What did Nepal do?

Interventions delivered through community-based care

A number of Nepal's interventions to reduce under-five mortality were delivered through community-based care systems. One of the key pillars of community-based care was the Female Community Health Volunteers (FCHVs), who were the primary community health worker cohort. The FCHVs provided reproductive, neonatal, and child health interventions, including prevention, treatment, and nutrition regimens. In addition, they expanded access to care to rural and hard-to-reach communities. (For more detail on the FCHVs, see the How did Nepal Implement section.)  

The vitamin A campaign

When the FCHVs were started in 1988, their primary focus was family planning. As the scope of their work grew, one of the first expansions of FCHVs’ responsibilities beyond family planning was involvement in a national campaign to address vitamin A deficiency.

Inadequate levels of vitamin A are associated with heightened risk of mortality from common diseases such as measles, respiratory ailments, and diarrheal illnesses. Multiple studies worldwide have demonstrated that high-dosage vitamin A supplementation twice a year significantly reduces mortality in children between 6 and 59 months of age.¹

One partner organization interviewee said that in the late 1980s, around the time the FCHV program was being developed, Nepal had a clear need for a supplementation campaign: “It was prioritized because vitamin A deficiency was a big public health problem, as cases of night blindness and keratomalacia [a severe eye disease directly related to vitamin A deficiency, in which the cornea clouds over] were very common during that time.”

In a pattern that would become a familiar feature of Nepal’s under-five mortality efforts, the government carried out extensive local research on the issue before deciding to implement it on a wider scale. Studies conducted with nongovernmental organization (NGO) partners in the Sarlahi and Jumla districts in the late 1980s and early 1990s showed that vitamin A supplementation reduced child mortality by about 30 percent.²

“The vitamin A field trials that were done in Sarlahi and Jumla started small and presented the evidence to the government,” said one interviewee. “Since they were done under direct government vigilance it [the evidence] had a good acceptance from them, and later on it was incorporated in the national plan.”

To expand the program to other districts, the national government decided to draw upon the country’s decentralized care-delivery network -- including the FCHVs, who organized distribution days in their communities, visiting all households in their catchment area to make sure families received the supplements.³

The government initiated an implementation plan in 1993, with the intention to expand nationwide over the following decade. By 2002, the campaign had covered all of Nepal’s 75 districts.⁴ A study conducted three years later showed that vitamin A supplementation had reduced the odds of dying between 12 and 59 months of age by slightly more than half.

Oral rehydration campaigns and community-based IMCI

Another early expansion of the FCHV role also involved a straightforward, low-tech response to the prevalence of diarrhea among children. This was oral rehydration therapy, or ORT. FCHVs were trained in diarrheal case management and received prepackaged oral rehydration salts (ORS) to distribute as needed.

Over the course of the 1980s and 1990s, the MOH variously promoted the prepackaged ORS dosages or a homemade mixture of salt, sugar, and water known as nun chini pani. Eventually, the MOH stopped promoting nun chini pani due to concerns about the availability of ingredients as well as the imprecision of the homemade mixtures.⁴

While awareness of ORT became almost universal, adoption rates remained low.⁵ Interviews and prior studies suggested a variety of possible reasons for this gap, including poor understanding of causes of diarrhea, reliance on traditional treatments, quality-related issues with providers not recommending ORT consistently, and a desire for medication rather than ORS.^6,7  In 1999, ORT was folded into a new comprehensive treatment protocol that targets several major causes of under-five mortality simultaneously-and further expands the  FCHV role. This integrated approach is called the Integrated Management of Childhood Illness (IMCI).⁸

Developed by WHO and the United Nations Children’s Fund (UNICEF) in 1995 as a holistic approach to improving child health systems in low-income countries, Integrated Management of Childhood Illness (IMCI) seeks to strengthen both health facilities and community-based health practices.⁹

IMCI arrived just as Nepal was aggressively seeking better ways to deliver health care at the community level. In 1998 and 1999, the government merged its local immunization, nutrition, respiratory-health, and anti-diarrheal programs into a community-based IMCI program (CB-IMCI).^10,11  By 2009, IMCI was present at the community and facility level in every district in Nepal.

CB-IMCI was integrated into the existing FCHV program and gave the volunteers a new treatment-and-referral role as part of their standard duties. Beginning in 2003, FCHVs were also trained to diagnose pneumonia symptoms in children, provide oral antibiotics, and refer clients for more advanced treatments.

However, some weaknesses were identified in the delivery of some CB-IMCI services. The 2015 MOH Annual Report identified problems with frequent stockouts at the district and community levels, poor data quality, and inadequate referral mechanisms.⁵²  Multiple interviewees expressed doubts about the sustainability of the CB-IMCI program as FCHVs are given more responsibilities. The MOH identified the necessity of improving on-site supervision and training, supply chains, and quality-improvement mechanisms if the CB-IMCI program (now known as CB-IMNCI following the integration of neonatal health) is to continue.

Nevertheless, despite some of these weaknesses, treatment-seeking behavior for various diseases did improve over time, as can be seen with the example below of improvements in care-seeking for lower respiratory infections.

Facility-based improvements in neonatal care

Access to skilled birth attendants

In 2001, only 11 percent of all deliveries (whether in a facility or at home) were attended by a skilled birth attendant.¹² In 2006, Nepal set an official goal to reach 60 percent within a decade. It came very close, falling short by only two percentage points.¹³

Impressive as this achievement was, Nepal still has room for improvement, as the South Asian regional average for births attended by skilled staff was 76 percent in 2014.¹⁴ In addition, MOH officials have expressed concern about the quality of skilled birth attendance in Nepal. Remote birthing centers have struggled to hire and retain nurses, and the quality of training is uneven. The ministry has sought to recruit individuals from remote communities to train as nurses and skilled birth attendants who will then return to their villages, but this effort has had variable success, with many simply never going back home.

Nevertheless, the substantial increase in percentage of deliveries attended by a skilled birth attendant has shown the country's ability to set and achieve its goals, despite some remaining challenges.

Facility-based delivery: Maternity Incentive Scheme and Safe Delivery Incentive

In addition to its efforts to increase the prevalence and use of skilled birth attendance, Nepal has sought to make it easier for expectant women to make use of the growing number of facilities capable of handling deliveries.

First, Nepal used research to determine some of the largest barriers to women delivering in facilities. A study in eight districts found that cost was a barrier to facility-based delivery for many women, with transportation accounting for a significant proportion of the potential expense.¹⁵

In response to this, in 2004, the MOH introduced the Maternity Incentive Scheme, which offered women a cash payment to defray the costs of delivering at health facilities. The following year, the ministry folded this program into a new one, the Safe Delivery Incentive Program.¹⁶  It was rolled out nationwide, in all districts at once, because of concerns that a limited pilot run might worsen existing inequities. The Safe Delivery Incentive Program included several components: cash incentives for women using a birth facility, cash incentives for skilled birth attendants following each delivery they support, free delivery services in the 25 poorest districts, and antenatal care incentives for women attending four or more antenatal care visits.

There were initially some challenges with the program, including delays with transferring funds from the central to the district levels, the lack of a coordinated publicity campaign, and only 26.5 percent of women who had delivered in public facilities two and a half years after introduction of the incentive program having actually received the cash payment. ^17 18 

Despite these challenges, the program did show progress. Evaluations in six districts had found that women exposed to the incentive program were 24 percent more likely to deliver in a public health facility, and 13 percent were more likely to have an SBA on hand.¹⁹

In addition, Nepal's national government showed resilience to these challenges by continuously reevaluating their program throughout implementation. To address the aforementioned shortcomings, the national government streamlined the fund-disbursement process and organized a national awareness campaign. The Safe Delivery Incentive Program was renamed the Aama Program ("aama" means “mother” in Nepali) in 2009, and was expanded to support free delivery at all public and accredited private facilities in every district nationwide.

In 2013, the MOH added the Nyano Jhola Program ("nyano jhola" means “warm bag”) as an additional incentive for mothers to deliver in public hospitals. Following delivery, each mother receives a gown and two sets of warm baby clothes, thereby providing not only an enticement to deliver at a facility, but also practical protection from hypothermia and infection.

Emergency care protocols

To improve the quality of facility-based care, and to persuade more women to give birth at health facilities, Nepal also sought to expand the availability of emergency obstetric and newborn care. This was done by establishing nationwide protocols for basic emergency obstetric and newborn care (BEmONC) and comprehensive emergency obstetric and newborn care (CEmONC)-known collectively as EmONC.

BEmONC is a seven-intervention checklist, assessing facilities’ capability to provide such basic services as the administration of antibiotics, treatment of preeclampsia, and effective response to postpartum hemorrhage. CEmONC additionally lists blood transfusions and surgical capacity (including the ability to perform C-sections).²⁰

According to a former Secretary of Health in Nepal, these protocols were identified as a priority for two reasons: (1) to help advance the international discussion and prioritization of obstetric and neonatal care issues, and (2) to increase the geographic prevalence of centers meeting these basic childbirth standards across Nepal’s unique geographical terrain.

UNICEF and the UK Department for International Development (DFID) were the MOH’s primary partners in the technical and financial support of EmONC programs. In 2000, both of these partner agencies supported a pilot of EmONC services in seven districts. EmONC was then incorporated into the Aama Program, with all districts expected to have at least one facility capable of providing CEmONC.

One indication of improvement in the quality and accessibility of facility-based deliveries is the increased prevalence of C-section births. These increased from 1 percent of all births in 2001 to 9.6 percent by 2016.²¹  According to WHO, C-section rates between 10 percent and 15 percent are associated with reductions in maternal and newborn deaths.^22,23

Nepal still has room for improvement; according to the 2016 DHS, facility-based deliveries were only 57.4 percent of births nationwide, with significant geographic and economic disparities.²⁴ Nevertheless, these incentives and facility-improvement measures did succeed in increasing the proportion of births conducted at health facilities under the supervision of skilled personnel.

Community-based improvements in neonatal care

Growing interaction between community health workers and health facilities

Nepal’s campaign to strengthen the health system was about more than the building and staffing of health facilities. It also included service delivery improvements, including community-centered models of neonatal care.

A major component of community-centered care is an increased interaction between health facilities and community health workers, particularly FCHVs. The expanded health facility network increased the feasibility of using hospitals and clinics as bases for FCHV support and supervision.

One interviewee referred to FCHVs and other community health workers as “a bridge between the health system and the community.”

“The health workers regularly contact them and even invite them to the health facilities, and also try to understand if they have any problems.”

According to a 2014 survey, almost all FCHVs (96 percent) reported having some contact with health workers from a local facility over the preceding month.

The majority (78 percent) reported having a formal review meeting at their local health facility within the past month, and 65 percent said they had taken part in a two-day review meeting within the previous six months.²⁵ 

“Since there are [so many] FCHVs, health workers cannot regularly supervise them, so we call FCHVs to the health facility every six months, which we call a ‘supervision meeting,’” said one MOH interviewee. “It’s a two-day meeting to discuss issues and problems.”

This connection between FCHVs and the health facilities is vital to effective community health care in Nepal. It provides the facilities with an on-the-ground picture of community conditions and ensures that the FCHVs are carrying out their roles properly.

During postnatal care home visits, FCHVs counsel postpartum mothers on protecting low birth weight infants from hypothermia and can refer mothers or newborns for facility-based treatment if any danger signs arise.²⁶

Community Based Newborn Care Package

When Nepal introduced the Community Based Newborn Care Package (CB-NCP) in 2007 in response to continued elevated levels of neonatal mortality, FCHVs expanded their role beyond CB-IMCI (which focused only on children starting at two months of age) to provide immediate care to newborns, including those with perilous conditions such as prematurity, low birth weight, and hypothermia.²⁷  In addition, FCHVs receive performance-based incentives to accompany expectant mothers to a health facility for delivery, or to be present at a home delivery.²⁸

Under an initiative piloted in 2009 and implemented nationwide in 2015, FCHVs also play an essential role as breastfeeding advisors for new mothers and caregivers.

To improve implementation, feasibility, and effectiveness, the CB-NCP program was adapted and integrated into the existing CB-IMCI program in 2014, creating the Community-Based Integrated Management of Childhood and Neonatal Illness program (CB-IMNCI).

All components of the community-based service delivery were integrated under CB-IMNCI as one comprehensive program, including counseling and education; postnatal visits; and the distribution of essential commodities such as iron, zinc, ORS and chlorhexidine.

An initially-included birth asphyxia intervention was dropped from the CB-IMNCI program, due to FCHVs’ concerns that they would be blamed if their infant resuscitation efforts were unsuccessful.

Data and research-driven interventions

To inform many of their interventions, Nepal made use of data from both the Health Management Information System (HMIS) and Demographic and Health Survey (DHS). In addition, they used local research to evaluate effectiveness and suitability of global interventions in the country context. (For more detail on data and local research, see the How did Nepal Implement chapter.) 

Measles surveillance and vaccination campaigns

One example of Nepal's use of data to inform decision-making was with the measles vaccination. The measles vaccination was first introduced in Nepal in 1979 in a limited number of districts, and was scaled up nationally in 1989, although coverage remained low at 57 percent in 1996 and only 71 percent in 2001. ^31,32 By 2016, this rate increased to 90 percent, according to that year’s DHS.

Nepal worked to improve coverage through HMIS surveillance, conducting outreach campaigns in the poorest and most inaccessible communities.

Until 2003, this was the exclusive method of measles surveillance, but it did not provide the level of detail needed for timely response to outbreaks.³³ Due to this limitation, the MOH supplemented the HMIS with a more detailed measles surveillance system, building on a polio monitoring program for acute flaccid paralysis that had been in place since 1996.

This network collects weekly reports from health centers in every district on suspected measles cases. If there are five or more such cases over a two-week period, a surveillance team initiates an investigation. This team collects blood samples, investigates the causes of the outbreak, and starts an immunization campaign for unvaccinated individuals in the area.

After implementation of the new surveillance system, data showed that measles continued to occur, and that approximately 90 percent of confirmed cases were in children under 15 years of age.³⁴

Based on these data, the MOH conducted a secondary immunization round, targeting children ages 9 months to 15 years. The estimated coverage of these campaigns ranged from 93 percent to 105 percent.^35,36

According to MOH interviewees, measles outbreaks still occur, primarily in rural regions and in poor or low-caste communities. The MOH maintains its surveillance and reporting systems in order to respond rapidly to outbreaks with treatment and immunization campaigns.

Use of data in antimalaria campaigns

Data surveillance would prove useful in combating one of the most dangerous potential threats to child survival: malaria.

By South Asian standards, Nepal’s malaria incidence rate is relatively low. However, 13 lowland districts are at high risk for ongoing transmission of the disease.³⁷

In addition to measures embedded in its IMCI programs, Nepal introduced a variety of specific interventions to reduce malaria, with use of indoor residual spraying (IRS) and long-lasting insecticide-treated nets (ITNs) as the top interventions.

As a result of spraying with dichloro-diphenyl-trichloroethane (DDT) combined with individual antimalarial treatment, large parts of Nepal were nearly malaria-free by the 1970s.³⁸

As DDT resistance increased and new disease vectors emerged, malaria made a comeback. Nepal continued investing in IRS, but switched from DDT to pyrethroids in 1990, in accordance with recommendations from WHO. ^39,40

According to one interviewee who served at the MOH in the 1960s and early 1970s, bed nets were not discussed as a possible intervention at that time, since the use of DDT seemed to keep malaria under control.

By the early 2000s, the MOH once again noticed an increase in malaria transmission. In 2004, the government rolled out a major expansion of its malaria-control efforts. This included intensive collection of data and other research by the MOH’s Epidemiology and Disease Control Division (EDCD), which had recorded a peak in disease incidence.

The EDCD used data on malaria incidence to monitor risk patterns at the national level and down to the ward level. This information was then used to target interventions such as IRS and ITNs. With financial assistance from the Global Fund to Fight AIDS, Tuberculosis and Malaria, Nepal added long-lasting ITNs to its preventive arsenal in 2005.⁴⁰

Over the following three years, the Global Fund (which accounted for 70 to 80 percent of Nepal’s total malaria-control budget at the time⁵³) supported a series of high-impact interventions in the 13 high-risk districts, including rapid diagnostic testing, artemisinin combination therapy (ACT), and distribution of ITNs. Acting on local evidence showing cases arising even outside these targeted areas, the Global Fund approved expansion of the interventions to 18 moderate-risk districts. This expansion began in 2011, and Nepal has not had any recorded malaria deaths since that year.

Citing a public preference for the use of ITNs over IRS, as well as cost-effectiveness considerations, the MOH decided to phase out spraying in communities where at least 80 percent of households had adequate bed net coverage.

Chlorhexidine

Perhaps the most notable example showing the value of Nepal’s local research is the nationwide adoption of chlorhexidine in the treatment of newborns’ umbilical-cord stumps. The handling of umbilical cord stumps is a culturally sensitive aspect of neonatal care, and the new method represented a significant departure from traditional methods.

A 2002 Save the Children report found that cord care during home-based deliveries varied widely in Nepal.⁴¹ The cord was cut anywhere from minutes to hours after delivery, and by a variety of means-including with a new or used razor blade, a sickle, or a piece of wood. Substances applied to the cord stump included mustard oil, ash, turmeric, and spider webs.

Nepal conducted two randomized control trials of chlorhexidine in the southern Sarlahi District. One of the studies found a 28 percent decline in neonatal mortality for low birth weight infants with use of chlorhexidine.⁴² The other study found a 24 percent decline in neonatal mortality for all infants as a result of the treatment.⁴³

This local research established the effectiveness of chlorhexidine and provided a precedent for introducing the treatment as an alternative to traditional cord care practices in Nepal.

In 2011, the MOH issued a national policy recommending use of chlorhexidine for umbilical cord care at all deliveries. The rollout of the CB-NCP in 2007 had included chlorhexidine cord care, and in 2011 chlorhexidine was added to the training program for skilled birth attendants and auxiliary nurse midwives.⁴⁴

In a country of deeply entrenched cord care practices, however, community education was essential. The rollout of the chlorhexidine campaign included radio ads, television spots, posters, and flyers.⁴⁴ It also included extensive community engagement on the part of the FCHVs, as noted by one MOH interviewee: “The FCHVs played a very big role in convincing people to accept chlorhexidine, and through them we managed to achieve success.”

Other immunization programs

Local research has also informed Nepal’s large-scale immunization programs. Such campaigns have long presented a challenge, due to widespread poverty and the difficulties of transportation and cold-chain maintenance across its terrain.

At the start of this century, Nepal’s immunization program administered five vaccinations for children: oral polio vaccine; diphtheria, tetanus, and pertussis (DTP) vaccine; tetanus toxoid, Bacillus Calmette-Guérin (BCG) tuberculosis vaccine; and measles vaccine.

According to the 1996 DHS, fewer than half of Nepali children ages 12 months to 23 months (43 percent) had received all basic immunizations (BCG, measles vaccine, three doses of DTP vaccine, and three doses of polio vaccine).⁴⁵ 

Beginning in 2007, the MOH launched a series of comprehensive multiyear immunization plans, which supported supply-chain improvements, as well as improved service delivery, community engagement, and mobile-clinic access-functions in which FCHVs played a significant role, as noted by several interviewees.⁴⁶

To improve vaccination coverage, in 2011 the MOH and its NGO partners adopted a strategy of “reaching every child” (later renamed “reaching the unreached”), focusing on poor and remote populations with low immunization coverage. In some regions, this required airlifting the vaccines, since shipping them by road was not feasible. According to interviewees, routine monitoring and monthly reporting data collected in the HMIS data were integral to identifying gaps in immunization coverage.

“Since FCHVs knew every child from their ward, we could ask them to bring the child to the immunization ward,” said one interviewee. “This is how good coverage was achieved.”

Indeed, prior to introducing new vaccines, Nepal collects research data on local prevalence, disease strains, and feasibility to ensure high coverage levels can be achieved, with a corresponding impact on disease burden.

Haemophilus influenzae type B vaccine

The campaign to reduce Haemophilus influenzae type B (Hib) offers an example of how Nepali officials used local research to inform a nationwide vaccination rollout. Gavi started funding introduction of the Hib vaccine in low- and middle-income countries in 2001, and WHO recommended adding Hib vaccine to all routine immunization schedules in 2006.

The MOH and its academic partners undertook local research to assess the burden of Hib in Nepal. They examined nasopharyngeal carriage rates in children, mathematical modeling of the burden of disease, and prior surveillance of cases in four hospitals across the country.^47,48

Only after this review established high levels of incidence did Nepal apply to Gavi in 2007 for the funding of a pentavalent vaccine that would cover Hib along with DTP and hepatitis B. That year, the national government and WHO performed an assessment, which found that cold-chain capacities were insufficient for rollout of the pentavalent vaccine.⁴⁷ The government built an additional cold storage room in 2008.

The pentavalent vaccine was introduced in 25 districts in March 2009, and rolled out to all 75 districts by December 2009, rapidly achieving high rates of coverage.

By 2015, Nepal was able to introduce five new vaccines to its national immunization program, in addition to Hib: hepatitis B vaccine, rubella vaccine, Japanese encephalitis vaccine, injectable polio vaccine, and pneumococcal vaccine.

Overall, across all vaccines, a statistical analysis conducted by the Institute for Health Metrics and Evaluation (IHME) found that 12.2 percent of the reduction in under-five deaths was attributable to vaccine interventions.⁵⁴

HIV prevention campaign

In 2005, the country embarked on a comprehensive campaign to reduce another threat to child survival, HIV. This effort focused on the prevention of mother-to-child transmission (PMTCT) of HIV.

In February 2005, the MOH piloted comprehensive PMTCT services in Kathmandu, Nepalgunj, and Dharan. This service package included voluntary HIV counseling and testing, antiretroviral (ARV) treatment of pregnant women and exposed infants; safe obstetric care, infant-feeding counseling and support; family planning; and referral care and support of HIV-infected women and children.⁴⁹

Two years later, the National Centre for AIDS and STD Control (NCASC), UNICEF, and other members of a National PMTCT Working Group issued an operational review of the PMTCT pilot programs. The review found that the existing program had a strong focus on hospital‐based services, but had weaker provisions to reach the community through prevention‐based interventions and the provision of care, treatment, and support for people living with HIV/AIDS.⁴⁵

The review recommended a deeper integration of PMTCT programs with community-based maternal and neonatal health services – including increased involvement of FCHVs and other community health workers.⁵⁰ It also called for a deeper involvement of district-level authorities and civil society organizations to manage and support PMTCT services, and for a strengthened role of NCASC in overall program management.⁵⁰

Following these recommendations, the government launched the Community Based Prevention of Mother to Children Transmission (CB-PMTCT) program in 2009. This intervention increased antenatal care coverage and expanded HIV counseling and testing of pregnant women.

Combating malnutrition

In 2008, a nutrition survey of Bardiya District, in west-central Nepal, found that the severe acute malnutrition rate was nearly 3 percent, and a global acute malnutrition rate (the total proportion of severe and moderate acute malnutrition) was 16 percent among children under five. The survey labeled the situation “critical” and recommended the implementation of a nutrition intervention to address acute malnutrition in the district.⁵¹

In response, the national government introduced the Community-Based Management of Acute Malnutrition (CMAM) program. The program included a broad spectrum of interventions, such as supplementary feeding, patient stabilization, outpatient therapeutic care, and community mobilization.

This emphasis on community-centered solutions meant that FCHVs had a significant role in reducing malnutrition. By 2009, FCHVs received instruction on how to identify acutely malnourished children. From 2012 to 2016, nearly 22,000 children received treatment for severe malnutrition in Nepal-with a cure rate of 87 percent.⁵⁰ 

Decomposition

A decomposition analysis undertaken in collaboration with the Institute for Health Metrics and Evaluation (IHME) at the University of Washington identified the top interventions and risk factors that contributed to reductions in under-five deaths in Nepal. These interventions and risk factors can be seen in the bottom two bars of the visualization below.

• Some of the largest contributors to reduction in under-five mortality were health system interventions, which were responsible for 33 percent of the reduction in under-five deaths from 2000 to 2017.
• Within this, vaccines (especially Hib vaccine, PCV, and DTP3) were a significant factor, and were attributed to 12.2 percent of the reduction.
• Beyond health system interventions, reductions in other communicable disease risk factors, population growth, and reduction in child growth failure were also found to have significant contributions to reduction in under-five deaths.⁵⁴