PCV-10 or the PCV-13 variant of the vaccine; while the MOH initially preferred PCV-13 because it would cover more serotypes, the ministry eventually opted for PCV-10 due to limitations in cold-chain space.⁵ 

Ultimately, Nepal applied for financial support from Gavi to implement PCV in September 2012, with plans to introduce the vaccine in August 2014 - four years after Gavi opened up its funding program, and eight years after WHO issued its recommendation.⁴ As a result of these and other factors (including developing training manuals and organizing advocacy meetings), the government did not introduce PCV nationally until 2015, after 47 other Gavi-assisted countries had already done so.^{6, 7}

Another example of a delay caused at least partly by time-consuming local research was the vaccination against rotavirus - the main cause of severe diarrhea among children. As of 2000, rotavirus was the most commonly diagnosed cause of diarrhea in children in Nepal, accounting for up to 39 percent of cases, according to one study.⁸

WHO recommended the rotavirus vaccine in 2009, and the Nepali National Immunization Program added introduction of the vaccine to its 2011–2016 Comprehensive Multi-Year Plan, with the initial aim of introducing the vaccine in 2016.¹⁵

 However, the start date was pushed back to 2018, and one interviewee reported that the government has recently put it on hold again. These delays are due partly to local research studies examining the incidence of rotavirus in different age groups, seasonal patterns of disease, and the most common serotypes,^{9,10,11,12,13} all with an eye toward establishing baselines for the introduction of a rotavirus vaccine.¹⁴ The delays are also due to the time required for other preparation and planning efforts, including a complete cold chain assessment, approval for vaccine adoption being sought from the Logistic Management Division and Ministry of Finance, and development of training manuals and community education materials.²⁰  

Persistent inequities

While Nepal has made strides in addressing its long-standing social and geographic inequities, those disparities still present obstacles to the reduction of under-five mortality. Indeed, Nepal’s efforts to address under-five mortality must be seen against the backdrop of a broader campaign to improve health and other social outcomes for previously excluded populations.

Such equity considerations are especially relevant in a country where inequities of various kinds run deep, including the economic isolation of the mountainous regions, and the persistent effects of the traditional caste system.

The country has defined health care access as a fundamental right of all citizens, and has more recently announced a national policy of “reaching the unreached”¹⁶ in the development of health policy and in the delivery of services.

The 1991 National Health Policy mandated decentralization, a crucial element in addressing geographic and economic disparities.¹⁷ Subsequent national health care plans - and a new national constitution, finalized in 2015 - underscored the official commitment to broadened access.

For all the progress that has taken place, inequities of various kinds still hinder health care access for many in Nepal – especially women, the poor, and the geographically isolated.

In addition, a substantial rise in out-of-pocket health expenses raises the prospect of continued or even worsening health disparities between Nepal’s lowest-income residents and the rest of the country. Nepal’s more affluent citizens - especially in Kathmandu - are increasingly turning to private providers, raising the possibility of a multi-tiered national health system in which offerings and outcomes vary substantially by income level.

Nepal’s plan to graduate to lower-middle-income-country status by 2022 couldresult in the betterment of conditions for citizens across the income spectrum, but it will also lead to a reduction in international donors’ contributions to the country’s health budget - an outcome that is likely to land hardest on those programs that serve the poorest members of society.

Inequities are likely to be further compounded by increasingly erratic forces of nature. The government of Nepal has recognized that health problems caused by climate change, food insecurity, and natural disasters are on the rise and must be recognized in future health strategies.¹⁸