A Framework for Developing Reproductive Health Policies and Programmes in Nepal

Abstract

Based on experience in Nepal from 1996–2001, this paper presents a six-element framework to support governments in poor countries in developing and implementing reproductive health programmes. The six elements of the framework are: (i) collaborative planning and programming; (ii) strategic assessment; (iii) policy and strategy development; (iv) guideline and material development; (v) reproductive health programme management; and (vi) policy review. Its implementation calls for collaborative work between policymakers and programme managers at all levels of the health system, external donors and development agencies. Change in Nepal is constrained by poor human and financial resources, extremely difficult geography and strong cultural, religious and social traditions. An informal assessment at district level and below found that information tools, clinical protocols and operational guidelines were highly relevant, though problems with utilisation and motivation were noted. Utilisation of strategy and policy documents and tools was reported to be high at national level, but no causal link can be drawn between instruments in the framework and changes in reproductive health indicators. However, access to the tools described in this article can contribute to improvements in coverage and quality of reproductive health services in the hands of motivated people; improved indicators in family planning use, antenatal care and assisted delivery in Nepal in this period support this view.

Résumé

S'inspirant de l'expérience népalaise (1996–2001), cet article présente un cadre en six étapes pour aider les gouvernements de pays pauvres à définir et appliquer des programmes de santé génésique. Voici ces six éléments: i) planification et programmation concertées; ii) évaluation stratégique; iii) définition des politiques et des stratégies; iv) préparation des directives et des matériels; v) gestion des programmes de santé génésique; et vi) examen des politiques. L'application du cadre exige une collaboration des décideurs et des gestionnaires des programmes à tous les niveaux du système de santé, des donateurs externes et des institutions de développement. Le changement au Népal est limité par les faibles ressources humaines et financières, une géographie extrêmement difficile et de fortes traditions culturelles, religieuses et sociales. Une évaluation informelle a montré la pertinence des outils d'information, des protocoles cliniques et des directives opérationnelles, mais a noté des problèmes d'utilisation et de motivation. L'utilisation des documents et des outils stratégiques et politiques était élevée au niveau national, mais aucun lien causal n'apparaı̂t entre les instruments du cadre et les changements des indicateurs de santé génésique. Néanmoins, l'accès à ces instruments peut améliorer la couverture et la qualité des services de santé génésique avec du personnel motivé; des indicateurs affinés sur le recours à la planification familiale, aux soins prénatals et aux accouchements assistés au Népal pendant cette période étayent cette idée.

Resumen

Basado en experiencias en Nepal (1996–2001), este artı́culo presenta un marco conceptual que puede servir servirle los gobiernos de los paı́ses pobres al desarrollar e implementar programas de salud reproductiva. Hay seis nociones a considerar (i) planificación y programación colaborativas; (ii) evaluación estratégica; (iii) desarrollo de polı́ticas y estrategias; (iv) desarrollo de pautas y materiales; (v) gestión de programas de salud reproductiva; (vi) revisión de polı́ticas. La implementación requiere la colaboración de polı́ticos y los directores de programas en todos los niveles del sistema, los organismos donantes extranjeros y las agencias de desarrollo. Una evaluación a nivel de distrito y más abajo descubrió que las herramientas informativas, los protocolos clı́nicos y las pautas operativas eran altamente pertinentes aunque se notó problemas con la utilización y motivación. Se reportó una alta utilización de las herramientas y documentos de polı́tica y estrategia al nivel nacional, pero no existe un vı́nculo causal entre los instrumentos en el marco conceptual y cambios en los indicadores de la salud reproductiva. Sin embargo, el acceso a las herramientas descritas en este artı́culo por personas motivadas puede contribuir a mejorar la cobertura y la calidad de los servicios de salud reproductiva; indicadores mejorados del uso de planificación familiar, atención prenatal y parto asistido en Nepal en este perı́odo apoyan este punto de vista.

Keywords:

• reproductive health policy and programmes
• health planning and management
• Nepal

The 1994 International Conference on Population and Development (ICPD) in Cairo brought unprecedented global attention to the inter-linkages between population and development, and set forth an ambitious agenda for improvements in reproductive health and comprehensive quality reproductive health care accessible to all. In the years following the ICPD, progress has been demonstrated, for example, in legal and policy reforms, partnerships between government and civil society, and efforts to redress gender inequalities.^{1 2}

Experience with family planning programmes has shown that effective management of reproductive health programmes is linked to improvements in information and services.³ A series of reviews of progress since Cairo, however, have indicated that such improvements have not been universal. Many countries continue to face constraints in their efforts to operationalise a national reproductive health programme^{4 5 6} due to limited human and financial resources and a lack of high-level commitment to a comprehensive, rights-based approach. The reviews also point to the absence of practical tools to guide efforts to define and structure reproductive health services, often within the context of health sector reform and more recently, sector-wide approaches.⁷ The obstacles involved in integrating services—including financial, administrative and management systems–and the addition of new services within already overstretched health systems have hampered programme development. As a result, more often than not, national reproductive health policies have not been able to be translated into improved programmes and service delivery.⁸

This article describes a six-element framework for developing a national reproductive health policy and programme, intended for use by programme planners and managers at the national level. The framework emerged during a decade of efforts to improve the health system in Nepal, and can offer insights into improving reproductive health services through policy and programme interventions that can be adapted for use by other countries.⁹

In Nepal, health service delivery is notoriously difficult. Great disparities in access and resources exist between the country's 75 districts. Diverse factors account for this, such as geographic terrain and remoteness, socio-cultural traditions, gender relations, resource constraints and low health sector and infrastructure development. Nevertheless, from the mid-1990s onward, a timely combination of strong leadership in the Ministry of Health, capacity-building in the health sector and multi-donor funded health and commodity programmes created the momentum for dialogue on reproductive health policy and programme implementation. This momentum preceded subsequent broader decentralisation and reform, including but not limited to the health sector, articulated in the 1999 Local Self-Governance Act.¹⁰

UNFPA and the Netherlands Royal Tropical Institute (KIT) support the Nepalese Ministry of Health in linking national policy and strategy development with operational activities at the regional and district levels. UNFPA has been a longstanding partner of the Department of Health Services (DoHS) in Nepal, and is currently in its fifth five-year cycle of assistance. Since 1993, UNFPA and the Ministry of Health have contracted KIT for long-term technical support, including for the development and management of reproductive health services. A senior technical advisor has been posted since then within the Family Health Division of the DoHS to facilitate this process.

The framework

As organisational change in the health sector began to take shape in Nepal in the mid-1990s, a series of simultaneous and inter-linked activities took place. At the time, no framework existed for integrating reproductive health care. Rather, the DoHS was co-ordinating a series of externally supported, vertical national programmes including for family planning, safe motherhood and child health, HIV/AIDS and STIs. These were formally integrated in the DoHS in 1993–94, through a written policy directive. However, without support structures for service providers, integration only partially took place. HIV/AIDS remained a distinct entity, while family planning, safe motherhood, and adolescent and child health programmes were brought together under the Family Health Division. The framework described here, captures some of the policy and operational strategies that were implemented after 1995 in order to support a more comprehensive reproductive health programme.

The framework is designed as a management tool for policy and programme development. It is built upon the premise that each country has the potential to carry out effective and strategic management of reproductive health care. Ultimately, this framework should contribute to improved coverage and quality of reproductive health service delivery at each level of the health system: family/community, sub-health post, health post, primary health care centre and district hospital.

The framework is shown in Figure 1. It is in circular form, to indicate that the six elements are closely interlinked and involve a continuous process of consensus building, prioritisation and activities. It includes a range of tools, some of which are relatively straightforward instruments, such as a reproductive health atlas, more elaborate tools such as clinical protocols, and processes such as consensus forecasting of family planning and other commodities. No one element in the framework needs to be completed before initiating (parts of) another. Similarly, they can be initiated in any order. The pace of implementation depends on a country's capacity to undertake far-reaching review and reorganisation of its existing reproductive health programme. Concurrent devolution and decentralisation schemes also need to be taken into consideration.

Figure 1 Operationalising reproductive health: a six-element framework from Nepal

Element 1: Collaborative planning and programming

The 1994 ICPD Programme of Action promoted multi-sectoral partnerships for reproductive health programme development, implementation and evaluation. Perhaps one of the most difficult steps in the process to integrate or broaden reproductive health care is to create an organisational structure to co-ordinate the efforts of all stakeholders, often under the mandate of the Ministry of Health.

In Nepal, following discussions over almost two years, a national Reproductive Health Co-ordination Committee was created in 1999 which brought together directors of Ministries and other public sector institutions involved in reproductive health (Box 1). The Co-ordination Committee serves as a technical body for policy review, networking and collaboration; it reviews the technical and financial contributions of government, civil society, bi-and multilateral partners to the national reproductive health programme and provides leadership in national initiatives, such as the development of an integrated Health Management Information System (HMIS). It holds meetings three times per year in conjunction with the government's four-monthly planning cycle to review ongoing activities in reproductive health, discuss problems and constraints in implementation and negotiate with donors to fill shortcomings in resources.

During 1999–2001, the Co-ordination Committee met eight times. Continuity of leadership from the DoHS has facilitated the follow-up of Committee members' workplans, but time pressures on high-ranking officials have hindered efficient and timely action. The Committee initially depended on external assistance for preparation of the agenda, venue and follow-up of recommendations from the meeting. However, the Committee has not yet managed to develop and sustain an integrated workplan as originally conceptualised in its terms of reference. Instead, each meeting has briefly reviewed the activities of key stakeholders, as well as addressed a particular theme such as adolescent reproductive health, reproductive health research or safe motherhood. A stronger secretariat is needed to move the concept of an integrated workplan forward. The Committee has also not yet been able to ensure the participation of important stakeholders such as the National Centre for AIDS and STD Control (who may perceive the initiative as competitive in nature), and representatives from line Ministries such as Youth and Population and Environment. Another difficult area for the Committee is negotiating collaboration between NGOs and Government.

The Reproductive Health Co-ordination Committee has three sub-committees, for IEC, research and training. Each of these sub-committees consists of external NGO and Government partners who work together with technical staff of UNFPA/KIT, USAID, GTZ, UNICEF, WHO and others. The IEC sub-committee was responsible for the national IEC strategy, developed in 1998.¹¹ The Research sub-committee coordinated the development of a National Reproductive Health Research Strategy, which was produced in 1999. Many research initiatives had been taking place, for example a comprehensive maternal mortality and morbidity study,^{12 13} but these could now be placed within a larger strategic framework. This allowed for the identification of research gaps and priorities. There was also an Adolescent Reproductive Health sub-committee, with support from WHO. However, interest to remain involved in these sub-committees dwindled after the completion of these initial activities. At the moment, all sub-committees need revitalisation.

Box 1. National Reproductive Health Co-ordinating Committee, Nepal

Chairperson

–Director General of the Department of Health Services (DoHS)

Secretariat

–Chief, Reproductive Health Section, Family Health Division, DoHS

Members

–Director, Ministry of Women and Child Welfare

–Director, Ministry of Education

–Director, Ministry of Local Government

–Director, Planning Commission, DoHS

–Director, Information Education and Communication (IEC), DoHS

–Director, Research Division, DoHS

–Director, Logistics Management Division, Planning and Foreign Aid Department

–Director, National Health Training Centre

–Director, National Health Education, Information and Communication Centre

–NGOs: Family Planning Association of Nepal

–External development partners, governmental and non-governmental: DFID, GTZ, UNFPA, UNICEF, WHO, USAID, Save the Children USA, Save the Children UK, JSI USA, EngenderHealth USA

Element 2: Assessment of reproductive health needs and priorities

In Nepal, it was agreed to carry out an ongoing assessment of the reproductive health situation in order to place policy and programme choices in the context of overall service delivery capacity and the needs of those seeking services. Trimesterly monitoring of reproductive health indicators is published in reports by the Health Management Information System (HMIS) section of the Ministry of Health. There are also annual performance reviews of achievements in reproductive health that involve district, regional and national Ministry of Health staff. This information, aggregated for all 75 districts in Nepal, along with other health-related data, is published in official DoHS annual reports.¹⁴ The maternal mortality and morbidity study, quality assurance assessments of family planning, and a study of community perceptions of reproductive health services, in addition to the Demographic and Health Surveys, have provided data on reproductive health needs and priorities.¹⁵ Information and reports are disseminated to all members of the Reproductive Health Co-ordination Committee and its sub-committees. Original copies are stored in a resource and documentation centre located in the Family Health Division of the Ministry of Health, and copies are made available for all who are interested.

A team of national researchers at the Ministry of Health, with support from KIT, developed an annotated, English language bibliography that summarises much of this information¹⁶ from over a one-year period in 1999–2000. The bibliography has chapters on family planning, safe motherhood, neonatal health, STI/HIV/AIDS, adolescent reproductive health, abortion, subfertility/infertility, life cycle issues, reproductive cancers and gender. With the exception of gender, these categories match the elements of the Essential Reproductive Health Package, defined by the Ministry of Health in 1998 when the national reproductive health strategy was developed.¹⁷ Available information is further classified into policy or programme documents, planning, management and evaluation of services, community-based studies, training and IEC/advocacy.

The National Reproductive Health Research Strategy was built on the annotated bibliography to determine gaps in information and priority research needs. The bibliography was designed for and widely disseminated among policy and programme managers at national level. As assessed during an evaluation of UNFPA/KIT project outputs, reported familiarity with and use by donor partners, technical advisors and MOH staff of the document is good (UNFPA, KIT, Department of Health Services, Family Health Division. Personal communications. Kathmandu, Nepal, 2001). The Research sub-committee is responsible for updating the bibliography, but has not held regular meetings and has not managed to mobilise external support. As a result, the bibliography has not been updated since its first edition.

Another information tool is the Reproductive Health Atlas, which consists of selected national reproductive health data assembled in 1999 by the HMIS section of the Ministry of Health from data in the DoHS annual reports for 1997–1998.¹⁸ The Atlas consists of pictorial maps and graphs for 15 key reproductive health and gender indicators for every district in Nepal. This allows comparison between districts, and between district, regional and national statistics. A comparison over time within districts can also be seen for indicators such as skilled attendance at birth or couple-years of contraceptive protection. As this district information is standardised, routine monitoring of resource inputs and requirements and comparison of performance between districts is facilitated. This type of information forms the basis for the annual performance review meetings.

Donors, expatriate and national technical advisors and other national partners often informally refer to the Atlas as a starting point for assessing local needs and priorities in reproductive health, and decision-making on new initiatives or investments in this area. In 2001, the Reproductive Health Initiative, funded by the EC and UNFPA, produced an updated version of the Atlas for the six districts in Nepal where its activities in reproductive health were taking place. As with the bibliography, the full version of the Atlas needs updating. To date, no external partner has committed funds for this, despite their interest in the Atlas as a decision-making tool and the relatively low cost involved.

Element 3: Reproductive health policy and strategy development

Nepal developed its first National Reproductive Health Strategy in 1998, which conceptualises an integrated approach and merges the previously vertical programmes of family planning, safe motherhood and child health. With the development of this Strategy, an important first step was taken in disseminating the Cairo concept among health officials and setting joint priorities for policymakers, donors and NGO partners. The strategy clearly outlines goals and objectives, defines indicators to measure progress and serves as a guideline for the formulation of supporting programmes by donors.

Prior to 1998, the same reproductive health services existed as today, but service standards were fragmented and services were not consistently provided at designated health facility levels.

The Strategy itself offers little guidance on service delivery issues,¹⁹ so a process of consensus-building took place in the corridors and the meetings of the Co-ordination Committee. An Essential Reproductive Health Package was developed (Box 2), which includes the information and services that should be offered at each level of the health system. For example, safe motherhood services at the community level refer to the provision of IEC on danger signs and symptoms, safer delivery at home by trained birth attendants or health workers, and timely referral for complications. At the sub-health post, complications are stabilised and obstetric first aid provided. Some health posts in remote areas, but certainly all primary health care centres, must be equipped to provide basic obstetric care, and district hospitals must be capable of providing comprehensive emergency obstetric care. A similar systematic classification of services per level is done for the other elements of the Package. Given evolving programmatic and technical changes, such as the recent changes in the law with regard to the provision of safe abortion services, the Package will need periodic updating.

As both government officials and donor representatives have remarked, the 1998 National Reproductive Health Strategy is ambitious, but it clearly outlines what reproductive health services should be provided at each level. However, in order to improve both the quality and coverage of this basic package of services, more investment would need to be made in outreach activities, referral mechanisms, clinical training and provision of commodities.

Box 2. Elements of the Essential Reproductive Health Package (as outlined in the National Reproductive Health Strategy), Nepal

–Family planning

–Safe motherhood and newborn care

–Child health

–Prevention and management of complications of unsafe abortion

–RTIs/STIs/HIV/AIDS

–Prevention and management of infertility

–Adolescent reproductive health

–Life-cycle issues, including prolapsed uterus and reproductive cancers

In addition to the National Reproductive Health Strategy, Nepal developed an HIV/AIDS and STD Control Policy in 1996, a National Fifteen-Year Plan for Safe Motherhood in 2002^{20 21} and in 2001 a multi-sectoral committee finished a national Adolescent Health and Development Strategy.²² Ideally, such policies should be an integral part of the overall National Reproductive Health Strategy. In Nepal, however, they were largely the result of externally funded and semi-autonomous initiatives. Despite this weakness, however, the same stakeholders were involved, and operational linkages were drawn between the various policy and strategy instruments. It is important to note that at the health facility level, it is the same maternal and child health worker and auxiliary nurse midwife who implement all of these programmes.

Four specific strategies were developed to link the community with the health system and improve programme management:

• a national Female Community Health Volunteer programme in 1993 which trained more than 35,000 volunteers in basic health education and information and linked them with first-line providers;

• a national Primary Health Care Outreach strategy in 1994, in which trained health staff from the health post or primary health care centre provide mobile basic health care to communities on a monthly basis;

• a national integrated HMIS in 1995 (see Element 5); and

• an annual consensus forecasting system in 1998 for family planning commodities (Box 3).

As the Ministry of Health began promoting an integrated strategy for reproductive health, better systems were needed to address logistics requirements. An annual forecast for family planning commodities assists the Ministry to assess needs and enable forward-looking management. Since the mechanism for annual updating of a “rolling” five-year consensus forecast was put in place in 1998, stock-outs of contraceptive supplies were reduced to a minimum. Some commodities, such as Norplant, were strategically phased out in areas where trained service providers were not available.

A longer-term aim is expansion of the commodities forecasting system to include STI drugs, micronutrients and emergency obstetric care supplies. A weakness of the system is that it is currently entirely dependent on financial input from external aid partners.

Element 4: Guidelines and other informational and training material development

To support health workers in providing an integrated package of reproductive health services, the Ministry of Health together with the National Health Training Centre and JSI, JHPIEGO and EngenderHealth developed a variety of IEC and training materials, including:

Box 3. Consensus forecasting for family planning commodities

Process

–An agreement between the Nepali Government and external aid partners (GTZ, DFID, USAID, Family Planning Association of Nepal, KIT/UNFPA) on the five-year requirements of a selection of family planning commodities (IUDs, oral contraceptives, Depo Provera, condoms).

–Trend analysis in family planning service delivery for the three preceding years, using routine monitoring data from Logistics and HMIS.

–Calculation of estimated needs based on logistics supply information and family planning service delivery information.

–Consensus forecasting, with annual update and identification of gaps in resources.

–Resource mobilisation through the Reproductive Health Co-ordination Committee.

Results

–Five-year funding framework with 100% resources committed from multiple donors for 1–2 years and 50% funding committed 3–4 years ahead of each annual forecast.

–The 1998 forecast mobilised US$28 million for family planning commodities.

• • Operational guidelines and service standards for managers at district health office, primary health care centre and health post levels,²³ which spell out who is responsible for reproductive health-related activities at the different levels, how these should be planned, implemented and monitored, and what human, logistic and financial resources are required.

With support from UNFPA and KIT, a small team from the DoHS developed and field tested the guidelines, and disseminated them during orientation workshops in each of Nepal's five regions. Yet despite regular re-training during routine monitoring and supervision, performance review workshops and supervision by UNFPA regional field officers, checklists and guidelines are not optimally used in the health facilities.

• • Clinical protocols²⁴ for staff training and quality improvement (Box 4). These protocols reflect contemporary international practices, adapted for Nepal from those used by WHO, UNICEF, JHPIEGO, Family Care International and the Ghana Ministry of Health. Each of the seven staff cadres has a separate clinical protocol manual.

In Nepal, the most comprehensive clinical protocols are those for the medical doctor. They consist of 66 items, covering all reproductive health services according to the Essential Reproductive Health Package. Protocols are presented in the form of flowcharts showing each step of the diagnostic and treatment process. For each level staff cadre below the doctors, the number of protocols and competencies required is fewer, according to their job descriptions. It took 18 months for protocol and guideline development, and implementation is ongoing. However, supervision has shown that use of the protocols for diagnosis and treatment in health facilities is inconsistent and irregular. Revision and re-formatting is needed for easier reference and use, which was planned to be carried out by the Ministry of Health, USAID and UNFPA in 2002.

• • IEC and community mobilisation materials. These were developed by the IEC sub-committee in 1998, with assistance from Johns Hopkins University, and provide guidance for the development and dissemination of materials. Different communication channels are being used; for example, female community health volunteers in isolated districts of Nepal were provided with a radio for distance learning and communication of reproductive health messages.

Element 5: Management of reproductive health information and services

New and improved management structures for service delivery take on growing importance under the country's decentralisation schemes. Substantial effort went into developing a “bottom-up planning, monitoring and evaluation cycle” which was designed to ensure the four major programmes (Family/Reproductive Health, Child Health Disease Control and Curative Services) would all manage their efforts in as complementary a way as possible. More specifically, this reform led to one integrated annual review at the health facility, district, regional and national levels, as well as one district, regional and national health plan.

Box 4. Clinical protocols

Purpose

–To standardise clinical diagnosis and treatment procedures for a rapid and quality response

Process

–All stakeholders agree on clinical standards.

–Collaborative design and field testing of clinical procedures by Johns Hopkins University, DFID.

–Protocols and operational guidelines prepared for the medical officer, nurse-midwife, health assistant, staff nurse, auxiliary health worker, maternal and child health worker, and village health worker.

–Protocols and operational guidelines for each staff cadre matched with appropriate job descriptions.

Content

–Each protocol consists of a one-page outline for assessment and diagnosis and a one-page flow chart for treatment and follow-up, presented in different chapters, for each element of the reproductive health package.

Using this integrated system, the DoHS introduced a series of system-wide managerial interventions, which included:

• building planning capacity from the health facility upwards through districts and regional health offices to the national level, with annual planning sessions at all operational levels;

• a monitoring and support system that includes detailed work plans, supervision schedules and checklists, provision of travel costs and transportation schemes; and

• a bottom-up performance review and evaluation mechanism to examine achievements, constraints and action to be taken for improved performance, within the context of the broader health system.

Until now, however, these essential management functions remain the “Achilles heel” of effective service delivery, particularly in remote areas of Nepal. Although plans and annual reports are more thorough and fully integrated, poor staff morale associated with work in extremely remote postings, low pay and little recognition continue to plague staff motivation. No managerial initiative has yet successfully addressed these underlying issues.

A second large-scale management initiative focused on improving the Health Management Information System (HMIS) (Box 5). The timing of efforts to establish a sector-wide HMIS largely coincided with the Ministry's decision to integrate previous vertical health projects within the DoHS (1993–94). This decision was complemented by growing interest among external aid partners to improve data collection systems for monitoring of national reproductive health programme performance. It took 15 months to prepare the HMIS, and nationwide training and implementation took an additional 12 months. Reporting from district level in the period 1994–99 increased from below 25% to 100%. Data are now being utilised more consistently to review performance, identify constraints and adjust work plans, although this is not yet systematic at district level and below. However, problems remain to be resolved. The quality of data and monitoring reports is inconsistent. Feedback systems are not well institutionalised below the district level and the lack of a recurrent budget for printing of the data collection and reporting instruments results in occasional stock-outs of forms.

Element 6: Policy review for continued progress

In 1998, a multi-sectoral Reproductive Health Steering Committee was constituted with the Ministry of Health as the Secretariat. It meets annually in December to review policies and adjust strategies as required, based on the decisions of the four-monthly meetings of the Reproductive Health Co-ordinating Committee and complemented by information from annual performance review meetings, international donor strategies and current health sector developments. This Committee involves health authorities and policymakers with decision-making authority from the highest levels and includes the Secretaries from the Ministry of Law and Justice, Women and Social Welfare, Local Development, Population and Education and the National Planning Commission. This Steering Committee takes decisions on policy direction, resource mobilisation strategies and collaborative mechanisms. It represents an important forum for partnership and high level co-ordination.

The first two meetings of the Reproductive Health Steering Committee took place in 1998 and 1999. The 1998 meeting launched the national reproductive health programme based on the draft National Reproductive Health Strategy document and in 1999, the Steering Committee formally approved the National Reproductive Health Strategy. The meeting in 2000 approved the Reproductive Health Contraceptive Consensus forecast and the meeting in 2001 focused on abortion and adolescent sexual and reproductive health policies.

Box 5. Health Management Information System

Process

–Reduction in data collection and reporting instruments from more than 100 to 29.

–Training of approximately 15,000 health workers (all district managers and service providers from the 75 districts) in the integrated HMIS reporting format.

Partners

–The Ministry of Health, with support from technical agencies (New Era/JSI, GTZ, USAID, UNFPA/KIT) for design and field testing, and training in data collection instruments and computerised data analysis.

Discussion

To date, no systematic evaluation has taken place to identify the impact of the policy and programme changes described in this article. Most of what happened was the result of a slow and often opportunistic change process. Two sources of information provide a useful perspective on the progress of this change process. In 2001–02, UNFPA/KIT and the Nepal Department of Health Services assessed the relevance and extent of utilisation of selected HMIS tools, operational guidelines and reproductive health protocols at health facilities in 15 districts. In a separate exercise, they looked at the availability and use of the reproductive health atlas, the national reproductive health research strategy and the reproductive health annotated bibliography at national level. Both were informal, internal assessments, and as such, the findings were used for feedback to programme managers only.

While there was nearly uniform agreement among health workers interviewed at facilities at district level and below that HMIS tools, clinical protocols and operational guidelines were highly relevant to their work, several persistent problems with utilisation were noted. Health workers pointed to a lack of financial resources and limited motivation to undertake the additional work required for more efficient, quality reproductive health programming. This attitude was widespread throughout the different levels of the health system and was most prevalent among the lowest level (sub-health post/health post) trained staff. However, lack of motivation is observed across the entire civil service and is not unique to the health sector. It is likely that substantial structural reform would be required to tackle it.

The response rate among donor and technical assistance agencies, (international) NGOs and Government representatives at national level was not high enough to allow for meaningful analysis of availability and utilisation of strategy and policy documents, and tools. Anecdotal evidence suggests that availability of these documents in offices around Kathmandu is excellent, and that the documents are appreciated and consulted in policy and programme dialogue on reproductive health. Virtually all visiting missions and consultants refer to the DoHS annual reports, and many also refer to the Atlas. At the same time, neither donors nor the MoH have taken steps thus far to revise and improve existing policies or to produce updated versions of the Atlas and bibliography.

Evidence of the impact of policy and programme changes for the Nepalese population comes from the 2001 Demographic and Health Survey.²⁵ It reports considerable improvements for three reproductive health indicators. A sharp increase in new family planning clients was observed during the period 1989–99, as compared to the previous two decades. As could be expected with increased family planning coverage, total fertility rates dropped from 4.6 in the period 1993–95 to 4.1 in 1998–2000. Similarly, steady increases in antenatal coverage and assisted deliveries were noted during 1996–2001.

While a multitude of factors contribute to changing trends in impact indicators, we believe that the gradual translation of policy and programme changes into operational strategies has motivated health workers to improve performance and increase quality and coverage of services. To those attending the regional and national annual performance reviews, it is clear that health workers appreciate the peer review of performance and seek opportunities to show progress in their respective coverage areas. Improved performance of the health system can also be linked to the increase in the number of community volunteers and primary health care outreach sites, and the increase in the number of sub-health posts during the same period.

Certain characteristics of the Nepalese context have facilitated the gradual implementation of policy and operational changes in the health system, particularly in relation to the national reproductive health programme. These include:

• continuous and dedicated leadership within the Department of Health Services during 1994–2001.

• a broader policy environment where an essential reproductive health service package could be introduced through dialogue and consultative priority setting;

• a consortium of innovative and well resourced technical assistance agencies (USAID, DFID, GTZ, UNFPA/KIT, UNICEF, WHO, JHPIEGO) able to place residential and short-term national and international advisors in the DoHS in Kathmandu as well as the regions;

• willingness of Government and external development partners to work together toward common goals and objectives; and perhaps most importantly,

• a substantial pool of unmet need for reproductive health services, which enabled “supply side” approaches to have a rapid impact.

The Nepal model is being adapted and used in the operationalisation of reproductive health in other countries, with the involvement of the authors and colleagues of ours, in the following ways:

• national reproductive health strategy (Eritrea, Mozambique, Viet Nam, Zimbabwe);

• clinical protocols and operational guidelines (Mozambique);

• clinical protocols (Eritrea);

• consensus forecasting of reproductive health commodities, supplies and equipment (Eritrea).

Country-level experiences with a strategic approach for integrating reproductive health in the context of broader health system changes are limited. Where they exist, they are not well articulated, documented or shared. This six-element framework presents the constituents of a complex change process in a health system constrained by poor human and financial resources, in a country with extremely difficult geography and strong cultural, religious and social traditions. The most causal or direct evidence of change was observed at the national level, and to a lesser extent among regional and district health management teams. However, no causal link can be drawn between instruments and tools described in each element and the marked improvement in a selection of reproductive health impact indicators. This suggests a need for future research to identify linkages between reproductive health policy reform and improvements in implementation. Such research would improve our capacity to prioritise and select the most cost-effective strategies and interventions possible in a given context. In any case, the authors believe that there will always be a motivated few who, when given access to some of the policy and operational tools described in this article, will contribute to improvements in coverage and quality of reproductive health services.

Figure 2 Clinic for the poor, Calcutta, India, 1993

Acknowledgements

The authors wish to thank Dr Kalyan Raj Pandey, former Director General, DoHS, and TB Dangi, Muniswor Mool and Ajit Pradhan, DoHS team members. Additional thanks go to Sher Choudhary, Pradeep Pyakuryal, Chet Nath Chaulagai, Gyanu Shrestha, Vinaya Dhakhwa, Madhukar Shrestha and Mahesh Suwal, invaluable members of the UNFPA Technical Support team. DB Lama, former Assistant Representative, UNFPA/Nepal, facilitated the provision of technical and financial support. The authors also gratefully acknowledge support from the Health Department of KIT and the Department of Foreign Affairs, Netherlands.