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Responding to Increased Demand for Institutional Childbirths at Referral Hospitals in Nepal: Situational Analysis and Emerging Options, 2013 All Rights Reserved

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Responding to Increased Demand for Institutional Childbirths at Referral Hospitals in Nepal: Situational Analysis and Emerging Options, 2013 All Rights Reserved Recommended citation: FHD/NHSSP (2013) Responding to Increased Demand for Institutional Childbirths at Referral Hospitals in Nepal: Situational Analysis and Emerging Options, 2013 All rights reserved. The document may, however, be reviewed, quoted, or translated in part or in full provided the source (Family Health Division (FHD)) is fully acknowledged. The document may not be sold or used for any kinds of commercial purposes without prior written approval from the FHD. The FHD does not warrant that the information contained in this publication is complete and correct, and shall not be liable for any damages incurred as a result of its use. © Family Health Division 2013 Study Team Core Team Dr. Madhu Dixit Devkota, Lead Consultant Dr. Devi Prasad Prasai, PhD, Senior Advisor Mr. Jagadishwor Ghimire, Research Assistant Ms. Saroj Kumari Jaiswal, Data Assistant Advisors Dr. Senendra Raj Upreti, Director, FHD Dr. Shilu Aryal, RH Coordinator, FHD Dr. Ganga Shakya, Lead Advisor (MNCH), NHSSP Dr. Maureen Dariang, EHCS Advisor, NHSSP Ms. Alison Dembo Rath, Technical Oversight, Options, UK Dr. Louise Hulton, Technical Support, Options, UK Ms. Rachel Phillipson, Technical Support, Options, UK Acknowledgements On behalf of the team, I would like to extend my special thanks to Dr. Senendra Raj Upreti, Director, Family Health Division, for his guidance, support, and constructive feedback at every stage of this study. Similarly, I would like to acknowledge our gratitude to all the members of the Technical Advisory Group for their input and guidance from the inception until the formulation of the recommendations based on the findings: your input was invaluable, and we are indeed grateful. The stakeholders at the hospitals, the Chairs of the Hospital Development Committees, the Medical Superintendents of the referral hospitals, the nurses in-charge, matrons, and the Skilled Birth Attendants – without your input, this study would not have been complete. Similarly, the District Public Health Officers, District Public Health Nurses, and the Skilled Birth Attendants working at the BCs are acknowledged for their input and help in facilitating our work. The management at the private medical colleges is thanked for sharing their realities. Last but not least, all the mothers and their families who gave us their time, despite being the pain and stress, are sincerely acknowledged. We are grateful to all the stakeholders who attended the consultative meeting for their suggestions; their input has been crucial in deriving the recommendations of the study. The challenging task was made enjoyable at every step of the way through to the sincerity and the commitment of the team. My special thanks therefore to Dr. Devi Prasai for his invaluable guidance and insights, and Mr. Jagadishwor Ghimire and Ms. Saroj Jaisawal for their relentless hard work. The contribution of Mr. Samriddhi Shakya with Geographic Information System mapping must be acknowledged as invaluable. Special thanks are also due to the NHSSP team, especially Dr. Ganga Shakya, Dr. Maureen Dariang, Ms. Alison Dembo Rath, Ms. Rachel Phillipson, and Ms. Louise Hulton, for their technical support. Dr. Madhu Dixit Devkota On behalf of the study team iii Table of Contents SUMMARY .................................................................................................................................. VI BACKGROUND ............................................................................................................................. 2 1.1 INTRODUCTION ........................................................................................................................... 2 1.2 PROBLEM STATEMENT .................................................................................................................. 4 1.3 PURPOSE AND OBJECTIVE OF THE REVIEW ....................................................................................... 4 REVIEW PROCESS AND METHODOLOGY ........................................................................................ 5 2.1 FORMATION AND ENGAGEMENT OF A KIG ....................................................................................... 5 2.2 METHODOLOGY FOR THE FIELDWORK ............................................................................................. 5 FINDINGS ................................................................................................................................... 10 3.1 UTILISATION PATTERN OF INSTITUTIONAL CHILDBIRTH BY DISTRICT .................................................... 10 3.2 UTILISATION PATTERN AT REFERRAL HOSPITALS .............................................................................. 10 3.3 OVERCROWDING AT REFERRAL HOSPITALS AND ITS IMPLICATIONS ..................................................... 16 3.4 LOCAL RESPONSES TO ADDRESS OVERCROWDING ........................................................................... 23 3.5 UTILISATION PATTERNS OF THE BCS .............................................................................................. 26 3.6 UNIT COSTS OF HOSPITAL AND BC DELIVERIES AND RESOURCE IMPLICATIONS ..................................... 28 DISCUSSION ............................................................................................................................... 37 4.1 SERVICE PROVISION ................................................................................................................... 37 4.2 SERVICE UTILISATION AND EQUITY ................................................................................................ 39 4.3 OVERCROWDING ....................................................................................................................... 40 4.4 COST AND QUALITY .................................................................................................................... 42 KEY ISSUES AND EMERGING OPTIONS ........................................................................................ 44 6.1 KEY ISSUES ............................................................................................................................... 44 6.2 EMERGING OPTIONS .................................................................................................................. 45 RECOMMENDATIONS ................................................................................................................. 47 REFERENCES .............................................................................................................................. 49 ANNEXES ................................................................................................................................... 51 ANNEX 1: HUMAN RESOURCES FOR HEALTH FOR MATERNITY SERVICES AT REFERRAL HOSPITALS .......................... 51 ANNEX 2: RECOMMENDATION BY HEALTH SYSTEM AREA ............................................................................. 52 ANNEX 3: RECOMMENDATIONS FOR THE DISTRICTS FROM GROUP WORK AT THE FHD WORKSHOP IN NOVEMBER 2012 .................................................................................................................................................. 54 ANNEX 4: RECOMMENDATIONS BY JOINT ANNUAL REVIEW (JAR) MEETING FOR EHCS ................................... 59 Annex 5: INDICATIVE COSTINGS FOR IMMEDIATE AND LONG-TERM RESPONSES TO INCREASED DEMAND FOR MATERNITY SERVICES……………………………………………………………………………………………………………………..…60 iv Summary A. BACKGROUND AND OBJECTIVES The Government of Nepal (GoN) is committed to providing skilled care to women during childbirth, and to ensuring that, in line with Millennium Development Goal (MDG) targets, 60% of births are assisted by a Skilled Birth Attendant (SBA) by 2015. The Safe Motherhood Long-term Plan (2006-17), the National Policy on Skilled Birth Attendants (2006), and the Second Nepal Health Sector Programme (2010-15) (NHSP-2) envisage the availability of basic delivery services in 70% of all Health Posts (HPs), Basic Emergency Obstetric and Neonatal Care (BEONC) services in 80% of Primary Health Care Centres (PHCCs), and Comprehensive Emergency Obstetric and Neonatal Care (CEONC) services in 60 districts (out of the total 75 districts). To reduce financial barriers, the Aama Surakshya Programme (Aama) provides free delivery care to women, fixed payments to institutions to provide services, and transportation costs to mothers. The country has made significant progress in maternal health in the last 20 years with the reduction of the Maternal Mortality Ratio (MMR) from 539 to 170 deaths per 100,000 live births. In addition, the proportion of deliveries at health institutions increased almost fourfold from 9% in 1996 to 35% in 2011. Increased utilisation of facilities in Nepal reflects the success of the GoN’s policies to promote institutional childbirth and Emergency Obstetric Care (EOC). However, in recent years, concerns have been raised that the changed demand for services may not have been matched by the distribution of supply. The purpose of this study is to assess the utilisation patterns of childbirth services in selected health facilities and to propose evidence-based options for reducing overcrowding in referral hospitals in order to inform Ministry of Health and Population (MoHP) policy and planning. B. STUDY METHODS Six hospitals (out of a national total of 17) were Box A: Sampled Referral Hospitals selected purposively to represent the country’s development and ecological regions (Box A). Two Terai: Birthing Centres (BCs) (one PHCC and either a HP
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