Biannual Report_July_Dec_2009

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					Support to Safe Motherhood Programme, Nepal
   A part of Government of Nepal National Safe Motherhood Programme




                                            Bi-Annual Report


                                                 Reporting Period:
                                            July to December 2009




                                                       630/05/DFID
                     Support to Safe Motherhood Programme, Nepal
           (A part of Government of Nepal National Safe Motherhood Programme)



                                  General Information




Country:                         Nepal

Project Title:                   Support to Safe Motherhood Programme (SSMP), Nepal

Project Duration:                Five Years (including no-cost extension)
                                 (1st December 2004 – 30th June 2010)

Reporting Period:                1st July – 31st December 2009

Date of Report:                  February 2010

Project Reference:               CNTR 04 5769

Participating Institutions:      Ministry of Health and Population, Government of Nepal
                                 Options Consultancy Services Ltd., UK
                                 HLSP Ltd
                                 Organisation Development Centre, Nepal

Options Contract Director:       Todd Petersen

Options Project Manager:         Sarah Hepworth

Team Leader, Nepal:              Wilda Campbell (up to end November 2009)
                                 Greg Whiteside (from December 2009)

Next Report Due:                 July 2010




                                                  HLSP Ltd
Table of Contents

LIST OF ACRONYMS...................................................................................................... i

EXECUTIVE SUMMARY ............................................................................................... iv

   1. Overview ........................................................................................................................... iv
   2. Progress against goal and purpose .................................................................................... v
   3. Summary of key achievements for each output .................................................................. v

1. INTRODUCTION AND OVERVIEW ............................................................................ 1

2. PROGRESS AGAINST THE LOGICAL FRAMEWORK: NARRATIVE ...................... 3

   2.1 INTRODUCTION ............................................................................................................ 3
   2.2 PROGRESS AGAINST GOAL AND PURPOSE ............................................................. 3
   2.3 PROGRESS AGAINST OUTPUTS ................................................................................. 5
     Output 1: Equity and Access ............................................................................................... 5
     Output 2: Service Strengthening ......................................................................................... 9
     Output 3: Public Private Partnerships.................................................................................24
     Output 4: Decentralisation ..................................................................................................25
     Output 5: Human Resource Development ..........................................................................26
     Output 6: Information .........................................................................................................30
     Output 7: Physical Assets and Procurement ......................................................................33
     Output 8: Finance and Aama Programme ..........................................................................36


3. PROGRESS AGAINST INDICATORS IN THE LOGICAL FRAMEWORK: MATRIX
...................................................................................................................................... 42

ANNEX 1: Key Findings of the Maternal Mortality and Morbidity Study ................. 52

ANNEX 2: Summary of Key Points for EAP End of Contract Report ...................... 53

ANNEX 3: Equity and Access Programme KAP Study: Summary of Findings ...... 56

ANNEX 4: CEOC Sites established and functioning by Region: July to December
2009 .............................................................................................................................. 61

ANNEX 5: Executive Summary of Appreciative Inquiry Evaluation ........................ 64

ANNEX 6: Hints and Tips for District Safe Motherhood ........................................... 67

ANNEX 7: UNITED MISSION TO NEPAL END OF PARTNERSHIP REPORT ........... 71
ANNEX 8: UNICEF END OF PARTNERSHIP REPORT .............................................. 77

ANNEX 9: SBA Follow Up Recommendations .......................................................... 81

ANNEX 10: Terms of Reference for Regional Training Coordinators ..................... 85

ANNEX 11: Standard Function and Space Allocation for all levels of Health
Facility .......................................................................................................................... 88

ANNEX 12: Summary of Points from Field: August and September 2009 ............. 89

ANNEX 13: Distribution of New Facilities ................................................................. 91

ANNEX 14: Progress of Construction Work by Facility Type ................................ 92
LIST OF ACRONYMS


AAN      ActionAid Nepal
AI       Appreciative Inquiry
ANC      Antenatal Care
ANM      Auxiliary Nurse Midwife
BCC      Behaviour Change Communication
BEOC     Basic Emergency Obstetric Care
BPKIHS   BP Koirala Institute of Health Sciences
CAC      Comprehensive Abortion Care
CBS      Central Bureau of Statistics
CEOC     Comprehensive Emergency Obstetric Care
CREHPA   Centre for Research in Environment Health and Population Activities
C/S      Caesarean Section
CTEVT    Council for Technical Education and Vocational Training
DACAW    Decentralised Action for Children and Women
DDC      District Development Committee
DfID     Department for International Development
DoHS     Department of Health Services
D/PHO    District Public Health Office
DUDBC    Department for Urban Development and Building Construction
EA       Equity and Access
EAP      Equity and Access Programme
EOC      Essential/ Emergency Obstetric Care
FA       Financial Aid
FCHV     Female Community Health Volunteer
FHD      Family Health Division
FPAN     Family Planning Association of Nepal
FY       Fiscal Year
GIS      Geographic Information System
HFMC     Health Facility Management Committee
HIIS     Health Infrastructure Information System
HMIS     Health Management Information System
HP       Health Post


                                                                               i
HSIS      Health Sector Information System
HSR-SP    Health Sector Reform Support Programme
IoM       Institute of Medicine
IUD       Intra Uterine Device
JAR       Joint Annual Review
KAP       Knowledge Attitudes and Practices
LMD       Logistics Management Division
LMIS      Logistics Management Information System
MBBS      Bachelor of Medicine and Surgery
MCHW      Maternal and Child Health Worker
MD        Management Division
MDGP      Medical Doctor General Practitioner
MMM       Maternal Mortality and Morbidity
MMR       Maternal Mortality Ratio
MoHP      Ministry of Health and Population
MSI       Marie Stopes International
MVA       Manual Vacuum Aspiration
NAMS      National Academy of Medical Science
NDHS      Nepal Demographic and Health Survey
NESOG     Nepal Society of Obstetricians and Gynaecologists
NFHP      Nepal Family Health Programme
NGO       Non-Governmental Organisation
NHEICC    National Health Education Information Communication Centre
NHTC      National Health Training Centre
NHSP II   Nepal Health Sector Programme (2)
NPHL      Nepal Public Health Laboratory
NSI       Nick Simons Institute
PHCC      Primary Health Care Centre
PNC       Postnatal Care
PHN       Public Health Nurse
QI        Quality Improvement
RHCC      Reproductive Health Coordination Committee
SBA       Skilled Birth Attendant
SDIP      Safe Delivery Incentives Scheme
SHP       Sub Health Post

                                                                       ii
SMNF     Safe Motherhood Network Federation
SMNH     Safe Motherhood and Newborn Health
SSMP     Support to the Safe Motherhood Programme
TA       Technical Assistance
TCIC     Technical Committee for Implementation of Comprehensive Abortion Care
THW      Trained Health Worker
TUTH     Tribhuvan University Teaching Hospital
UMN      United Mission to Nepal
UNFPA    United Nations Fund for Population Activities
UNICEF   United Nations Children’s Fund
VDC      Village Development Committee
WHO      World Health Organisation




                                                                                 iii
EXECUTIVE SUMMARY


1. Overview

The Support to the Safe Motherhood programme (SSMP) partnership agreements with
UNICEF, United Mission to Nepal (UMN), Ipas and ActionAid ended during this reporting period,
and as SSMP moves towards closure, the focus has been on evaluation of achievements at all
levels, and ensuring their sustainability. To this end, the SSMP/ Options team and partner
organisations have been actively involved in planning for the next Nepal Health Sector
Programme (NHSP II, 2010-15).

Two major SSMP/ Options supported studies, the Maternal Mortality and Morbidity (MMM)
Study and the Equity and Access Programme (EAP) Knowledge Attitudes and Practices (KAP)
Study were completed and disseminated, providing important benchmarks on sub-sector
progress and pointers for the future. Both studies highlight the importance of human resource
availability in determining facility functionality. The MMM Study validates the Maternal Mortality
Ratio (MMR) of the 2006 Nepal Demographic and Health Survey (NDHS), estimated at 281
deaths per 100,000 live births. However, the finding that suicide has replaced maternal causes
as the leading cause of death among women of reproductive age raises urgent questions about
the rights of women and underlying issues of mental health and gender based violence. SSMP/
Options is working closely with ActionAid to better understand and respond to these issues.

The KAP study found dramatic increases in Safe Motherhood and Newborn Health (SMNH)
service utilisation among targeted communities, with facility deliveries up from 20% to 40% in
the three-year EAP period and the equity gap closing across social groups. This is highly
relevant to NHSP II design, which is expected to carry a major equity focus.

Evidence is emerging that the new Aama programme (combining free delivery care with
maternity incentives) is a strong contributing factor to a doubling in the number of birthing
centres offering 24-hour delivery services (from 254 to 532). A recent SSMP/ Options
contracted study, examining the impact of Appreciative Inquiry (AI) in 50 health facilities in 28
districts, found the combined effects of Aama and AI inputs resulted in all facilities initiating 24-
hour services shortly after the AI review and planning workshop and a consequent increase of
55% in institutional deliveries.

Additional DfID funding to study the impact of Free Essential Health Care Services will be used
to assess Aama at household, facility and Ministry level: a six-district household study will
examine usage of the scheme; an Emergency Obstetric Care (EOC) facility study will track
delivery types and quality of monitoring; and a fee reimbursement study will examine the impact
on facility finances. A final Rapid Assessment is also planned and a synthesis of findings from
all studies will be used to inform implementation under NHSP II.




                                                                                                   iv
2. Progress against goal and purpose

Comparing figures for the Fiscal Year (FY) 2008/09 with those of FY 2007/08, three of the four
purpose level indicators were met1:

1.   Skilled attendance at birth increased by at least 4% per year: There was an increase of
     0.9%, from 23.9% of births to 24.8% (source HMIS) – target not met.

2.   Facility deliveries increased by at least 2% per year: There was an increase of 2.3%, from
     20.2% of births to 22.5%. This is a considerable improvement on progress in 2007/08,
     when the increase was only 0.5 percentage points (source HMIS) – target met.

3.   Met need for EOC increased by at least 3% per year: There was an increase of 6.3%, from
     24.9% in 22 districts to 31.2% in 26 districts (source FHD) – target exceeded.

4.   Met need for caesarean sections increased by at least 4% per year: There was an increase
     of 51%, from 50% in 22 districts to 101% in 26 districts (source FHD) – target exceeded.

This is the first year comparative figures have been available for delivery by Skilled Birth
Attendant (SBA), as opposed to trained health worker, for indicator 1. It is interesting to note
that in fact total deliveries by trained health worker have remained the same, at 41.3%, because
assisted home deliveries dropped from 21.2% to 18.8%, exactly compensating for the increase
in facility deliveries2.



3. Summary of key achievements for each output

Output 1: Equity and Access

The contract with ActionAid Nepal to manage targeted social mobilisation activities in eight
selected districts, with mass media inputs in two districts, ended in September, but minimum
support is continuing under a short term agreement (December 2009 to end of June 2010),
enabling ActionAid to extend their community level support for district NGO partners, local
groups and networks. It is hoped this will promote sustainability of achievements by building the
capacity of groups and networks to continue activities and encouraging NGOs to incorporate
SMNH activities, including addressing violence against women, into their other programmes.

Key Achievements during the reporting period were:




1
 For these calculations, a new lower denominator was used, based on the revised figure for expected pregnancies
calculated from the reduced fertility levels found in the 2006 NDHS
2
 All facility deliveries are professionally assisted, but it is not possible to identify whether by SBA (doctor, nurse,
ANM) or trained health worker (doctor, nurse, ANM, Health Assistant, Auxiliary Health Worker, Maternal and Child
Health Worker).

                                                                                                                     v
   Completion of the EAP end-line KAP survey, with excellent results, showing substantial
    increases in SMNH knowledge and healthy practices, including greatly increased service
    utilisation
   Scaling up of EA activities under Financial Aid (FA) funding in new areas of seven of the
    existing EA districts and in three new districts
   Expansion of the National Health Education Information and Communication Centre
    (NHEICC) Safe Motherhood BCC Working Group to include a wider membership, thus
    promoting increased collaboration among stakeholders and greater consistency in message
    and materials development.

Output 2: Service strengthening

With the ending of the partnership agreements with UNICEF, in eight districts, and UMN, in two
districts, SSMP/ Options has focused on ensuring their learning and achievements are
incorporated into future planning and policy development, both immediately and for NHSP II.
Human resource deployment continues to be a critical issue for service delivery in all districts.
The agreement with Ipas for safe abortion support ended in June, but has continued in a
reduced form through FA in the areas of infrastructure, equipment, training and policy advocacy.
Using alternative funding, Ipas is continuing to support Family Health division (FHD) in
implementing the national safe abortion programme.

Key Achievements during the reporting period were:

   Establishment of Comprehensive EOC (CEOC) services with caesarean sections in four
    new districts
   Completion of the AI evaluation, showing a positive impact on health facility functionality,
    including provision of 24-hour services at peripheral facilities, improved quality of services
    and better relations between facilities and communities
   Approval of the Remote Area Guideline for Safe Motherhood, outlining practical measures
    to help meet the specific needs of marginalised women living in remote areas.

District support: United Mission to Nepal (two districts)

The SSMP/ UMN partnership was scheduled to end in July, but a limited extension was agreed
until November. During this period formal support was discontinued in Rupandehi, but activities
have continued in Mugu, as this is a remote and under resourced district where UMN has a
wider, continuing programme. All 13 supported health facilities in the two districts are providing
24-hour services (one of the Mugu health posts for home deliveries only), with Health Facility
Management Committees (HFMC) taking responsibility for sustaining this.

Key achievements during the reporting period were:

   Completion of a video, based on SSMP/ UMN experiences in Mugu and Rupandehi, which
    was widely shared
   Establishment of blood transfusion services at Mugu District Hospital
   Continuation of increased delivery service utilisation in all supported health facilities. In
    Mugu Hospital there was a 15% increase compared with the same period last year.




                                                                                                vi
District Support: UNICEF (eight districts)

The SSMP/ UNICEF partnership supporting SMNH service strengthening and equity and
access inputs in eight districts (Saptari, Panchthar, Udayapur, Kavre, Dang, Achham, Jumla and
Humla) ended in December, but UNICEF is continuing the work using alternative funding. At the
request of FHD, UNICEF has also provided support to Bheri Zonal Hospital in Nepalgunj, Banke
District, as a referral hospital for women from Humla needing CEOC services.

Key achievements during the reporting period were:

   Increased availability of 24-hour delivery services at peripheral health facilities, with a
    further 19 new birthing centres established, making a total of 109 since the programme
    started in 2005/06
   Increase in health facility births in the supported districts, from an average of 11% in
    2005/06 to 18% in 2008/09
   Six out of the nine CEOC sites are currently functioning, up from three in 2006, although
    this is dependent on the availability of surgically skilled doctors at the sites. Met need for
    EOC has increased in all districts except one, and averages 28%, up from 24% in 2005/06.


Output 3: Public private partnership

SSMP/ Options has continued to seek opportunities for promoting involvement of the private
sector in supplementing and expanding public health services. This ranges from small
community hospitals and organisations to larger private hospitals and medical colleges,
including both non-profit and for-profit. Professional associations and councils are also
important partners in areas such as human resource development. Private sector institutions
are major providers of safe abortion services and are involved in the SBA training programme.

Output 4: Decentralisation

SSMP/ Options and partners have contributed to significant local capacity building and
institution development, which will be important in feeding into government decentralisation
efforts or plans for state restructuring along federal lines. Rights based training and orientation
for local stakeholders, including government line staff, has increased the accountability of duty
bearers and empowered right holders to claim these rights. Appreciative inquiry approaches
have complemented this effort and promoted local initiatives such as staff recruitment and
mobilisation of local resources for infrastructure improvements. Supportive work with local
institutions, such as Village Development Committees (VDC), HFMCs, Reproductive Health
Coordination Committees (RHCC), District/ Public Health Offices (D/PHO) and other line
agencies, has increased their capacity to further develop local services.

Output 5: Human Resources

Production of SBAs continues to be the major focus for this output, particularly through in-
service training, in collaboration with the National Health Training Centre (NHTC). A total of
1,215 SBAs have been trained since 2007, when the programme began. During this reporting
period, 286 were trained, representing just over 25% of the planned numbers (1,010) for the
fiscal year (by July 2010). Training start-up was delayed by the late approval of the annual
national budget, which means the target for the year may not be met. SSMP/ Options has
continued to work closely with the safe motherhood focal person in NHTC, building capacity for

                                                                                                vii
planning and implementation, and to collaborate with FHD, JHPIEGO and Nick Simons Institute
(NSI). The short term agreement for technical assistance with IntraHealth ended in June.

Key achievements during the reporting period were:

   NHTC’s implementation of the in-service SBA training operational plan developed in the last
    reporting period to ensure strategic need based training
   Completion and dissemination of SBA post-training follow up pilot and report, providing
    substantial learning for the trainers about facility level realities for SBAs and proving that
    effective follow up is possible using government systems
   Approval of the Strategy for Human Resources in Safe Motherhood and initiation of its
    implementation to address some of the critical staff shortages that constrain service
    provision.
   Completion of advanced CEOC training (caesarean section) for the first batch of two MBBS
    doctors, who are now confidently providing regular services.

Output 6: Information

This area of SSMP/ Options technical assistance has continued to support work under all the
other programme outputs, especially during this final phase of the programme, when evaluation
of activities and achievements is a major focus. Areas of particular importance during this
reporting period have been the 2008/09 MMM Study analysis, report and dissemination, and
piloting of the new Health Sector Information System (HSIS).

Key Achievements during the reporting period were:

   Completion of analysis of MMM Study data and dissemination of the main preliminary
    findings at a half-day stakeholder meeting, accompanied by publication of a summary
    report. The event was a high spot for SSMP, attracting widespread interest and high level
    discussion, which will certainly feed into future sub-sector planning
   Completion of the Geographic Information System (GIS) based SMNH atlas, with final
    corrections
   Completion of analysis of the EAP end-line KAP, providing solid evidence of the success of
    targeted EA inputs.

Output 7: Physical assets

Technical assistance under this output has continued to cover all aspects of physical assets
management and procurement, including construction and maintenance of health buildings, and
procurement of drugs, commodities and equipment. Although the main focus is on enabling
quality SMNH services, support has also contributed to systems development that benefits the
whole health sector.

Key achievements during the reporting period were:

   Completion of construction of two CEOC sites, two Basic EOC (BEOC) sites, nine birthing
    centres and three Comprehensive Abortion Care (CAC) sites, making a total of 10, 15, 86
    and 4 respectively since the programme began
   Completion of standard designs for Terai health facilities of all levels; these are based on
    agreed health facility standards and are now being implemented


                                                                                               viii
   Completion of a five-year district analysis of construction work and investments, showing
    increasing investment in peripheral facilities and in previously under-resourced districts in
    the mid and far west.

Output 8: Finance

Detailed analysis of FA spending by all the divisions and centres shows the total government
spending decreased to 66% of the allocated FA in FY 2008/09, down from 71% in 2007/08.
However, this represents a larger amount of money; Rs.452,455,650 compared with
Rs.293,394,320 in 2007/08, an increase of 54% in actual spending. The National Public Health
Laboratory, NHEICC and Management Division were the highest percentage spenders, at 99%,
86% and 83% respectively. NHTC and Logistics Management Division (LMD) were the lowest,
at 35% and 11% respectively. The NHTC figure reflects a lack of capacity to organise a very
centralised training programme; LMD’s spending was reduced by their decision not to go ahead
with the planned construction of a biomedical laboratory. FHD’s spending is generally high, but
this time was reduced by the lack of procurement, which was managed directly by DfID.

Aama Programme

The Aama Programme was launched in January 2009, combining maternity incentives with free
delivery care at all government health facilities and certain approved community/ NGO and
private institutions. The new programme has benefited from the learning of the previous safe
Delivery Incentives Programme (SDIP), reflected in better management procedures. Already
there are indications of its potential to significantly increase facility deliveries and provision of
24-hour services at peripheral level. Many more private (NGO and for-profit) institutions are
requesting inclusion in the scheme.

Key Achievements during the reporting period were:

   Revision of the facility level cost guidelines to more realistic levels that fully cover the cost
    of providing services, based on feedback from hospitals
   Increased numbers of peripheral health facilities implementing Aama, contributing to a 26%
    increase in the number of local birthing centres providing 24-hour services. There has also
    been a 55% increase in the number of CEOC sites, although this is mainly due to private
    sector growth, and a 32% increase in BEOC service provision (mainly government)
   Increased numbers of women receiving the cash incentives; this has risen from 30% of
    women delivering in a facility in FY 2005/06 to 89% in 2008/09.




                                                                                                   ix
1. INTRODUCTION AND OVERVIEW

As the Support to the Safe Motherhood Programme (SSMP) entered its final year, the period
July to December 09 provided an important opportunity to apply programme learning to early
planning for MoHP’s new Nepal Health Sector Programme (NHSP II, 2010-15). Thus, even as
the majority of programme partnerships drew to a close, a heightened emphasis was placed on
analysis and dissemination – particularly through NHSP II’s various thematic working groups.

Important new knowledge also became available in the reporting period through two SSMP/
Options supported studies. These were the Maternal Mortality and Morbidity (MMM) Study
funded by USAID and DFID and the Equity and Access Programme (EAP) Knowledge, Attitudes
and Practices (KAP) Study.

Chief among the MMM Study’s findings was broad verification of the 2006 Nepal Demographic
and Health Survey (NDHS) Maternal Mortality Ratio (MMR) of 281 deaths per 100,000 live
births and confirmation that Nepal is on track to meet Millennium Development Goal Five.
Improved referral practices and significant reductions in postpartum haemorrhage were notable
improvements reported on 1997 levels. However, the finding that suicide had replaced maternal
causes as the leading cause of death among women of reproductive age is alarming and raises
urgent questions about women’s rights in the family and related issues of mental health and
gender based violence. Following the provision of additional funding from DFID’s social
development budget, SSMP/ Options is now continuing its partnership with ActionAid to better
understand and address these issues.

The EAP end-line KAP study provided important insights into overcoming demand side barriers
to Safe Motherhood and Newborn (SMN) health care services with substantial increases
reported in service utilisation among targeted marginalised communities. Deliveries in health
facilities rose from 21% to 40% in a three-year period - several times the national average - with
a clear closing of the “equity gap” across social groups. Importantly, this reverses the trend
reported in the 2006 NDHS of increasing differentials across wealth quintiles and is seen to
have high relevance for NHSP II which is expected to have a strong equity focus.

Both studies highlighted the importance of human resource availability in determining health
facility functionality and several advances were made on this critical issue in the reporting
period. Firstly, the Ministry of Health and Population (MoHP) approved its Safe Motherhood
Human Resource Strategy and Plan which includes the expansion of local health staff
contracting, the establishment of new training facilities and the launch of a new one-year
diploma course for gynaecologists. And secondly, SSMP/ Options supported a study on post-
training follow up of Skilled Birth Attendants (SBAs) which identified a clear need for more in-
service monitoring, mentoring and support. This led directly to the National Health Training
Centre (NHTC) establishing five new Regional Training Coordinator positions. Much more
needs to be done however if Millennium Development Goal targets are to be met including a
substantial scaling up of SBA production with over 10,000 additional SBAs required by 2015.

Other significant developments in the reporting period include the full roll out of MoHP’s flagship
“Aama” programme which combines free delivery services with maternity cash incentives.
Following revision of the operating guidelines – and notably the adjustment of reimbursable fees
- a doubling in the number of birthing centres offering 24-hour delivery services (from 254 to
532), has been reported with Aama seen as a major contributing factor. Further, the third Aama
Rapid Assessment, submitted by CREHPA in July, showed that 89% of eligible women had

                                                                                                 1
received the cash incentive – up from 30% under the Safe Delivery Incentive Programme
(SDIP) in 2005/06. Aama has also attracted attention from top political leadership in Nepal with
Prime Minister Madav Kumar Nepal highlighting the initiative in his Fall 2009 address to the UN
General Assembly.

Despite these positive indications, it is acknowledged that more needs to be done to fully
understand the impact of Aama at household, facility and institutional levels and in November
2009, DFID provided some additional funding for several focused studies. These include a six-
district household study to examine utilisation and impact at community level; an Emergency
Obstetric Care (EOC) facility study to track deliveries by type and service quality; a fee
reimbursement study to examine the impact of the programme on health facility finances and,
finally, a fifth Rapid Assessment.

While Aama appears to be impacting decisively on service availability and utilisation
Appreciative Inquiry (AI) inputs are also seen to be contributing to improved service availability
and quality of care. A recent SSMP/ Options study examined the impact of AI review and
planning workshops in 50 health facilities in 28 districts and showed that all facilities moved to
24-hour opening shortly afterwards and that institutional deliveries rose by 55% in the study
period. The study further suggests that AI’s approach of promoting individual responsibility
within a team work structure is an effective means for bringing about much needed changes in
deeply engrained traditional working practices. These inputs appear well suited to scaling up
under NHSP II and have been proposed as a key activity in the draft results framework.

Other Family Health Division (FHD) initiatives supported in the reporting period include trials on
the use of mobile phones by peripheral health workers in three districts. Early results show
promise with more accurate medical diagnosis, improved case management and referral
practices all reported.

In addition, FHD approved the local contracting of NGOs for equity and access programming in
ten districts using Financial Aid (FA) funds. This initiative is further supported by MoHP’s recent
approval of a Gender Equity and Social Inclusion Strategy, supported by RTI with SSMP/
Options. Prospects for expanding Equity and Access (EA) initiatives under NHSP II are seen to
be significantly strengthened as a result of these initiatives.

Implicit in government plans to improve the quality of health facilities is the need for upgraded
architectural designs, engineering standards and building construction guidelines. To this end
the Department of Urban Development and Building Construction (DUDBC), supported by
SSMP/ Options, finalised designs for all health infrastructure in the Terai and is currently on
track to complete the same for hill and mountain facilities in early 2010. During the reporting
period, procurement of the medical equipment and furniture needed for health facilities was
undertaken directly by DfID through Charles Kendall and Associates, with two of six batches
reaching Nepal by December. Responsibility for procurement for 2009/10 has reverted to
Logistics Management Division (LMD) but with Crown Agents lined up to provide third party
quality inspection.

Measuring sub-sector progress under NHSP II will, to a great extent, depend on baseline and
trend data drawn from the national Health Management Information System (HMIS). During the
reporting period, SSMP/ Options supported revision of the denominator figures used for all
population and pregnancy related calculations under HMIS. This resulted in national purpose
level data for SMNH being adjusted upwards.


                                                                                                 2
2. PROGRESS AGAINST THE LOGICAL FRAMEWORK: NARRATIVE


2.1 INTRODUCTION

During this reporting period, the SSMP/ Options advisers have been closely involved in the
process of developing the next phase of NHSP II, participating actively in the thematic working
groups, which cover: essential health care; human resources; procurement and distribution;
physical facilities; primary health care; non-state engagement; resources and budgeting;
accountability and governance; cross cutting issues (such as gender and social inclusion). This
is an important activity to ensure the learning and achievements of SSMP, in working so closely
with government colleagues, are carried forward and built upon in the future.

The agreements with the five implementing partners have now all ended: Johns Hopkins
University in September 2008, and the other four in 2009 - Ipas in June, ActionAid in
September, United Mission to Nepal (UMN) in July (extended to November) and UNICEF in
December. This marks the end of directly supported district implementation activities, but
partners are continuing to provide inputs in different ways. This reporting period and the coming
months are therefore a time of consolidation and evaluation of achievements, feeding into
recommendations for future areas of support for the Government. Finalisation of the Maternal
Mortality and Morbidity (MMM) Study and the Equity and Access Knowledge Attitudes and
Practices (KAP) Survey has been an key element of this, and other studies are planned.



2.2 PROGRESS AGAINST GOAL AND PURPOSE

Goal: The results of the MMM Study were very powerful, with indications of good progress in
some areas, such as reduction in deaths from postpartum haemorrhage, but also highlighting
areas that require more attention. The Maternal Mortality Ratio (MMR) found for the eight study
districts was 229 maternal deaths per 100,000 live births, a figure that supports the national
estimate from the 2006 Nepal Demographic and Health Survey (NDHS) of 281 deaths per
100,000 live births, which represents significant progress towards the Millennium Development
Goal target of 134 by 2015. Annex 1 lists the key findings of the study.

Purpose

Indicator 1: The last full Fiscal Year (FY), ending in mid-July 2009, was the first time
comparative figures were available from the national Health Information Management System
(HMIS) for total deliveries (home and facility) assisted by a Skilled Birth Attendant (SBA). Using
a denominator based on the revised figure for expected pregnancies, which was calculated from
the reduced fertility levels found in the 2006 NDHS, a modest increase of 0.9 percentage points
is seen, from 23.9% of births to 24.8%. Although this does not meet the target of 4% increase
per year, it can be argued that the rate of increase will rise as more SBAs are trained and more
people know about them. (Indicator not met but likely to improve)

Indicator 2: Facility deliveries have also increased, by 2.3 percentage points, from 20.2% of
births to 22.5%. This is just over the target of 2% increase per year, and represents a
considerable improvement on progress in 2007/08, when the increase was only 0.5 percentage
points. (Indicator met)


                                                                                                3
Figure 1 shows the trend lines for facility delivery (by trained health worker), home delivery by
trained health worker and the new data for delivery by SBA3. It is interesting to note that total
deliveries by trained health worker have remained the same, at 41.3%, as home deliveries have
dropped, from 21.2% to 18.8%, exactly compensating for the increase in facility deliveries. This
is very encouraging in the light of the government aim to increase the number women delivering
in a facility, and previous experiences showing that figures for home delivery by trained health
worker were often inflated.

Figure 1: Trend lines for skilled assistance at delivery




Note: For 2007/08 and 2008/09 the new denominator, based on lower expected pregnancy rate, has been used

As the Aama programme (providing free delivery care with incentives) was only launched in
January 2009, more than half way through the last fiscal year, it can be expected that, in this
first full year of implementation (2009/10), facility deliveries will increase even more, as more
women know about the programme and are able to utilise it. It should also be noted that
deliveries in Emergency Obstetric Care (EOC) centres that are being monitored by Family
Health Division (FHD) have increased by 6.9 percentage points, from 15.4% in 22 districts in FY
2007/08 to 22.3% in 26 districts in FY 2008/09 (see Figure 2).

Indicator 3: Again using the new denominators based on revised figures for expected births,
results for met need EOC increased by 6.3 percentage points, from 24.9% in 22 districts in FY

3
 Trained health worker includes doctor, nurse, ANM, Health Assistant, Auxiliary Health Worker, Maternal and Child
Health Worker, whereas SBA covers only doctor, nurse, ANM.

                                                                                                               4
2007/08 to 31.2% in 26 districts in FY 2008/09, comfortably exceeding the national target of 3%
increase per year. (Indicator exceeded)

Indicator 4: Met need for caesarean section increased by an astounding 51 percentage points,
from 50% in 22 districts in FY 2007/08 to 101% in 26 districts in FY 2008/09, well above the
national target of 4% increase per year. See Figure 2 for trends in EOC monitoring data.
(Indicator exceeded)

Figure 2: Trends for met need for EOC and caesarean section and births at EOC centres




Note: New denominator, based on lower fertility rate, used for 2007/08 and 2008/09 figures only




2.3 PROGRESS AGAINST OUTPUTS

Output 1: Equity and Access

The Equity and Access (EA) component of SSMP comprises three main areas of activity and
support to the Ministry of Health and Population (MoHP): (1) advocacy and support at Ministry
level to promote incorporation of rights, social inclusion and equity in health programming,
particularly a Gender and Social Inclusion Strategy for Health; (2) support to the National Health
Education Information Communication Centre (NHEICC) in Behaviour Change Communication
(BCC) initiatives and materials development; (3) support for district and community level
activities to increase equitable access to Safe Motherhood and Newborn Health (SMNH)
services and thus increase service utilisation.

Until September 2009, targeted social mobilisation activities in eight selected districts, plus
mass media inputs in two districts, were managed by ActionAid Nepal, as the EA agency under
a long term contract with SSMP/ Options. The EA Programme (EAP) was implemented through


                                                                                                  5
26 district NGO partners and two voice capturing agencies. With the ending of this contract in
September, minimum support has been continued for successful district level activities under a
short term agreement with ActionAid (December 2009 to end of June 2010), enabling them to
extend their work with local partners and encourage them to incorporate SMNH activities,
including addressing violence against women, into their other programmes. Key points from the
EAP end of contract report, summarising achievements, reflecting on the partnership process
and including recommendations for the future, are included as Annex 2.

Key Achievements

   Completion and dissemination of EAP end-line survey, with excellent results
   Scaling up of EA activities under Financial Aid (FA) funding in new areas
   Expansion of Safe Motherhood BCC Working Group to include a wider membership

EAP end-line survey: Data analysis and report writing for the EAP end-line KAP survey has
been a substantial area of activity during this reporting period. The SSMP/ Options team, with
technical assistance from Options London, has worked closely with Valley Research Group,
who were contracted to undertake this important evaluation of EAP achievements. While not all
changes can be directly attributed to EAP, the findings are very encouraging, demonstrating the
success of targeted approaches in empowering poor and excluded people. Comparison of
household and facility baseline and end-line survey data shows great improvements in
knowledge, attitudes and practices related to health care seeking across all caste groups
including, importantly, a closing of the equity gap for several key indicators. For example,
institutional delivery rates have almost doubled in the three-year programme period, up from a
baseline figure of 21% to 40% of total births in the target areas, which is considerably higher
than the national average of around 18%. See Annex 3 for a summary of the key findings

The EAP provides important lessons related to targeting of poor and excluded communities,
community mobilisation, voice capture, public private partnerships and engaging with health
service providers to improve local health services. These potentially have high relevance to
planning for the next phase of the Nepal Health Programme, NHSP II.

Taking forward EAP learning: In September, with SSMP/ Options support, ActionAid
organised a half-day dissemination meeting to share the results of the end-line KAP survey and
learning from EAP implementation activities among stakeholders, including representatives from
MoHP and the Social Welfare Council. ActionAid has also agreed to continue working on
women's health rights and SMNH equity and access issues as part of their own district
programmes, integrating SMNH and social inclusion messages with their existing activities. This
represents an important step in sustaining and broadening this successful work.

The new short term agreement between SSMP/ Options and ActionAid will use additional DfID
funding to continue work on specific EA activities from December 2009 to the end of June 2010.
This will enable 24 district NGO partners in eight districts (Morang, Chitwan, Rupandehi,
Nawalparasi, Parbat, Myagdi, Dailekh, Dadeldhura) to continue supporting the women’s groups
and networks initiated under EAP, monitored by a small support team within ActionAid.
Addressing violence against women will be a particular focus, complementing existing SMNH
and social inclusion work. Short term regionally based officers have been hired and oriented to
facilitate the local NGOs in planning, implementing and monitoring activities. They are working
on development of a monitoring framework for capturing field experiences, while the NGOs are
preparing their plans for the next six months.


                                                                                             6
Scaling up EA initiatives: SSMP/Options has provided intensive technical support to plans for
scaling up EA activities under FA funding in new areas of existing EA districts and in new
districts (covering Morang, Chitwan, Gorkha, Nawalparasi, Rupandehi, Parbat, Myagdi, Dailekh,
Kanchanpur and Doti). Orientation for the District/ Public Health Office (D/PHO) teams has been
completed, contracts are being prepared for one local NGO in each district to implement
activities, and a notice requesting letters of interest has been published. Some districts have
already begun collecting technical proposals from NGOs. Support has been provided through
joint visits with government counterparts.

Social inclusion and voice: The MoHP Gender Equality and Social Inclusion Strategy for
Health has been published, the result of lengthy and intensive work by SSMP/ Options and the
Health Sector Reform Support Programme (HSR-SP) team. To support future government
implementation of the strategy, SSMP/ Options is finalising social inclusion orientation
guidelines for SMNH service providers, a voice for action guideline and equity and access
process manual, as resource materials. Sharing of the second round of voice capture findings at
regional and central level forums has continued.

Advocacy: The continuing partnership with Safe Motherhood Network Federation (SMNF) is
helping to increase awareness about SMNH and women’s health rights among Constituent
Assembly members and political parties. A series of regional consultation meetings on the draft
safe motherhood bill has been organised, including with Constituent Assembly Members of all
political parties, and medical professionals. After incorporation of feedback, the final draft bill is
ready for high level consultation with senior Constituent Assembly and political party leaders, to
lobby for their support in gaining its approval.

A follow-up meeting was organised with key participants in the advocacy workshop held in
Nepalgunj in March 2009, to discuss monitoring of the contributions of airlines in transporting
women with delivery problems (or other sick people) from remote districts. A simple process
was agreed upon, which will be easy for the airlines and Regional Health Directorate to
implement. It was noted that, as agreed, the airlines are making two seats available for women
with delivery complications on all flights from Mid-Western hill and mountain districts.

District and regional support: By working with the Central Regional Health Directorate,
SSMP/ Options has enhanced inter-sectoral coordination between D/PHOs and local
development offices, creating an enabling environment for local resource mobilisation for safe
motherhood. As a result, District Development Committees (DDC) are placing safe motherhood
on their development agendas, leading to increased allocation of funds, particularly for
construction of birthing centres, purchase of drugs and equipment and recruitment of additional
Auxiliary Nurse Midwives (ANM). Promotion of emergency transport using stretchers (in the
hills) and cycle ambulances (in the Terai) has also increased.

Supporting NHEICC: SSMP/ Options has continued working with NHEICC to plan and
implement FA funded communication activities, such as continued airing of a weekly Aama
serial on Nepal Television and a new arrangement for airing on Image Television. Aama radio
programme also continues to be aired nationally through Radio Nepal and from various local FM
radio stations. Radio and television spots are being aired from Radio Nepal and Nepal
Television, and preparatory work has begun on the development and production of safe
motherhood BCC media and materials, including some linked with Aama Programme. Under the
NHEICC umbrella, the Safe Motherhood, Newborn and Child Health Communication Technical
Sub-Committee (with wider membership than the previous BCC group), has been approved by
the Director General of Health Services.

                                                                                                    7
International profile: SSMP/ Options has facilitated several international visits during this
reporting period, enhancing the profile of SMNH activities:

   The DfID Permanent Secretary visited to Lubhu PHCC (Lalitpur) in early July, focusing on
    the impact of the new Aama programme; a newly delivered woman at the Primary Health
    Care Centre (PHCC) assured her that the programme encouraged women, particularly poor
    women, to go to a facility for delivery.
   The DfID Communication Consultants, Storyline Associates, also visited in July to record
    safe motherhood stories. They visited Dhakdhai PHCC and Rudrapur Sub-Health Post
    (SHP) in Rupandehi district, meeting key stakeholders and hearing their success stories.
   SSMP supported SMNF in organising a visit by the Duchess of York, Sarah Ferguson, in
    September, including an exhibition in Kathmandu and visits to the Maternity Hospital and a
    PHCC.
   A cross learning visit to Dadeldhura district in December included representatives from
    DfID, UNICEF, SSMP/Options and ActionAid. The idea of complementary interventions for
    SSMP networks and UNICEF paralegal committees was discussed.

UNICEF inputs: In four of the UNICEF supported districts in the mid and far west regions
(Jumla, Humla, Achham and Dang), a further 252 Watch Groups4 have been formed, 63 in each
district, covering the most marginalised Village Development Committees (VDC). This was
implemented as a part of the UNICEF Decentralised Action for Children and Women (DACAW)
project, which covers ten districts in the mid and far western regions.

Using other funding sources, UNICEF has built on previous BCC initiatives (airing of radio spots
and episodes and developing BCC materials) by initiating a partnership with the BBC World
Service Trust, UNFPA and Nepal Family Health Programme (NFHP) to create a national
communication radio programme on maternal, newborn, child health and nutrition.

Challenges and Future Directions

   The success of targeted social mobilisation activities has increased demand for maternal
    health services. However, the availability of 24-hour delivery services at local health
    facilities still does not match demand, often due to the absence of qualified nursing staff or
    ANMs. SSMP/ Options advisers continue to lobby MoHP and FHD for need based
    allocation of additional appropriate staff.
   Scaling up the complex package of EA activities without the intensive technical support
    provided by SSMP/ Options and ActionAid will be a challenge, especially ensuring
    transparent selection of local implementing NGOs capable of undertaking the work and
    targeting the most disadvantaged groups. EAP learning has been extensively shared with
    government partners and is expected that this will help new EA partners to carry this work
    forward effectively. However delays have occurred in the contracting process due to
    delayed budget approval, local dynamics and lengthy contracting processes. There is also
    a need to provide multi-year contracts for implementing NGOs, since annual contracting, as
    currently provided under FA regulations, is complex, wasting implementation time and
    creating gaps between contracts, which hinders the work.
   Continuation of the social inclusion work, which is still a relatively recently accepted

4
 Watch groups are community based mobilisation groups of pregnant women led by FCHVs and DACAW frontline
workers. They track and inform pregnant women about birth preparedness and care and manage emergency funds,
based on a guideline recently endorsed by the Ministry of Local development.

                                                                                                         8
    concept, will also require increased levels of future support at central level, to ensure it is
    mainstreamed and rolled out to all levels and within all programmes.
   Integrating work against gender based violence in rights based social mobilisation
    programming is also new and thus requires increased levels of support to ensure
    mainstreaming and rolling out at all levels.

Key recommendation: Given the success demonstrated by the EAP work and its targeted
approach, it is essential that ways are found to scale up this work in some form across the
country.


Output 2: Service Strengthening

SSMP/ Options technical assistance to service strengthening includes support for central level
policy development and planning, led by the SSMP/ Options SMNH Adviser, with specific inputs
in ten selected districts, led by UNICEF (eight districts) and United Mission to Nepal (UMN, two
districts). These partnerships ended in December and November respectively, although both
agencies intend to continue much of their work in these districts using other sources of funding.
Safe abortion was supported through a partnership with Ipas until June 2009, and has since
continued through FA in the areas of infrastructure, equipment and training and policy advocacy
through FHD. Using alternative funding, Ipas is continuing its support to FHD for implementation
of the national safe abortion programme.

SSMP/ Options also works with stakeholders such as the Nepal Society for Obstetricians and
Gynaecologists (NESOG), Nepal Public Health Laboratory (NPHL), MDGP Forum, and Safe
Motherhood Sub-Committee, to widen understanding of critical SMNH service issues and
advocate for support.

Key Achievements

   Increase in local delivery service availability
   Positive evaluation of progress in health facilities following appreciative inquiry
   Approval of the Remote Area Guideline for safe motherhood

Service availability: Table 1 shows a 26% growth in the number of local birthing centres
providing 24-hour services (from 422 in December 2008 to 532 in December 2009). The number
of Comprehensive EOC (CEOC) sites has also increased, from 51 to 76, although most of this
is due to growth of the private sector, including medical colleges, and has not resulted in
significantly increased district coverage, as most private sites are concentrated in a few of the
more developed districts. Government CEOC coverage remains patchy and inconsistent due to
the unpredictability of posting of surgically doctors, with nine government CEOC facilities
currently not functioning due to lack of a provider. Annex 4 gives a breakdown of district
availability of CEOC services, showing that out of 41 districts where CEOC services have been
established, 35 have one that is functioning, of which 25 are government sites, and ten have
only a private/mission/NGO site. The 76 functioning CEOC facilities include 25 government
hospitals, 16 medical colleges and 36 mission/NGO/private facilities. (Note: one of the medical
colleges is also a government hospital, hence is counted twice, making the total number of sites
76 not 77)



                                                                                                 9
Table 1: Comparison of SMNH service coverage for 2007/8 and 2008/9

  Fiscal       CEOC           BEOC       BEOC      BEOC     24-hour    24-hour       24-hour      Total
   year                      hospital    PHCC      Total    delivery   delivery      delivery    birthing
                                                           at PHCCs    at health     at SHP      centres
                                                                         posts
2007/08       51 in 33         31          37       68       168          219          35          422
(Dec)         districts                                    (79% of
                                                           PHCCs)
2008/09       76 sites
(Dec)          in 35           45        45/ 211    90     167/ 211    301/ 674     64/ 3,130      532
              districts                   (22%)             (79%)       (45%)         (2%)




New CEOC services: CEOC services were established in four additional districts earlier this
year: Nuwakot, Gulmi, Dailekh (through partnership with Nepalgunj Medical College) and
Sankhuwasabha (through partnership with Kist Medical College). Table 2 shows the surgical
interventions performed at these centres since their establishment.

Table 2: Surgical interventions performed at new CEOC sites

             Hospital                       Operations performed                   Time period

District Hospital, Dailekh              17 C/S and 35 hysterectomies   12 months (July 08 to July 2009)
                                        (UP cases)
District                 Hospital,      18 C/S                         6 months (July-Dec 09)
Sankhuwasabha
District Hospital, Gulmi                27 C/S                         8 months (mid-April to mid-Dec
                                                                       09)
District Hospital, Nuwakot              4 C/S                          6 months (Feb to July 09)


Unfortunately two of the sites, in Dailekh and Nuwakot, stopped providing services in July
because the surgically skilled doctors were transferred, once again highlighting how the
resources invested in developing sites are wasted when there is no doctor available.
Conversely, two CEOC sites that had stopped functioning (Saptari and Dang, both UNICEF
supported) have restarted after the MBBS doctors stationed there received advanced CEOC
training enabling them to carry out caesarean sections. Since training, the doctor at Saptari has
carried out 41 caesareans and the one at Dang has carried out 23.

Visits to newly established sites at Makwanpur (CEOC) and Puythan (BEOC), to provide on-site
coaching and support, found that Makwanpur is now providing standard quality services in line
with national protocols and could be developed as an SBA training site in future. Puythan is
functioning adequately as a BEOC site and could be upgraded to provide CEOC services with
additional support.

Blood transfusion services: Three blood transfusion sites were followed up by NPHL and Red
Cross Society (Nuwakot, Gulmi and Sarlahi). Unfortunately, lack of space has prevented
initiation of services at Nuwakot and Sarlahi, despite their receiving training and equipment, but
Gulmi is functioning. Mugu district hospital also initiated blood transfusion services after training
and equipment supply from UMN.


                                                                                                      10
Safe abortion service: The SSMP contract with Ipas ended in June, but SSMP support to the
FHD safe abortion programme and Ipas continues in the areas of advocacy, infrastructure and
equipment supply. As shown in Table 3, by December 2009 a total of 704 service providers
(610 Doctors and 94 staff nurses) had received training and 245 safe abortion service sites
were officially listed (115 Government, 130 non-government). In the recently ended fiscal year
(2008/09) 83,978 clients received services. Although this appears to be a decrease from the
previous year’s figure of 97,378, it should be noted that this is the first year data has been
collected through HMIS, and some under reporting, particularly from the private sector, is likely.
Up to this point there has been a steady increase in service utilisation each year, with the vast
majority of clients going to the private/ NGO sector. All 75 districts continue to be covered by at
least one service site, either public or private/ NGO. According to Ipas monitoring data, 75% of
women accepted a post abortion contraceptive method.

Second trimester abortion is available in nine referral hospitals. Medical abortion, using the
internationally approved drug, Medabon® has been piloted in six districts. A strategy for scaling
this up across the country has been approved, including expanding services down to health post
level (medical only, not surgical), to increase access to safe abortion for poor rural women.
Implementation of the strategy has begun, with 69 sites now able to provide medical abortion
services, and around 4,000 women have utilised this option .

Table 3: Summary of safe abortion service data from 2004 to 2009

 Fiscal year       Providers        Sites listed       Service          Public: private         Districts
                    trained                           utilisation        service ratio           added
 2003/04 (3            54                12               719               100:0                   9
 mnths only)
  2004/05               95               57             10,561               49:51                 38
  2005/06              111               64             47,451               17:83                 21
  2006/07              114               35             73,474               13:87                  3
  2007/08              138               38             97,378               13:87                  4
  2008/09*             192               39             83,978                N/K

     Total                704              245           313,561                                   75
*This is the first year that data was taken from HMIS, previously the source was Ipas records

Human resources for CEOC: In response to the Tippani forwarded to the MoHP for creation
of additional posts for gynaecologists, MDGPs and anaesthesia assistants to enable more
CEOC services, an organisation and management survey was recommended. The Department
of Health services (DoHS) is planning to undertake this with SSMP/Options support. Meanwhile
a Memorandum of Understanding has finally been developed between FHD and the National
Academy for Medical Sciences (NAMS) for implementation of a one-year diploma course for
gynaecologists. Management Division (MD) is also recruiting 28 MDGP/gynaecologists for
district CEOC services, based on a list provided by SSMP/ Options, showing where these
human resources are required. This indicates the commitment of DoHS to increasing the
number of caesarean section providers at district level. As agreed, districts are recruiting ANMs
and staff nurses locally, although most are finding it difficult to get staff nurses, in which case
they are allowed to recruit ANMs instead.

Appreciative inquiry evaluation: As previously reported, Appreciative Inquiry (AI) has been
used as a management strengthening tool in 50 health facilities in 28 districts through a
Technical Assistance (TA) funded contract with Genesis Management, with activities funded

                                                                                                            11
under FA. The main aim was to encourage facilities to start 24-hour delivery services and to
improve the quality of service. Genesis Management conducted participatory planning
workshops in selected B/CEOC facilities and trained teams of district based facilitators to roll
this out to peripheral health facilities (total of 82 persons received training in 2008). Four
implementation modalities were used: 1) Genesis Management facilitation, 2) facilitation by
district focal persons with backstopping from Genesis Management, 3) facilitation by district
teams with support from regional coordinators, 4) facilitation by district teams without any
backstopping.

An evaluation of the outcomes was carried out by a team led by Deborah Thomas from Options
UK, supported by two local consultants (see Annex 5 for the executive summary of the draft
report). Twelve health facilities were selected as a sample, representing the five development
regions, various types of facility and modalities of facilitation. The purpose was to evaluate the
AI implementation model, compare the effectiveness of modalities used, and make
recommendations for sustaining the positive changes achieved at reasonable cost.

Key findings were:

    Small increases in the percentages of women accessing four Antenatal care (ANC) check-
     ups and one Postnatal care (PNC) check-up (4% and 5% respectively).
    Institutional deliveries increased by 55% and provision of newborn care by 21%.
    Improved cleanliness of ANC/ PNC rooms, waiting areas and surrounding environment,
     availability of clean toilet facilities and drinking water for patients and care takers.
    Almost all stakeholders (including local leaders of political parties, HFMC members,
     community volunteers and health staff) said the AI workshop had encouraged them to
     establish 24-hour delivery services, explore local resources and use positive problem
     solving approaches.
    There were no clear differences between the results for different facilitation modalities.

The evaluation found the AI process had helped increase demand for services as well as
strengthening services. It recommended scaling up the process through district level AI
coaching facilitated by external consultants and the DHO, rolled out to peripheral facilities by
DHO staff and others who participated in the district level workshop.

Joint annual planning: The joint planning and review process for reproductive health and safe
motherhood was completed at a three-day workshop in December. Progress achieved during
FY 2008/09 was reviewed and partners committed to supporting the FY 2010/11 SMNH Joint
Annual Plan and made strategic recommendations, including:

1.   Continuing expansion of local birthing centres and B/CEOC services
2.   Multi-year contracts for locally recruited staff, to avoid the current gap and loss of services
     caused by delays in budget approval at the beginning of the fiscal year and time taken for
     recruitment
3.   Provision of SBA or other appropriate training for locally hired staff, bearing in mind the
     likelihood of their remaining in the area
4.   Bonded scholarships for training candidates from remote areas as doctors or staff nurses
5.   Scaling up the AI process for strengthening HFMCs
6.   Technical strengthening of regional capacity to ensure quality monitoring and mentoring, or
     contracting an external organisation to support this
7.   Continuing technical support to FHD to retain the focus on safe motherhood.


                                                                                                 12
Additional reproductive health initiatives planned include support for prevention and treatment of
uterine prolapse, screening for cervical cancer, and addressing gender based violence. The
annual SMNH plan developed on the basis of the meeting will feed into the health sector Joint
Annual Review (JAR) planned in January.

Regional support and planning: Six new regional coordinators have been recruited to
continue the work of the previous incumbents, following the end of their contracts. Unfortunately
there was a six-month gap due to delays in central level programme and budget approval and
the lengthy recruitment process. As a result, monitoring of district data for SMNH services has
lapsed, although the biannual review meetings for reproductive health and safe motherhood
have continued in all five regions, led by the Regional Health Directorates and guided by a
review checklist developed by FHD. All six meetings were completed in this reporting period
(two in the central region) with Regional Health Directorates taking an active lead role, including
collecting reports and regional data for analysis. The results of the 2008/09 MMM study and
progress with Aama programme were major areas of discussion during the meetings, and work
plans were developed for 2010/11.

Remote Area Guideline: This guideline for improving access to quality SMNH services in
remote areas (included as an annex in the last biannual report, January to June 2009) has been
approved by FHD and is being printed in Nepali and English. Development partners UMN,
Nepal Family Health programme (NFHP) and UNICEF, all of whom were involved in its
development, are planning to begin implementation immediately in their programme districts.

District Hints and Tips: At the request of MoHP, this booklet has been developed from SSMP
programme learning, outlining ten ways in which local stakeholders can improve SMNH services
in their area. The aim was to enable districts that have not received SSMP support to gain some
benefit from programme experience, by helping them to initiate activities themselves. Case
studies are drawn from SSMP supported districts demonstrating how each activity has been
successfully implemented and highlighting key practical points about how to do this. The booklet
has been approved by FHD and will be printed and distributed to district stakeholders through
partners and at regional review meetings. See Annex 6 for summary of key areas.

Telemedicine: The monitoring reports of piloting of CDMA mobile telephone use by peripheral
health workers in Solukhumbu, Rupendehi and Dailekh districts are very encouraging. It was
found that CDMA phones effectively supported peripheral health workers in provision of clinical
services during pregnancy, delivery and the postpartum period, helping them to diagnose and
manage problems at community level and facilitating prompt referral to the district hospital
where needed, reducing delays in provision of treatment. Telephone communication also
facilitated administrative and monitoring work, such as collecting reports, arranging meetings
(mothers’ groups, Female Community Health Volunteers (FCHV), district reviews), preparation
of field visit schedules, and sharing new health information heard on FM radio among all health
workers, mothers, FCHVs and other stakeholders. All users said they felt more confident in
providing clinical services knowing backup was available from senior staff.

The monitoring visit to Solukhumbu, in October, found that during a period of six months
(December 2008 to June 2009), 51 patients had benefited from telephone consultation; 19 were
managed locally with telephone advice and 24 were taken to the district hospital. Two of the
patients were referred on from Solukhumbu hospital to Kathmandu. Five calls were related to
ultrasound results during mobile clinics. All 24 patients admitted to hospital did well except for
two babies (one with neonatal sepsis and one premature), who died after the first and third day

                                                                                                13
of treatment respectively; and there was one maternal death after five days of treatment, due to
heart disease.

Sarmila Basnet’s family called the local MCHW, Durga Devi Basnet, after Sarmila had delivered a
premature baby, at seven months. An hour after delivery, the placenta had not been expelled and the
baby’s shock reflex was poor. The MCHW called the public health nurse, Bhagawati, at the district health
office. She advised the MCHW on the procedure of active management of third stage of labour
(immediate 10 unit intramuscular injection of syntocinon, fundal massage and controlled cord traction).
This was successful and the placenta was expelled, after which the mother’s vital signs were normal.
However, the premature baby had poor sucking reflex. They wrapped it in a cloth and warmed it against
the mother’s chest, then gave it the mother’s milk with a spoon. Soon the baby improved and the family
was advised to continue with kangaroo mother care, and ensure the baby is immunised. Now both mother
and baby are doing well. – Goli VDC, Solukhumbu

In Dailekh, Ms Goma KC, a Senior ANM at the district hospital, also recalled how they were able
to save a critical delivery case because of timely referral and telephone information from the
health post nurse, which enabled them to prepare in advance and treat the woman as soon as
she arrived. ANMs at peripheral facilities also confirmed how helpful they found the improved
communications.

“Having a CDMA set in my duty at the PHCC, I feel I am always with my senior nurses, even though I am
physically far from them. The phone network overcomes the feeling of loneliness and creates an
opportunity to treat women on time through medical advice. So it has increased respect from women's
relatives, and through them from whole community” – ANM from Dullu PHC, Dailekh.

Nepal Health Sector Planning: The SSMP Safe Motherhood Adviser has been specifically
involved in two thematic groups of the NHSP II planning, for: (1) Revision of the Essential
Health Care Package and (2) Human Resource Planning. Key new recommendations are:

Essential Health Care Package:
 Addition of three new indicators for: (1) newborn health, (2) EOC monitoring, (3) adolescent
    fertility
 Provision of safe abortion services at health post level (medical abortion only)
 Initiation of cervical cancer screening
 Adoption of targeted programming for remote areas, based on the Remote Area Guidelines
 Use of targeted approaches to increase access in under-served areas
 Strengthening of HFMCs using AI approaches
 Continuation of maternal mortality and morbidity monitoring in the eight MMM study
    districts, as initiated in the study.

Human Resources:
 At least two SBAs to be posted in each health post that has a birthing centre
 A further 7,000 SBAs to be trained between 2012 and 2015
 All CEOC sites to have at least two obstetrician/gynaecologists, two anaesthesiologists, 10
   staff nurses and blood transfusion service
 Multi-year contracts for locally recruited staff
 District (bonded) scholarships for local candidates to increase production of MDGP/
   Obstetrician/ gynaecologists, anaesthetic assistants, lab. technicians
 One health post (two SBAs) per 3,000 to 5,000 population; one PHCC (four SBAs) per
   50,000 population; and one district hospital bed per 5,000 population.



                                                                                                     14
Challenges and Future directions

   Lack of human resources (especially doctors, staff nurses and ANMs) continues to be a
    challenge to provision of 24-hour quality SMNH services - at least two SBAs are required
    per birthing centre. Local recruitment has helped considerably, particularly at health post
    and sub-health post level. Management Division’s provision for recruitment of 28 additional
    MDGP/gynaecologists demonstrates government commitment to investing in human
    resources, but attracting suitable applicants for these positions is a challenge. It is
    suggested that to ensure staffing for remote districts, bonded scholarships for training
    doctors, staff nurses and anaesthesia assistants should be made available. It is hoped that
    the DoHS organisation and management survey will assist with planning, and production of
    graduates from the NAMS diploma of gynaecology and diploma of anaesthesiology will also
    help.
   It has been noted that many specialist doctors, such as MDGPs and gynaecologists, are
    taking posts in PHCCs to collect marks for promotion. However, as their services are more
    urgently needed CEOC sites, this represents a waste of their skills and knowledge for two
    years, in posts that could be effectively filled by basic MBBS qualified doctors. The policy of
    giving marks for PHCC postings should therefore be amended for specialised doctors.
   The effectiveness of short term contracted staff, such as regional coordinators, local ANMs,
    nurses and doctors, is limited by the delays at the beginning of each fiscal year due to the
    approval process for budget release, which this year took five months, leaving only seven
    months for working, of which some time is needed for recruitment. This means that each
    year there is a significant gap in support. It is recommended that multi-year contracts be
    implemented until a permanent post can be created. This needs to be discussed at the JAR
    meeting and other appropriate forums.
   Government policy does not allow for providing temporary staff with government funded
    training, including SBA training, which means their service may not be of the required
    standard. SSMP/ Options and other partners have advocated for this to be changed and
    some partners have committed to supporting SBA training for locally recruited staff.
   The MMM and other studies have highlighted concerns over quality of services, indicating
    shortfalls in monitoring and mentoring of health staff. Capacity building at regional and
    district levels, particularly Public Health Nurses (PHN), is planned to address this, and it will
    be important to include strong central level technical support and good design of inputs.
   Physical facilities are often inadequate for the services to be provided. In particular, many
    referral hospitals have insufficient beds to cater for the demand generated by free delivery
    services, leading to instances of serious referral cases being refused due to lack of a bed.
    Every hospital should develop an expansion plan, based on anticipated caseload, and any
    future support should include provision of the required equipment and infrastructure to
    cover this. Normal delivery cases should be encouraged to go to birthing centres, leaving
    capacity for complicated cases in hospitals. Birthing centres should be adequately
    connected to and supported by hospitals, to ensure clients can feel confident of quality
    services with emergency backup.
   Initial funding of around Rs.30,000 should be available for new birthing centres at health
    posts, SHPs and PHCCs, for procurement of essential basic equipment and supplies, such
    as delivery sets, autoclave, vacuum delivery equipment, Manual Vacuum Aspiration (MVA)
    set and ambubag. This will ensure peripheral facilities are able to provide full services
    immediately, rather than waiting for the slow central procurement and distribution process
    to be completed. An alternative would be to give MVA and vacuum sets and ambubags
    from the regional or central stores to SBAs at the end of their training.



                                                                                                  15
District Support: United Mission to Nepal (two districts)

Although the SSMP/ UMN partnership was scheduled to end in July, a limited extension was
agreed until November. During the intervening period formal support was discontinued in
Rupandehi, but activities have continued in Mugu, where UMN has a broader ongoing
programme, which will still include SMNH, thus assuring the sustainability of achievements in
this very remote and under resourced district. All 13 supported health facilities in the two
districts are now providing 24-hour services (although one is for home deliveries only), with
HFMCs taking responsibility for sustaining this.

The UMN end of contract report, summarising achievements, reflecting on the partnership
process and including recommendations for the future, can be found in Annex 7.

Key achievements

   Completion of a video based on SSMP/UMN experiences in Mugu and Rupandehi
   Establishment of blood transfusion services in Mugu
   Sustained increase in delivery service utilisation in all supported health facilities

UMN has produced a video, entitled Maya, based on experiences in Mugu and Rupandehi
related to service strengthening and local involvement in establishing and sustaining improved
maternal health services. This has been disseminated widely to all UMN donors and other
interested stakeholders.

Rupandehi: All eight supported health facilities are providing 24-hour services, and Dhakdai
PHCC continues to provide BEOC services. Five of the facilities were ranked as model facilities
by the DHO. Most of the HFMCs have continued to meet regularly, even after formal support
from UMN was discontinued in July. They have continued to provide the salary for seven ANMs
and are involved in day to day management of the health facilities. Service utilisation has
continued to increase in all supported health facilities, as shown in Figure 3.

The piloting of support through CDMA phones has been appreciated by ANMs, who have begun
regularly accessing advice from higher facilities. The system has also facilitated timely referral
and care for women with complications.

Following the end of the SSMP/ UMN partnership in Rupandehi, UMN will continue to work with
local NGO partners and provide low level back up and technical support for the DHO as
required. As this is a relatively well developed and resourced district and programme inputs
have been successful, it is felt that the DHO and other local stakeholders are able to take this
work forward and use experience with UMN to strengthen other health facilities.




                                                                                               16
Figure 3: Service Utilisation Trends in Rupendehi 2008 to 2010

                                               Institutional Delivery, Rupandehi PHCC and Below
                              450

                              400

                              350

                              300
         Number of delivery




                              250
                                                                                                                     2008/9
                              200                                                                                    2009/10*


                              150

                              100

                              50

                               0
                                              Parroha HP         Ryapur PHCC       Rudrapur SHP        Majegaun HP
                                    Dhakdai PHCC       Motipur PHCC      Suryapura SHP      Lumbhini PHCC


Note: 2009-10 figures are estimated for 12 months from 3 months’ data.

Mugu: The district hospital continues to provide 24-hour BEOC services, with all signal
functions. In the first part of the fiscal year (2009/10), monthly service utilisation has increased
by 15%, compared with figures for 2008/09. Three staff from the hospital received a one-month
training on blood transfusion at the Blood Bank at Nepal Red Cross Society in Kathmandu and a
blood transfusion facility has been established at the hospital.

The District Health Management Committee has established a basket fund for emergency
referral, including obstetric emergencies. All 24 VDCs committed to contributing Rs.6,000 each
in 2009/10. The three supported health posts (Sreekot, Dhungedada and Natharpu) continue to
provide 24-hour services. Kimri health post provides a 24-hour home delivery service as they
have not yet been able to establish a delivery room. Service utilisation data from the health
posts is not currently available.

Following the end of the SSMP/ UMN partnership in Mugu, and in the light of the high level of
need in this remote district and the low capacity, UMN will use other funding to continue
intensively working with the hospital and health posts, to sustain and build on the SSMP funded
work and complement its broader programme in this district.

Challenges and recommendations for the future

Note: The comments below are summarised from the UMN end of contract report (Annex 7).




                                                                                                                                17
   Scaling up birthing centres and BEOC facilities needs intensive initial support, with external
    inputs and active involvement of DHO staff, until the facility is functioning and the HFMC is
    fully engaged, after which it should be handed over to the DHO as soon as possible.
   To enhance equitable access, upgrading health posts to provide 24-hour birthing services
    and strategically located PHCCs to provide BEOC should continue, with flexibility to support
    SHPs in selected areas and support for transport for referrals.
   Relying only on local capacity to run 24-hour services while the government provision for
    staff is so limited at health post and SHP level is not realistic in remote areas. Support from
    central level, especially for local staff recruitment will be necessary for long term
    sustainability.
   The Aama programme has greatly increased access to SMNH services for the poor who
    live near health facilities providing services. However, it widens the gap between women in
    urban areas (where facilities are available) and women from remote areas (where there are
    no facilities), as providing free services and incentives where services are not available
    does not increase women’s ability to access services. The government should take this into
    account when equity related policies are revised.
   The Aama programme also increases utilisation of delivery care services at specialised
    centres (zonal and regional hospitals). As noted above, this, in some instances, has led to
    compromise in quality of care at these facilities due to increased workload. The national
    policy should focus on strengthening peripheral facilities for normal deliveries, keeping
    specialised facilities for complicated cases.
   A comprehensive approach is most effective: service strengthening should be followed by
    increasing access activities in order to increase utilisation of services.
   Lack of ANM sanctioned posts in Mugu (Karnali zone) has greatly affected provision of 24-
    hour services, as there is little capacity to raise local financial resources in these remote
    areas to recruit their own additional staff.
   Different approaches to service provision and referral in mountain districts, such as Mugu,
    are needed. The Remote Area Guidelines have the potential to improve access to SMNH
    care in such remote locations, but need to cover preventive measures as well as service
    provision and referral.
   Frequent transfer of officers in district line agencies, including the DHO, and the perception
    of remote locations such as Mugu as a “punishment posting” make continuity and sustained
    strengthening of HFMCs almost impossible. Hospital services can only be sustained if all
    sanctioned posts are filled and there are regular supervision and monitoring visits from
    central/ regional levels.
   The approach of many development and humanitarian organisations in providing aid to
    Mugu for the past few years has created a dependency attitude. Future donor funded
    programmes need to consider such issues and seek to create local empowerment.

District Support: UNICEF (eight districts)

The SSMP/ UNICEF partnership supports SMNH service strengthening (construction,
equipment and training) and equity and access inputs in eight districts (Saptari, Panchthar,
Udayapur, Kavre, Dang, Achham, Jumla and Humla). At the request of FHD, UNICEF has also
provided support to Bheri Zonal Hospital in Nepalgunj, Banke District, as a referral hospital for
women from Humla needing CEOC services. Key points from the UNICEF end of contract
report, summarising achievements, reflecting on the partnership process and including
recommendations for the future, are included in Annex 8.




                                                                                                18
Key achievements

   Increased availability of 24-hour delivery service - 19 new birthing centres established
   Increased met need for EOC in all districts except one

A further 19 birthing centres have been established in this reporting period, all providing 24-hour
delivery services, making a total of 109 centres in the eight supported districts. This expansion
of peripheral services has largely been achieved through AI review and planning activities with
HFMCs, facility staff and local communities, creating a sense of local ownership and joint
commitment. Local efforts are supplemented by provision of equipment and other support as
necessary. Figure 4 shows the number and location of SMNH services in the supported
districts, including C/BEOC sites and birthing centres. Capacity for managing emergency
obstetric and newborn complications has also increased, as a further 30 ANMs from the
supported districts received SBA training. Whole site infection prevention training, including
local health facility management committees, continues to substantially improve quality of care
at birthing centres and hospitals.

Figure 4: SMNH facilities in the eight supported districts




As a result of increased availability of quality local services, complemented by community
awareness raising activities, the proportion of births taking place in health facilities in the
supported districts has continued to increase (see Figure 5), rising from 11% in FY 2005/06,
when support began, to 18% in 2008/09, an increase of seven percentage points in three years.
An additional factor is the initiation of the Aama programme in January 2009, which is expected
to further increase service utilisation for 2009/10. Figure 6 shows the breakdown of service


                                                                                                19
utilisation by district over the three-year support period, indicating increases in institutional
deliveries in all districts. It should be noted that this only covers deliveries at EOC sites, as data
from the birthing centres are not available.

Figure 5: Average trend of delivery at EOC sites in the supported districts




Figure 6: Deliveries at EOC sites by district from 2005/06 to 2008/09




                                                                                                   20
Figure 7: Met Need for EOC by district

Figure 7 shows increased met need for EOC in all districts this year, except Jumla. The average
figure rose from 24% in 2005/06 to 28% in 2008/09 (Figure 8), a total increase of 3.3
percentage points since 2005/06, and 5.6 percentage points since 2007/08. Fluctuations (for
example the dip in 2007/08) are due to human resource changes.


Figure 8: Average met need for EOC in the eight supported districts and Banke




                                                                                            21
The pattern of met need for caesarean section is similar, rising from 15% in 2005/06 to 31% in
2008/09 (Figure 9). In 2006, there were only three CEOC sites providing caesarean section
services in the supported districts. This increased to six in 2007, and nine in 2008. However, in
the following year two of these stopped functioning due to the transfer out of the doctor and one
site has never provided CEOC service (Jumla), there was thus a decrease in met need in FY
2007/08. In 2008/09, seven CEOC sites were again functional, for at least part of the year, and
the met need for caesarean section correspondingly increased. The CEOC site in Banke, which
is not a supported district, remains functional, acting as a referral centre for the hill and
mountain districts that do not have their own services. At the end of December 2009, six sites
were functioning (Banke, Dang, Kavre (2), Saptari and Panchthar) and three were not (Achham,
Jumla and Udayapur).

Figure 9: Average met need for caesarean section services




Figure 10 highlights the effects of loss of a surgically skilled doctor in Panchthar and Dang,
where met need dropped in 2007/08 when the doctors were transferred out, and began to
increase again in 2008/09 when doctors were again available. In Dang and Saptari the resident
medical officers have undergone the advance SBA (caesarean section) training, the first to do
so under the new policy, and they are now performing caesarean sections.




                                                                                              22
Figure 10: Met need for caesarean section by district




    The benefits of exchange visits
    As part of the effort to further improve quality and availability of services in peripheral areas, an
    exchange visit was organised for a team from Udayapur district, including 15 DHO staff and health
    workers from peripheral birthing centres. The team visited the district hospital, Gopetar PHCC and
    Tharpu Health Post in Panchthar district to see some of the “best practices” being implemented in
    the district. The visiting team were impressed by practices such as: coordination between health
    facility staff and health management committee; excellent mobilisation of FCHVs for SMNH
    activities; regular FCHV meetings; satellite clinics for remote wards of the VDC to increase access
    to services; 25% discount on ambulance services for delivery cases; display of SMNH messages in
    the waiting room of the maternity ward; and good management of health facilities. Since the visit at
    least one PHCC in Udayapur has adopted some of these ideas.


Challenges and future directions

      Lack of surgically skilled doctors remains a key challenge at CEOC service sites. Despite
       the availability of the required infrastructure and equipment, only five of the eight CEOC
       sites remained fully operational during the whole of the reporting period. This has affected
       service utilisation throughout the project period.
      Human resource shortage is also an issue at SBA training sites, where trainers, who are
       also service providers, may be overstretched trying to combine the two roles, especially at
       the smaller sites.
      Local recruitment and retention of key staff is important for establishing and maintaining 24-
       hour delivery services at peripheral health facilities where there are insufficient sanctioned
       SBA posts. This includes ensuring they receive SBA training, which currently contracted
       staff are not entitled to. Generating sufficient revenue to meet the salary costs of locally
       recruited staff is a challenge for smaller facilities with lower caseloads. A further problem is


                                                                                                            23
    the transfer of SBAs to facilities that are not birthing centres, or to non-maternal care
    departments within hospitals, which represents a waste of their skills.
   Regular supervision and monitoring by appropriately qualified and skilled staff is essential
    to ensure quality of care. The PHN is the direct supervisor of peripheral SMNH service
    providers (staff nurses and ANMs), but many lack the required skills as they have not
    received SBA training and are not hands on practitioners. Post training follow up of newly
    trained SBAs is also insufficient.

Specific recommendations

   The appreciative inquiry review and planning process should be scaled up at district and
    facility level to create local ownership and mobilise resources for SMNH services.
   More ANM posts are required in peripheral areas (at least two ANMs per birthing centre)
    through the MoHP, preferably using local hiring mechanisms.
   More doctors with caesarean section skills are needed at CEOC sites; these need to be
    posted through MoHP and retained for a substantial period without transfer.
   EOC data needs to be integrated into HMIS, with special attention given to monitoring and
    evaluation of facility data recording and reporting.


Output 3: Public Private Partnerships

SSMP/ Options has continued to seek opportunities for promoting involvement of the private
sector in supplementing and expanding public health services. This ranges from small
community hospitals and organisations to larger private hospitals and medical colleges,
including both non-profit and for-profit. Professional associations and councils are also
important partners in areas such as human resource development, especially the SBA training
programme.

SBA training: Private sector training sites can make an important contribution to the SBA
training programme. Dhulikhel Community Hospital has now been established as an SBA
training site and begun training; Amda Hospital in Jhapa is a private institution providing SBA
training and Palpa Community (mission) Hospital is also an SBA training site. Private sector
providers also receive training under the government programme, for which they pay an agreed
fee. This will help to ensure consistent standards across the sectors. The Institute of Medicine
(IoM) has also been an important player in the revision of pre-service medical and nursing
education curricula to incorporate SBA skills and the development and implementation of a
national strategy for this.

Safe abortion: Although the partnership with Ipas has ended, SSMP/ Options continues to
support abortion policy and planning as an essential part of services. Through the Technical
Committee for Implementation of Comprehensive Abortion Care (TCIC), Ipas continues to work
closely with non-government stakeholders, especially Marie Stopes International, Family
Planning Association of Nepal and other national NGOs, and with NESOG, the Nepal Nursing
Association and private medical colleges. The partnership approach has been successful in
enabling abortion services to be expanded to all districts, providing more choice for women and
a standardised service at realistic prices that are comparable with those of public sector sites.
NESOG was closely involved in piloting medical abortion in six districts, and this is now being
scaled up to expand access and choice for women in safe abortion services. TCIC has also
established a working relationship with three medical schools, which resulted in their

                                                                                              24
incorporating safe abortion training in their pre-service medical training, so that graduates are
immediately able to provide standard Comprehensive Abortion Care (CAC) services without
further training.

CEOC services: The concept of contracting private agencies, such as medical colleges, to
provide CEOC services in under-served districts has been explored in Dailekh district (with
Nepalgunj Medical College) and Sankhuwasabha (with Kist Medical College). This represents
an exiting opportunity to improve public service availability, especially in rural areas where it is
difficult to get trained staff, although results have so far been rather patchy (Output 2).

Equity and access: SSMP/ Options has supported the successful expansion of EA activities
into new areas (Output 1) through direct contracting between the government (D/PHOs) and
local implementing partner NGOs. With the ending of the ActionAid contract, for the next year
the government plans to roll this arrangement out in ten districts, of which seven are previous
EAP districts and three are new. This represents a significant step towards institutionalising EA
activities and promoting government/ NGO partnership. Guidelines have been developed for
contracting, to ensure transparent selection of NGOs most suited to carrying out the work.

Aama programme: Currently 21 non-government hospitals (seven NGO, four mission, seven
medical colleges and three private for-profit) are implementing the Aama programme (Output 8).
Requests from the non-government sector are increasing and MoHP is open to allowing more
private institutions to join, based on recognition of their substantial contribution to safe delivery
services and their role in meeting the national millennium development goal targets.

Information: The new Health Sector Information System (HSIS) currently being piloted aims to
be fully comprehensive in recording services provided by all private/ NGO services, although it
is acknowledged that this will be challenging and require the active cooperation of these
facilities. The success of the safe abortion programme in this respect demonstrates that it is
possible if conditions are created to enable private/ NGO establishments to understand the
benefits. This is important in view of the increasing role of the private and NGO sector in
providing SMNH services.


Output 4: Decentralisation

SSMP/ Options and partners have contributed to significant local capacity building and
institution development, which will be important in feeding into government decentralisation
efforts or plans for state restructuring along federal lines. Rights based training and orientation
for local stakeholders, including government line staff, has increased the accountability of duty
bearers and empowered right holders to claim their rights. Appreciative inquiry approaches have
complemented this effort and promoted local initiatives such as staff recruitment and
mobilisation of local resources. Supportive work with local institutions, such as VDCs, HFMCs
and Reproductive Health Coordination Committees (RHCC), D/PHOs and other line agencies,
has increased their capacity to improve local services.

Appreciative inquiry: Following the successful application of AI based review and planning at
health facilities in SSMP partner districts, the process has been scaled up to a further 28
districts (50 facilities) under FA. With support from a private agency, trained government staff
have facilitated and supported review and planning health facility workshops and followed up


                                                                                                  25
their implementation of action plans. The whole process has been important in strengthening
local institutions and ownership and increasing community investment in local health services.

Local recruitment: To meet the critical human resource shortages that have constrained local
health services, increasing numbers of health facilities are recruiting staff on local contracts,
especially ANMs and nurses, either using locally accessed resources (VDC or other) or through
additional FA funding provided to DHOs. This has proved very successful, as locally recruited
staff are often more acceptable and accountable to communities. However there is a need to
look at some of the issues around short term contracts, such as provision for extending
contracts at the end of the fiscal year or providing multi-year contracts, to ensure consistent
service provision. Contract staff should also be allowed to receive government training
(especially SBA) to ensure consistent standards (Output 2).

Institution building: The networks and cooperatives established in EAP areas promote
coordination with other organisations at VDC and DDC levels, increasing the effectiveness and
capacity of local community groups. Work with district RHCCs has also provided important
capacity building, resulting in their developing district reproductive health strategic plans, which
will be reflected in DDC planning. All major political parties active locally were involved in this
and committed to its endorsement.

Information: The new HSIS currently being piloted will promote establishment of an information
corner in all health facilities, including peripheral facilities such as health posts. This will include
a display board with key indicators and information about performance, which is accessible to
the community, in to ensure people’s right to information.

Output 5: Human Resource Development

Production of SBAs continues to be the major focus for this output, particularly through in-
service training, in collaboration with the National Health Training Centre (NHTC). SSMP/
Options has continued to work closely with the NHTC safe motherhood focal person, to build
capacity for planning and implementation and thus ensure sustainability. Collaboration with FHD
and partners UMN and UNICEF has also been important, to ensure training is responsive to
district needs and FHD priorities. Nick Simons Institute (NSI) remains a key partner in training
site development, especially in view of their focus on mid-level health workers in peripheral
facilities. IntraHealth provided valuable additional technical assistance under a TA funded
contract, which ended in June 2009. Technical collaboration with JHPIEGO has continued.

Key achievements

   Implementation of in-service SBA training operational plan
   Completion and dissemination of SBA training follow up pilot and report
   Approval of the Strategy for Human Resources in Safe Motherhood

In-service SBA training: Based on the operational training plan developed during the last
reporting period, with technical assistance from SSMP/Options and IntraHealth, NHTC has
continued to implement need based in-service SBA training. A further 286 providers received
SBA training during this reporting period, making a total of 1,215 since the programme began in
January 2007. At least three public sector providers have been trained from each district, with
priority for nurses and ANMs from PHCCs and health posts, especially in outlying areas, where
they are the main, and often only, service providers. Facilities with high caseloads and districts

                                                                                                     26
where partner organisations are providing support are also prioritised. Private sector providers
are receiving training, for which they pay from their own resources. However, although the
operation plan specified training 1,010 SBAs in this fiscal year, in the first half of the year only
just over a quarter of this number have been trained. This is largely due to the late approval and
release of government budget (five months into the year) but is also because the current
capacity of training sites does not match the operational plan, indicating the urgent need for
more training sites. As noted in the last biannual report, in FY 2008/09 the target for SBA
training was only 75% met.

Other safe motherhood training: During this reporting period 18 providers have received
anaesthetics assistance training and nine have received training in operation theatre techniques
and management. As noted in the last biannual report, the targets for FY 2008/09 for these
courses trainings were 116% and 95% met, respectively.

Training site development: One more SBA training site (Dhulikhel Hospital) began providing
training in September, after strengthening inputs were completed in partnership with UNICEF.
This brings to 15 the total number of currently operational SBA training sites:

1. Maternity Hospital, Kathmandu                     2. Western Regional Hospital, Pokhara
3. Koshi Zonal Hospital, Morang                      4. Seti Zonal Hospital, Kailali
5. Bharatpur Hospital, Chitwan                       6. Mid West Regional Hospital, Surkhet
7. Baglung Hospital                                  8. TU Teaching Hospital, Kathmandu
9. Lumbini Zonal Hospital, Butwal                    10. Bheri Zonal Hospital, Banke
11. Sagarmatha Zonal hospital, Saptari               12. Dang Hospital
13. Tansen/ Palpa Mission Hospital)*                 14. AMDA Hospital, Jhapa*
15. Dhulikhel Community Hospital, Kavre*
*Non-government

Needs assessment is beginning at two further potential training sites, the Naryani Sub-Regional
Hospital in Birgunj (Parsa district) and Mechi Zonal Hospital in Jhapa. Both sites have high
caseloads, but management and quality of services are poor and a good deal of external
support will be required to achieve the necessary standard.

As noted under Output 2, the Makwanpur district hospital also has potential for development as
a training site as it is functioning well and providing standard quality CEOC services. At present
it has insufficient nurses for a training site, but this is expected to be addressed by hiring
additional nurses under the FHD FA budget for local contracts.

Advanced SBA training: The first two MBBS doctors (from Dang and Saptari) completed the
caesarean section training course at Bharatpur Hospital training site. The course appears to
have been successful, as both doctors have been followed up by telephone and are carrying out
caesarean sections confidently. As noted under Output 2, they have carried out 23 and 41
caesarean sections respectively since returning to their hospitals. Another batch of three
doctors will begin training in January.

Post Training Follow up: Findings from the post SBA training follow up pilot, which was carried
out by NHTC with SSMP/ Options support during the last reporting period, have been finalised
and a report produced and disseminated. A total of 119 SBA graduates, mainly nurses and
ANMs, were visited at 38 health facilities by trainers from five training sites. The trainers
interviewed SBAs and their supervisors to gain an understanding of their perspective on the
SBA training and the realities of service provision. They also observed the SBAs’ performance,

                                                                                                 27
providing on-site coaching as required. Key findings were that most SBAs were using their new
life-saving skills and were confident and competent in providing delivery and emergency
obstetric care services, but there were areas in which greater support was required. Annex 9
gives the full recommendations, but key points were:

   All SBAs should be followed up within three to six months of their training.
   The SBA supervisors should receive a formal orientation on SBA skills and services to
    ensure they are able to give trained SBAs the necessary on site support.
   SBAs must have the required equipment for service provision, with a minimum package
    provided to individuals to take back to their place of work at the end of the training (at least
    MVA and vacuum delivery sets if these are not already there).
   Clinical practice opportunities need to be improved during training, especially for less
    commonly used skills, such as Intra Uterine Device (IUD) insertion.

One important outcome of the pilot is that the trainers who were involved recognised the
importance of follow up, although logistical problems remain a constraint. It is hoped that the
new regional training coordinators will be able to support this. NSI has also committed to
following up 200 newly trained SBAs from their programme areas.

Regional training coordinators: The process for recruitment of six regional training
coordinators (one for each outlying region and two for the centre) has begun and they are
expected to be in post by late January or February 2010. Annex 10 contains their terms of
reference, which include supporting training and follow up, especially for SBAs. They will be
managed by NHTC from a regional base, either the Regional Directorate or Regional Training
Centre. Their salaries and expenses will be covered under the FA budget. It is expected that
they will be able to ensure many of the recommendations from the SBA follow up report are
taken forward.

Quality improvement: The Quality Improvement (QI) tools developed for SMNH service
delivery and SBA in-service training with SSMP/Options, JHPIEGO, IntraHealth and SBA trainer
support have been printed in Nepali language and are in use at all the SBA training sites. The
next stage will be to distribute them to all hospitals, with support (including equipment and
supplies) to enable staff to implement them effectively. A few of the tools could also be selected
for distribution to PHCCs and health posts providing delivery services, but this would need to be
properly managed, and again they would need support.

Pre-service SBA education: The National Strategy for SBA Pre-service Education, developed
in collaboration with the IoM and NHTC, has been submitted to MoHP for approval. They
require comments from the Ministry of Education, and the file has been forwarded accordingly.
The revised curricula (Proficiency Certificate Nursing, BSc Nursing, MBBS, MDGP,
MD/Gynaecologist) are already being implemented at IoM medical and nursing campuses.
NAMS has also revised its curricula and begun implementation. The Council for Technical
Education and Vocational Training (CTEVT) has committed to implementing the IoM approved
curriculum for their certificate nurse training courses, but many of the campuses are of poor
quality and need additional inputs to ensure proper standards.

Human resource strategy: Implementation of the Strategy for Human Resources for Safe
Motherhood, which was finally approved in November, has begun, with government committing
to budgeting for additional recruitment of essential staff for delivery and EOC services. For
2009/10, budget was allocated for recruitment of 28 MDGPs/ gynaecologists, 50 staff nurses


                                                                                                 28
and 600 ANMs under local contracts. However, the current complex systems for posting and
frequent transfers will continue to complicate strategy implementation if they are not addressed.

PMTCT: In collaboration with the National Centre for AIDs and Sexually Transmitted Diseases
Control, UNICEF conducted an orientation on Prevention of Mother to Child Transmission of
HIV to all SBA trainers at Dhulikhel Hospital, with the objective of building the capacity of
trainers and thus increase awareness and understanding of this issue among SBAs.

Challenges and future directions

   There is an urgent need for more training sites to ensure training is completed in line with
    the operational plan and national needs, as currently there is a gap between planned
    numbers and training site capacity. However, strengthening and development of new
    training sites is becoming more challenging, as the best, which required only minimal
    support, were the first to be developed. Many of those remaining have serious limitations,
    requiring large amounts of time and other inputs to bring them up to standard. The
    fundamental problem is often poor motivation at top management level, which affects the
    functioning and morale of the whole site, effectively preventing other staff from taking the
    initiative to improve services. Services, even emergencies, may be strictly limited to the
    period between 10.00am and 2.00pm, with women referred elsewhere if they arrive outside
    these hours. Cleanliness and use of equipment are also huge issues, with equipment lying
    unused and rusted in store rooms, while the beds do not even have sheets. These
    problems can be addressed, but only with time, effort, patience and tact. In Terai areas,
    political problems are also a factor, linked to ethnic issues, and many women simply choose
    to go over the border to India for services. The development of more facilities is important,
    not only to increase the rate of production of SBAs, but also because the process has the
    additional benefit of greatly improving services at the training site itself. It is recommended
    that external partners and the private sector should be encouraged to participate in training
    site development, as UNICEF already has. Discussions are currently under way with
    UNICEF, NSI and Care-Nepal for their funding of another training site.
   Also related to development of new SBA training sites, it is essential to ensure there are
    enough trainers to maintain services and provide training. As trainers are also senior EOC
    service providers, work pressure can lead to conflicting demands, especially at smaller
    training sites. Ensuring sufficient caseload for training purposes is another challenge.
   In order to address the delay in training start-up at the beginning of the year, due to delays
    in budget release, other strategies need to be developed for funding important training,
    such as SBA. This year some privately funded trainings were carried out while budget was
    awaited, but an additional mechanism for releasing an interim budget for priority purposes
    is needed.
   Local recruitment of additional staff, especially ANMs, has been successful in increasing
    service availability, but in order to be fully effective, contract staff need to be given SBA
    training, which is currently not government policy.
   Although the advanced SBA (caesarean section) training for MBBS doctors appears to be
    successful, the number of candidates applying to do the course is very low because most
    medical officers prefer options that give them better career opportunities, such as post
    graduate diplomas, especially the many scholarship doctors working at district and zonal
    hospitals, who are only short term and looking to their next stage. One solution could be to
    ensure successful completion of this course carries credits of some kind.




                                                                                                29
   Similarly, the planned local recruitment of additional essential SMNH staff under the FA
    budget is constrained by lack of applicants for doctor and, in some places, staff nurse
    posts.
   Post training follow up is an essential part of training, but continues to be constrained by the
    limited numbers of trainers available to carry out visits and the gap left in service provision
    and training while they are away. It is expected that the new regional coordinators will help
    address this and every effort should be made to ensure these posts become longer term,
    rather than just short term contracts within one fiscal year (which anyway amounts to less
    than a year of work because of delays in budget approval at the beginning of the year). It is
    also suggested that, after the SSMP FA ends, their salaries could be taken from the pool
    fund to ensure future sustainability.
   Effective implementation of the QI tools needs external support and this has not yet been
    addressed. With proper orientation, the regional coordinators could help with this.
   The trainers’ interactive meetings are very important and have proved successful in
    identifying critical issues and solutions through sharing experiences between different
    facilities and across different age groups and levels of experience, ensuring more
    consistent training standards. Since residential events cannot be funded from the red book,
    they were funded under FA, which will end this year. As a result, no more are currently
    planned. It is important to ensure these meetings become a regular part of the SBA
    programme, funded under government budgeting (the Red Book). This could be achieved
    by organising them at NHTC, rather than a hotel.

Output 6: Information

This area of SSMP/ Options technical assistance influences and supports work under all the
other programme outputs, sometimes in a lead role, but often in the background, providing
essential information and advice on monitoring, research and data analysis to individuals and
working groups. Current areas of particular focus are piloting the new HSIS, and completion of
the 2008/09 Maternal Mortality and Morbidity (MMM) Study report.

Key Achievements

   MMM Study data analysis completed and main findings disseminated
   Geographic Information System (GIS) based SMNH atlas completed
   EAP end-line KAP survey completed

The MMMS 2008/09: This major study is a prospective (one year) surveillance of live births and
deaths of women of reproductive age. Field work was completed in eight study districts in April
2009, with extensive collaboration between SSMP/Options, who provided technical leadership,
key government staff, New Era, Centre for Research in Environment Health and Population
Activities (CREHPA) and JHPIEGO. Data analysis was completed in this reporting period and a
summary report of preliminary findings published and disseminated at a national stakeholder
meeting in November, providing a wealth of information that will help improve future safe
motherhood programming in Nepal, and may also be of interest internationally. The
dissemination meeting stimulated considerable discussion, with participants acknowledging the
far reaching importance of the study. The findings provide new insights into the effects of
community and facility related factors on maternal outcomes and encouraging evidence of the
success of some previous initiatives. An important finding was that maternal/ pregnancy related
causes are no longer the leading cause of death for women of reproductive age, but now rank
third, reflecting improvements in management of pregnancy complications over the last decade.

                                                                                                 30
For example the focus on postpartum haemorrhage has resulted in a drop from 41% to 24% in
its contribution to maternal deaths since the last MMM study in 1997, although it remains the
leading maternal cause. However, the percentage contributions of eclampsia and abortion have
increased, indicating a need for renewed efforts to address these. A shocking finding was that
suicide is now the leading single cause of death (16%), where it was only ranked third in 1997.
Also encouraging was the MMR result for the eight study districts, of 229 per 100,000 live births,
a figure that is consistent with the 2006 NDHS national result of 281, which represented a
dramatic drop from the 1997 figure of 539. See Annex 1 for summary of key findings.
Completion of the full report is in process and expected by early 2010.

The Demographer and Computer Officer of FHD have been closely involved in the study, which
has provided them with significant learning opportunities. Involvement of FCHVs in data
collection and Maternal and Child Health Workers (MCHW) and other senior paramedical health
workers in administering verbal autopsies and live birth capture were also important steps in
institutionalising the process, considerably increasing their capacity and confidence in this type
of work. Budget has been allocated in FY 2009/10 to continue the MMM Study work in the eight
study districts under FA funding, which will allow comparison of the MMR in these districts as a
time trend.

Health sector information system: The new HSIS is currently being piloted. The main
objectives are to: a) bring all other sectors, including private and NGO, into the system; b)
capture service utilisation and other information below district level; c) monitor service data by
gender, ethnicity and caste. To improve monitoring before the HSIS piloting is completed and it
is scaled up country wide, revision of the current HMIS, particularly the hospital recording and
reporting system and EOC monitoring, has begun. Systems software has been developed
through outsourcing of target population estimation work. This generates indicators using new
sets of denominator (target population) down to VDC level, allowing monitoring of health
programmes to that level. The new sets of target populations have been distributed to all district
public health offices.

GIS atlas: The GIS based Safe Motherhood and Newborn Health Atlas, with target population
projections, was completed in the last reporting period, but a few final adjustments were made
during this period to address inconsistencies found. Printing is planned within the next few
months. The GIS atlas provides essential and detailed district level information, including VDC
names/ boundaries, settlement areas, health institutions, populations, road networks, airports,
land cover types, water bodies and rivers. The atlas also provides information on key SMNH
indicators for each of 75 districts, making it an important resource for safe motherhood and
newborn programme planning.

Further MMR assessment: SSMP/ Options advocacy has influenced the decision of the
Central Bureau of Statistics (CBS) to include questions in the 2011 census that will enable
another assessment of the MMR. The CBS conducted a workshop on the questionnaire and
methodology for generation of an MMR figure from census data, to which the Monitoring and
Evaluation Adviser provided technical input, with an assurance of further support as needed in
the future.

New research: Support was provided to the FHD Demography Section for development of
terms of reference for The Community Obstetric Morbidity Study, funded under FA, to assess
the accessibility and quality of reproductive health services and the pattern of obstetric
morbidities within communities. This will be completed before the end of this fiscal year (mid
July 2010).

                                                                                               31
The EOC monitoring, which began in 1997 in 13 selected districts, continues to expand, and
now includes 26 districts. To enhance the usefulness of this data, another study will be
commissioned analysing data from 10 districts through an equity lens, using technical
assistance funding.

Government capacity building: The major research and data collection/ management
initiatives discussed above have all provided considerable opportunities for capacity building
and new learning for government staff, especially in the FHD Demography Section and
Management Division (MD) HMIS Section. In the case of the HSIS, developing and piloting has
gone beyond the safe motherhood field to influence the whole health sector. As an extension of
this, four DoHS staff (two from the Demography Section and two from HMIS) have been
supported to attend a safe motherhood monitoring and evaluation course in Mahidol University,
Thailand, as a part of government capacity development.

Main Challenges

   Although piloting of the HSIS is continuing, a number of problems remain, particularly
    related to software, lack of human resources (IT at central level, and others at district level),
    lack of funding, lack of uniform coding, and poor integration with other sub-systems, such
    as logistics, finance and human resource management information systems.
   Institutionalisation of the verbal autopsy and birth capture processes in the eight MMM
    study districts is challenging, as it requires dedication of district level government staff to
    provide training, supervision and management of the entire process and the data entry and
    analysis. If this is successfully achieved, further districts should be included to obtain a
    national figure for the MMR.
   Updating the GIS based SMNH atlas every year is essential and needs to be extended to
    below district level. This will depend on successful piloting and scaling up of the HSIS
    countrywide. However, due to the IT vacancy in the HMIS section, the GIS based SMNH
    atlas has not yet been uploaded and thus further developments cannot happen.
   As SSMP/ Options technical assistance moves towards closure, it will be important to
    ensure full government ownership and their capacity to manage the new information
    systems developed. With the current limited human resources in the Demography and
    HMIS sections, this will be a challenge.

Key Recommendations

   SSMP/ Options and other external agencies will need to continue providing technical and
    financial support to the DoHS to ensure successful completion of the HSIS pilot and its
    scaling up countrywide, including contracting out the IT work.
   As a key mechanism for institutionalising the process, it has been suggested that FHD
    should engage NESOG in reviewing the pregnancy related verbal autopsy questionnaires,
    and the Nepal Health Research Council in reviewing the non-pregnancy related verbal
    autopsy questionnaires. A mechanism will need to be developed to ensure these
    partnerships function smoothly.
   A user friendly data entry design is needed for the verbal autopsy questionnaires
    (pregnancy and non-pregnancy related) and live birth recording. Budget will be needed to
    contract this work out as both Demography and HMIS section staff are already committed
    to capacity.



                                                                                                  32
   In order to maintain the quality of data collection (verbal autopsy and live birth) periodic
    supervision visits and cross verification need to be carried out in the eight districts by the
    Demography and HMIS Section staff.


Output 7: Physical Assets and Procurement

Technical assistance under this output covers all aspects of physical assets management and
procurement, including construction and maintenance of health buildings, and procurement of
drugs, commodities and equipment. Although the main focus is on enabling quality SMNH
services, this output has provided considerable support to systems development that benefits
the whole health sector.

Key achievements

   Construction completed: 2 CEOC sites, 2 BEOC sites, 9 birthing centres, 3 CAC sites
   Standard designs completed for Terai health facilities of all levels
   Five-year analysis of construction work and investments, showing increased equity

Physical assets management

With support from SSMP/ Options, Management Division (MD) organised an interaction meeting
with health facility users and experts to finalise the Health Infrastructure Standards. The
proposed functions and draft designs were presented for all three levels of facility (hospital,
PHCC, health post) for each ecological zone. These were the result of many rounds of
discussion with experts, representatives of government divisions and departments, several
workshops and experience of field realities. A few additional adjustments were made on the
basis of discussions and suggestions at the meeting, and the standards are now considered
final, as shown in Annex 11. These will help to improve the capacity of district technicians to
ensure the quality of health infrastructure construction and improve the transparency,
accountability and responsiveness of implementation. They will also help policy makers,
planners, district users, communities and external partners to understand actual requirements at
micro and macro level, thus improving resource allocation, planning and monitoring. A detailed
construction guideline will be prepared, and the designs have been prepared in a way that will
enable expansion of buildings vertically, horizontally or as separate units, to accommodate
changing future needs.

Support was also provided to the Department of Urban Development and Building Construction
(DUDBC) for development of designs (based on the above standards) for different levels of
infrastructure in different ecological zones. Draft designs have been completed for the Terai,
and although official endorsement is still awaited, DUDBC has this year begun implementing
them.

SSMP/ Options worked with MD to select sites for development in this fiscal year (2009/10),
including C/BEOC sites and birthing units. Selection was based on information from the web
based Health Infrastructure Information System (HIIS) and criteria such as catchment area, high
local unmet need, user demand, ownership of land and the national long term SMNH plan.

This year the budget allocated for repair and maintenance work was substantially reduced,
amounting to only about one tenth of requirements. Within this limit, SSMP/ Options helped MD

                                                                                               33
to prepare a rational repair and maintenance plan using the HIIS.

The electronic database of the HIIS has greatly enhanced the capacity of the government to
plan repairs and maintenance, expansion of health facilities and selection of new sites, and to
develop appropriate policies and strategies. Recognising this, priority has been given to
updating and cleaning up the database in this year’s Annual Work Plan and Budget.
Discussions are also ongoing with a view to integrating it into a readymade licensed software
package purchased by KFW (the German Government agency) for MD and currently only being
used for equipment inventory. This would enable more coordinated planning of infrastructure
development and equipment supply.

Additional FA budget has been allocated to DUDBC in FY 2009/10 to directly contract technical
consultants to work in critical areas, supplementing the limited human resources available in the
department. Funding will also continue for monitoring and supervision, which is a key need, and
for implementing e-bidding for facility construction contracts. Budget has also been allocated for
establishing an infrastructure management unit in MD.

During this reporting period a number of monitoring visits were made to construction sites, in
order to assess the quality of work, provide relevant technical advice to the district technicians
and to expedite handing over of completed buildings, especially where difficulties have
emerged. Annex 12 provides some specific examples, but major observations are:

       Over the years, the capacity of DUDBC district staff has increased significantly in terms
        of infrastructure planning, but design and detailing (such as ensuring fittings meet the
        needs of users) still needs to be improved. DUDBC needs to develop or recruit more
        experts on health infrastructure to support this.
       More human resources are needed to meet site supervision needs, as where frequent
        monitoring visits have been carried out there is clear evidence of improvement, but in
        areas that have received less frequent support, the quality of work has suffered.
       DUDBC staff at all levels need to be updated on the latest construction methods and
        fittings, such as UPVC frames and fixtures, and on how to ensure they are properly
        fitted.
       There is a need to increase monitoring by central staff who understand health facility
        construction.
       More exposure visits, case studies and experience sharing for both district and central
        level staff are required, to provide practical examples of good practice.

Continued coordination with the GTZ Health Sector Support programme has helped
decentralise health construction work and build local capacity in planning and design, for
example in the recent technical orientation provided for District Technical Office staff (under the
DDC) who are involved in health infrastructure planning, design and monitoring.

During this reporting period, detailed analysis of construction work and investments in different
districts was carried out for the last five fiscal years, to support an equity study of the distribution
pattern. The analysis shows that investment in peripheral health facilities has increased
significantly in the SMNH sub-sector, with a total of 123 new birthing units added to existing
facilities, and 107 new health posts and 76 new PHCCs constructed, all with integrated birthing
units. Since poor and excluded people are more likely to use these peripheral facilities than to
go to the district hospital, this increases equity. The increase was particularly noticeable in the
Far Western Region, which had previously received less development input. Annex 13 gives a


                                                                                                     34
summary breakdown of new construction work in the last five years.

Drugs and commodities

Support was provided to DfID in the process of direct procurement of SMNH equipment
consignments. Based on needs assessment and demands from facilities and districts, a
distribution list was prepared and shared with SMNH partners at a meeting organised by FHD.

In response to FHD’s request, updated specifications, cost estimations and quantity work for
equipment to be purchased through FA in 2009/10 were prepared and submitted. Cost
estimation was derived from local and international market surveys carried out by internet and
based on prices quoted during recent procurement tenders (for SSMP/ Options and other
organisations) for similar items.

SBA training equipment was provided for Baglung SBA training site. The materials were
financed by NSI with technical support from SSMP/ Options for procurement.

Construction


        Table 4: Status of Construction of SMNH Facilities

          SN              CEOC Status                          Number
           1                Completed                            10
           2             Near Completion                          3
           3            Under Construction                        4
           4             Planned this year                        4
                             TOTAL                               17

          SN              BEOC Status                          Number
           1                Completed                            15
           2             Near Completion                          2
           3            Under Construction                        4
           4             Planned this year                        6
                             TOTAL                               21

          SN         Birthing Centre Status                    Number
           1               Completed                              86
           2             Near Completion                           3
           3           Under Construction                         19
           4            Planned this year                         35
                             TOTAL                               108

          SN               CAC Status                          Number
           1               Completed                             4
           2             Near Completion                         1
           3            Under Construction                       1
                             TOTAL                               6

Table 4 gives a summary of the current status of construction work. So far this year two CEOC
sites, two BEOC sites, nine birthing centres, and three CAC sites have been completed,

                                                                                           35
making a total of 10 CEOC, 15 BEOC, 86 birthing centres and four CAC units completed during
the programme period under FA. For further detail by facility type, see Annex 14. In this fiscal
year (2009/10), initiation of construction is planned for four CEOC sites, six BEOC sites and 35
birthing units.

Challenges and future directions

   Decentralisation of the HIIS, capacity building to ensure its regular updating and use, and
    capacity building for implementation of standard prototypes are high priorities and should
    be continued in the next phase of support (NHSP II).
   Rational budgeting for ongoing infrastructure is essential for timely completion of all health
    facilities. This means prioritising completion of existing building work before embarking on
    new ventures.
   Implementation of rational site selection criteria is important. In particular the current policy
    of constructing facilities on land donated by communities should be revisited, as it
    frequently results in health facilities being unsuitably located, in areas not easily accessible
    to users.
   All the support provided by SSMP/ Options in the area of physical assets will form a strong
    foundation for a reformed system of health infrastructure planning, design, implementation,
    monitoring and management. However, the fragile condition of the state and governance
    continues to be a crucial factor affecting the success and sustainability of reforms initiated,
    as reflected in real planning and implementation.
   It is not possible for the government to absorb all the efforts made in the area of physical
    assets management in the remaining short period of SSMP. New policies, strategies and
    guidelines developed, and new initiations, such as e-bidding, LMIS and building standards
    will take a few more years to mature and become fully institutionalised. These initiatives
    therefore need continuing support.
   In the current governance context, capacity building to ensure sound procurement practices
    is more important than increasing direct financial support for procurement.


Output 8: Finance and Aama Programme

Financial Aid

The SSMP/ Options TA has continued to support government counterparts in annual work
planning and budgeting (2009/10) for the national safe motherhood programme and preparation
of the Financial Monitoring Report (2008/09). The annual work plan and budget lists all the
activities planned by different divisions and centres for strengthening the national programme,
the sources of funding for each and targets. The total budget allocation in this year’s annual
work plan (2009/10) from SSMP FA is about Rs.820 million, which is around 35% of the total
budget allocation for the sub-sector.

Support is also provided for analysis and verification of the budget allocation from SSMP FA in
the annual work plan and budget for each division/ centre, against allocations in the Redbook.
For example, this year it was noted that Rs.110 million required for completion of ongoing
SMNH construction work had been missed out of the government budget, and this was followed
up at Ministry level and included in the budget plan.

Out of the Rs.820 million allocated through FA this year, the largest share was for the Aama

                                                                                                  36
Programme, based on forecasting from the previous expenditure pattern and projections from
different studies. The total amount allocated for Aama is Rs.465,790,000, of which Rs.370
million is from FA and the rest from government funds. SSMP/Options is supporting FHD in
monitoring financial records of the Aama Programme, in order to better understand facility level
economics, and how this is affected by, and interacts with, Aama programme.

Detailed analysis has been carried out for FA spending by all the divisions and centres during
2008/09, as summarised in Table 5. The total government spending as a percentage of
allocated FA decreased to 66% this year (2008/09) from 71% in 2007/08. However, this
represents a larger amount of money spent, Rs.452,455,650 compared with Rs.293,394,320 in
2007/08, an increase of 54% in actual spending. The NPHL, NHEICC and MD were the highest
percentage spenders, at 99%, 86% and 83% respectively, although it should be noted that the
NHEICC allocation is very small, and therefore quickly spent on printing costs. NHTC and LMD
were the lowest, at 35% and 11% respectively. The NHTC figure reflects a lack of capacity to
organise a very centralised training programme; LMD’s spending was reduced by their decision
not to go ahead with the planned construction of a biomedical laboratory. FHD’s spending is
generally high, but this time was reduced by the lack of procurement, which was managed
directly by DfID.

                     Table 5: Budget Expenditure vs. Allocation 2008/09

                                     Allocation in   Expenditure
                                        NRs (in        NRs(in         % spent
                                     thousands)      thousands)

                    FHD                   488,980    315,852.06         64.59

                    MD                    119,980      99,670.43        83.07

                    LMD                      2,800        296.42        10.59

                    NHEICC                 17,624      15,176.31        86.11

                    NHTC                   54,468      19,172.91        35.20

                    NPHL                     2,300      2,287.52        99.46
                                          686,152    452,455.65         65.94

Aama Programme

The Aama Programme was launched in January 2009, combining the previous Safe Delivery
Incentives Programme (SDIP) with free delivery services at all government and approved
community/ NGO and private institutions. Essential provisions include:

   Incentives to women: As a cash payment at the time of discharge after delivery at a health
    institution (NRs.1,500 ($20) in mountain areas, NRs.1,000 ($13) in hill areas and NRs.500
    ($7) in the Terai).
   Free delivery services at all public health facilities: Calculated from unit costs that include all
    drugs, supplies and disposable instruments plus a small incentive for the health workers:
    - Normal Delivery:                 NRs.1,000 or NRs.1,500 at hospitals of more than 25 beds
    - Caesarean section:               NRs.5,000 or NRs.7,000 at hospitals of more than 25 beds
    - Complication management:         NRs.3,000

                                                                                                    37
   Incentives to health workers:     NRs.200 per home delivery attended.

Key Achievements

   Revision of cost guidelines to more realistic levels, based on feedback from hospitals
   Increased number of peripheral health facilities implementing Aama
   Increased number of women receiving the cash incentives

Policy Amendment: Early implementation experiences and feedback from hospital staff
prompted MoHP to revise the Aama programme guidelines in July, to ensure the actual costs of
providing free institutional delivery were adequately covered by the capitation payments and to
clarify other components. Feedback at regional meetings indicated that the cost of providing
services was higher at the larger hospitals and so the unit costs defined for hospitals with more
than 25 beds was increased to NRs.1,500 for normal delivery NRs.7,000 for caesarean section.
To further encourage provision of institutional delivery services, the financial incentive for health
workers assisting at institutional deliveries was increased to NRs.300, but remained at NRs.200
for home deliveries. The role of DPHOs in monitoring the programme was also clarified by the
introduction of a simple supervision checklist in the programme guidelines.

Peripheral institutions implementing Aama: There has been a significant increase in the
reported number of facilities providing delivery services after the launch of the Aama
programme, evidence of Aama’s potential role in increasing access to delivery and EOC
services across the country. Data show:

   A 26% increase in provision of 24-hour delivery services, from 422 local institutions in
    December 2008 to 532 in 2009. The increase is mainly at health post and sub-health post
    level, with 301 of the 674 health posts and 64 of the 3,130 sub-health posts now providing
    24-hour services, compared with 219 and 35 respectively before Aama.
   A 32% increase in the number of health facilities providing BEOC services, from 68 in
    December 2008, before Aama, to 90 in December 2009.
   A 55% increase in the number of health facilities providing CEOC services, from 51 in
    December 2008, before the launching of Aama, to 76 in 35 districts in December 2009.
    However, it should be noted that much of this increase is due to a growth in private nursing
    homes providing CEOC services, most of which are not currently implementing Aama. It
    appears that more NGO and private facilities want to join Aama, and may then feel
    confident to start CEOC services, which would lead to increased service utilisation.

At present, 21 non-government hospitals (seven NGO, four mission, seven medical college and
three private for-profit) are implementing the Aama programme.

More women receiving the incentives: The percentage of women delivering at participating
health facilities and receiving the cash incentive has risen from 30% in 2005/06 to 89% in
2008/09 (Figure 11), strong evidence of improved programme management.




                                                                                                  38
Figure 11: Number of total institutional deliveries and women who received incentives




           Source: Aama programme claim forms, HMIS 2009


By contrast, reflecting the reduced priority now given to payments to health workers, the number
of trained health workers5 receiving the home delivery incentive has fallen over the years.

Figure 12 shows a steady rise in total number of deliveries by health workers has continued to
rise. In 2007/08, the increase was greater for home deliveries (17%) than for institutional
deliveries (1.1%). However in 2008/09, this trend was reversed, again a positive sign of the
success of the programme in increasing facility deliveries.

Figure 12: Place of assisted delivery from 2004/05 to 2008/09




           (Source: HMIS 2004-2009)




5
    Includes; Doctor, Nurse, ANM, Health Assistant, Auxiliary Health Worker, Maternal and Child Health Worker.

                                                                                                                 39
There are clear indications that Aama programme is the major cause of this change. In order to
reduce fraudulent claims for home deliveries new government policy guidelines require the
signature of the VDC secretary for payment authorisation, a copy of the birth certificate and
public auditing involving service users. These changes are in line with recommendations made
during the SDIP evaluation, rapid assessments, Aama programme working group and by the
FHD Director.

Fund expenditure: The Government’s contribution to the implementation costs of SDIP/ Aama
rose from zero in 2005/06 to 30% of total spend in 2007/08. However, with the introduction of
relatively costly free institutional delivery component, Government allocation in the current year,
while increased in absolute terms compared with 2007/08 levels, now represents only 21% of
total costs. As a result of increased DfID funds being made available for the programme, and
the programme’s mid-year start, only 70% of the total committed funds for the year were spent,
but this figure is expected to rise to around 85% for the current financial year (2009/10). It
should be noted that financial data for 2008/09 has still to be verified by the Financial
Comptroller General Office.

Rapid Assessments: The results of the third Rapid Assessment were submitted by CREHPA
in July, with the following main findings:

   Payment of incentives to mothers immediately following delivery has increased compared
    with the Round II assessment
   The flow of funds from the centre to districts has improved considerably, but flow from
    district to peripheral facilities varies widely, with D/PHOs frequently applying different
    norms, for example issuing lump sum amounts to remote facilities because of the distances
    involved
   Of the 333 institutional deliveries cross verified, 71 (24%) were found to be false, most
    relating to women who had delivered at home without a health worker. More of these were
    in Terai (30%) and hill districts (21%) compared with only 12% in the mountains
   Of the 65 home delivery incentive payments cross verified, 35 (54%) were found to be
    false, compared with 71% in Round II. However, the small numbers involved make it
    difficult to draw clear conclusions about whether or not this marks a real improvement
   It appears that the majority of women in the six districts assessed were still paying fees for
    institutional deliveries, ranging from Rs.10 to one case at Rs.16,000

The fourth Rapid Assessment began in November 2009, again in six districts.

Additional safeguards: Based on the findings of the third Rapid Assessment, FHD prepared a
framework of additional safeguards, which was submitted to DfID in August. This advises MoHP
to consider formation of an independent working committee to suggest ways to improve fund
flows, supervision, monitoring and hospital auditing. The committee should include a
representative administrator, health worker, civil society member, journalist, women’s leader
and external partner. FHD has sent an instructional letter to all 75 districts requiring them to
implement effective monitoring, and assure timely reporting, timely fund flow, free delivery care,
public auditing and information dissemination using local funds.

Other research studies: SSMP/Options has contributed learning from Aama programme to two
recent independent studies: (1) HSR-SP included selected questions related to Aama in a free
health care household survey questionnaire in 13 NDHS districts, administered to 6,000 recently
delivered women, and currently being analysed by HSR-SP, SSMP/ Options and Care-Nepal;


                                                                                                40
(2) The questions were also included in the SSMP funded EAP KAP study, implemented by
Valley Research Group, which showed an impressive level of awareness of the incentives
among recently delivered women in eight EAP districts (90%, up from 27% in 2006).

Challenges and Future Directions

   Evidence from district visits shows that many health facilities are still charging for deliveries.
    This issue is strongly addressed in the additional safeguard measures. FHD has also
    committed to engaging the six newly recruited regional coordinators in cross verification of
    records during their monitoring visits. Using FA funding, FHD will also conduct random
    cross verification in 14 selected districts to further examine this issue.
   Field visits indicate that some institutions are not conforming to the guidelines in their
    expenditure of the unit costs provided for institutional delivery. This is being looked at more
    closely in the monitoring of use of fees that began in December. It seems that lower level
    facilities are not using the unit cost money to provide free delivery care, and higher level
    institutions are paying incentives to health workers above the specified amount and
    spending funds for non-SMNH purposes. The Government needs to develop a standard
    prescription for costing of drugs, diagnostic services and blood transfusion services
    required for normal, complicated and caesarean section deliveries and ensure its proper
    publication and implementation.
   Since many of the health facilities below PHCC level do not have bank accounts, cash is
    kept by the facility in-charge or by nursing staff. The growth in numbers of these facilities
    implementing Aama increases the risk of misuse of cash. To address this, MoHP should
    require proof of public auditing for any health institution to receive Aama programme funds,
    which should be confirmed in the facility annual audit.
   Despite the Aama programme guideline’s specification of how HFMCs should allocate the
    unit cost, very few adhere to this. HFMCs and local civil society organisations need to be
    properly orientated to address this.




                                                                                                   41
3. PROGRESS AGAINST INDICATORS IN THE LOGICAL FRAMEWORK: MATRIX

Purpose level

Goal                                                                                                                 Comments
Improved maternal and newborn health and survival especially of the poor and excluded

Purpose                                                                                                              No indicators specified. SSMP feeds into the
To help improve safe motherhood and newborn health services and their utilisation particularly for poor and          national goal level indicators for the MMR and
socially excluded                                                                                                    neonatal mortality rate.

1. Increase in skilled attendance at birth by at         1. Deliveries attended by SBA increased by 0.9 of a            Calculations for all 4 indicators for
   least 4% per year, particularly for poor and             percentage point, from 23.9% in FY 2007/08 to 24.8%          2007/08 and 2008/09 used the revised
   excluded groups                                          in FY 2008/09                                                (lower) denominator, based on lower
                                                                                                                         fertility rates found in the 2006 NDHS.
2. Increase in deliveries conducted in health            2. Increased by 2.3 percentage points, from 20.2% in FY        Source HMIS (first year comparative SBA
   facilities by at least 2% per year particularly for      2007/08 to 22.5% in FY 2008/09                               figures have been available)
   poor and excluded.


3. Increased met need for EOC by at least 3% per
                                                         3. Increased by 6.3 percentage points, from 24.9% (22          Source FHD
   year particularly for poor and excluded groups
                                                            districts) in FY 2007/08 to 31.2% (26 districts) in FY      EOC monitoring report indicates
                                                            2008/09                                                      deliveries in B/CEOC sites increased by
                                                                                                                         6.9 percentage points, from 15.4% (22
4. Increased met need for caesarean section by at        4. Increased by 51 percentage points, from 50% (22              districts) in FY 2007/08 to 22.3% (26
   least 4% per year particularly for poor and              districts) in FY 2007/08 to 101% (26 districts) in FY        districts) in FY 2008/09.
   excluded groups                                          2008/09




                                                                                                                                                                      42
Output 1: Equity and Access
Indicator                                               Progress                                                  Comments

1. Knowledge about at least 3 danger signs in           1. Achieved. Knowledge of at least 3 danger signs among      Figures based on end-line KAP survey
   each period of pregnancy, delivery and after            poor and excluded women and men has increased to:          carried out by independent research
   delivery in selected SSMP districts among both          a. 42.8% during pregnancy                                  group, VaRG.
   men and women in selected VDCs with majority            b. 53.9% during labour
   poor and excluded populations (by June 2009)            c. 47.2% postpartum (up to 42 days)
     a. 13.1% to 40% during pregnancy
     b. 15% to 40% during delivery
     c. 8.8% to 35% with in 42 days after delivery

2. Knowledge about at least four out of the eight       2. Achieved. Knowledge of at least 4 out of 8 listed
   listed elements of essential newborn care in            elements of neonatal care among poor and excluded
   selected SSMP districts among men and                   women and men increased to 52.2%. Knowledge and
   women, including socially excluded groups,              practice of neonatal complications management also
   increased from 9.3% to 35% by June 2009.                increased in EAP areas.

3. Percentage of people practising birth                3. Achieved. Around 25% of families practise at least 2
   preparedness and complication readiness (at             out of 4 methods of birth preparedness and
   least 2 of: money, transport, blood, SBA) in            complication readiness.
   selected SSMP districts increased from 4% to
   12% by June 2009

4. Knowledge about legal provision of safe              4. Achieved. Knowledge about the legal status of safe
   abortion among men and women in selected                abortion among women and men increased to 58.4%.
   districts increased from 29.3% to 50% by June
   2008

5. At least 70% of SSMP partner supported groups        5. Achieved. All 3,500+ community groups in EAP areas        Knowledge of the existence of emergency
   in selected districts have emergency funds (from        have emergency funds, with 80% utilisation by poor         funds had increased considerably, from
   a current baseline of none) with 50% funds              and excluded women.                                        17% to 60% of respondents.
   utilised by poor and excluded groups by June
   2009.

6. Results from voice capturing used in at least four   6. Achieved. The voice capture results were shared in
   national forums and disseminated in all EA              more than 6 national forums and in all districts.
                                                                                                                                                                43
   programme districts by June 2008.

7. Gender and social inclusion task force formed    7. Achieved. MoHP developed a Health Sector Gender
   and functional at MoHP by December 2008             Equality and Social Inclusion Strategy, with high priority
                                                       allocated. MoHP has given additional responsibility to 3
                                                       officials within the Planning Division for Gender and
                                                       Social Inclusion (GSI). This is now the focal unit for
                                                       GESI.

8. Strategy paper setting out approaches for        8. Achieved. An independent qualitative review of EAP
   sustaining EA programming beyond SSMP               carried out last year will be the basis for EA programme
   support period prepared in consultation with        replication. Meanwhile the Government has begun
   MoHP by December 2008.                              scaling up the EA initiatives in 3 new districts and
                                                       further VDCs in 7 of the existing EAP districts, under
                                                       FA.

9. Percentage of men and women of all ages who      9. Achieved. Knowledge of the incentives increased to
   are aware of the maternity incentive scheme –       over 85% of respondents.
   MIS (SDIP) increased from 26.7% to 50% by
   June 2009


Output 2: Service Strengthening
Indicator                                           Progress                                                        Comments

1. At least 4 central level decisions made and/or   1. Achieved. Including revised SMNH long term plan                 Joint plans developed and implemented
   policies developed based on need and/or             (2006-17), SBA policy (2006) and training strategy               for previous years
   evidence, by June 2007                              (2007), blood transfusion policy, strategic plan (2009-
                                                       13) and guidelines, free delivery care policy (Aama)
                                                       (2009) and guidelines, training of MBBS doctors to do
                                                       C/s (2009), Remote Area Guideline for increasing
                                                       access to SMNH services in remote areas (2009)

2. Joint (SMNH partners) annual work plan and       2. Achieved. Joint Annual plan of FHD for 2010/11 for
   budget for strengthening health services            SMNH in process of development.
   (software, human resource, physical assets)
   completed by April of each year.


                                                                                                                                                                44
                                                                                                                           Among the 50 facilities, 23 were not
3. District level annual safe motherhood plan in        3. Achieved. District annual SMNH plans produced by all             providing 24-hour delivery service. After
   partner supported districts for strengthening           supported districts. Appreciative inquiry participatory          AI, 21 of these have started, the
   district health services (software, human               planning and review workshops conducted in 17 health             remaining 2 could not start because staff
   resources, physical assets) completed by                facilities in EA districts, in 90 facilities in UNICEF           transferred
   January of each year (in line with GoN planning         districts and in 13 facilities in UMN districts. AI review
   year) from 2008.                                        and planning process also scaled up by FHD in 28                New contracts for regional coordinators
                                                           districts in 50 health facilities.                               delayed by late budget approval and so
                                                                                                                            they were not able to provide support and
4. Regional level review of SMNH and RH                 4. Achieved in all five regions. Regional health                    facilitation.
   programme conducted annually to feed into               directorates now lead these reviews, including
   Joint Annual Review.                                    reproductive health as well as SMNH, with minimal               HFMCs have taken responsibility for
                                                           guidance from FHD. District reviews are ongoing.                 services, which will assure sustainability
                                                                                                                            of improvements in most facilities.
5. Quality SMNH services functional as defined in       5. UMN: 12 facilities provide 24-hour delivery services in 2
   MNH package in the UNICEF and UMN                       UMN districts and one provides 24-hour home delivery
   supported facilities districts and those receiving      service. Full BEOC functioning in Mugu hospital,
   software inputs by June 2009                            Dhakdai PHCC and Motipur HP. Additional 4 facilities in
                                                           Rupandehi providing some BEOC functions. All
                                                           facilities use partograph, IP protocol and active
                                                           management of third stage of labour.
                                                           UNICEF: 109 facilities in the supported districts now
                                                           provide 24-hour delivery services, 17 sites provide
                                                           BEOC services and 6 provide CEOC.

6. Utilisation of SMNH services increased in            6. UMN: Substantially increased utilisation in all UMN
   partner supported districts (4% increase in use          supported facilities. Service utilisation increased in FY
   of EOC, 5% increase of use by dalit/ janjati             2008/09 by 15% at Mugu Hospital. In Rupandehi
   EOC, 4% increase in skilled attendance) by               utilisation increased by amounts ranging from 13% to
   June 2008                                                80%.                                                           Meeting the need for EOC and caesarean
                                                           UNICEF: Deliveries at EOC sites in 8 districts and BZH           section services continues to be
                                                           increased in FY 2008/09 by an average of 3.6                     hampered by human resource transfers,
                                                           percentage points. Met need for EOC in 9 districts               especially surgically skilled doctors.
                                                           increased to 27.5%, up from 21.9 in 2007/08 (increase
                                                           of 5.6 percentage points). Met need for C/s increased
                                                           by 9.0 percentage points this year (21.7% to 30.7%)
                                                           making a total rise since 2005/06 of 15.4 percentage
                                                                                                                                                                         45
                                                          points.
                                                                                                                        This represents a reduction from last
7. CAC services available in all 75 districts by     7. Achieved. Service is available in all 75 districts. In           year’s figure of 97,378, but as 2008/09
   June 2008. CAC service utilisation increased         2008/09, 83,978 women received services (HMIS).                  was the first time data was collected
   and post abortion complications decreased. At        However, only 75% accept some kind of modern                     through HMIS, it is thought this apparent
   least 90% acceptance of post abortion                contraceptive method (Ipas M&E data).                            reduction is due to under reporting
   contraception. By July 2007.


Output 3: Public private partnerships
Indicator                                            Progress                                                        Comments

1. Agreements implemented between government         1. UNICEF: Agreement between Government and
   and non-government institutions (for profit or        Dhulikhel community hospital in Kavre to support
   non profit) for training (CAC and SBA at least)       service strengthening and SBA training. Public private
   by September 2007                                     partnership guidelines developed for Banke district.
                                                        Ipas/ TCIC: All pvt listed sites (MSI, FPAN and for-profit      Private/ NGO sites represent 53% of all
                                                        institutions) are implementing services with an                  safe abortion sites and this year provided
                                                        agreement approved by the DoHS for managing post                 87% of safe abortion services. Two (MSI
                                                        CAC complications                                                and FPAN) out of the six official training
                                                        All pvt training sites (MSI and FPAN) are implementing           sites are NGO.
                                                        an agreement approved by NHTC.
                                                        21 non-government hospitals have joined Aama.

2. Government contracts the national equity and      2.    Under FA funding, Government has begun
   access agency for implementing equity and               implementing EA activities in 3 new districts
   access work by June 2008.                               (Kanchanpur, Gorkha, Doti) and in additional VDCs in
                                                           7 of the existing EAP districts. NGOs are being
                                                           contracted by DHOs to implement activities.




                                                                                                                                                                      46
Output 4: Decentralisation
Indicator                                             Progress                                                      Comments

1. Annual health plans developed by VDC and           1. Around 75% VDCs and all DDCs of EA districts have
   DDC in partner supported districts covering            incorporated health activities in their regular annual
   SMNH and social inclusion by June 2008                 plan, covering SMNH and social inclusion issues.
                                                         UMN: All HFMCs of UMN and UNICEF supported
                                                         facilities are active.

2. All DDC annual budgets increase SMNH share         2. Annual budget for SMNH has been increased by VDCs
   by 3% in partner supported districts by June          and DDCs in EA areas in this year’s plan, compared
   2008                                                  with last year, although the exact amount has not been
                                                         calculated.

3. District level multi-sectoral committee (RHCC)     3. All RHCCs in EA districts are functional, with meetings       RHCCs in 5 of the 8 districts (Myagdi,
   functional in all partner supported districts by      conducted regularly and a focus on coordination among          Parbat, Dailekh, Dadeldhura, and
   June 2008                                             different local organisations regarding planning,              Rupandehi) have developed strategic
                                                         implementation, monitoring and resource sharing.               plans to improve the overall RH situation
                                                                                                                        of the district including institutional
4. HFMCs in partner supported districts producing     4. Most HFMCs in EA areas are active and meeting                  strengthening.
   annual plans (link with Output 2) by December         regularly, some focusing on birthing unit establishment,
   2007                                                  and around 20% implementing a work plan they have
                                                         developed.



Output 5: Human Resource Development
Indicator                                             Progress                                                      Comments

1. NHTC carries out need based planning for           1. NHTC 5-year operational training plan, including
   SMNH training and plans are at least 80%              training site expansion and SBA training site based
   fulfilled by June 2009                                plan, finalised and under implementation. Targets for
                                                         SMNH training over 90% met for 2008/09, except for
                                                         SBA, which was 75% met.

2. In partner supported districts, SMNH training of   2. In the two UMN districts a further 11 SBAs have been
   service providers is need based,                      trained, using SSMP funding, and in the 8 UNICEF              UMN and UNICEF supported some


                                                                                                                                                                    47
   complementing service strengthening and                  districts a further 30 ANMs have received SBA training         provider training from their own budgets.
   access activities by June 2008                           in this reporting period. Since training programme             Thus more SBAs have been trained from
                                                            began in January 2007, over 400 SBAs have been                 partner districts than from others.
                                                            trained from the 10 districts, in response to requests.

3. SBA policy and strategy approved and under            3. Achieved.
   implementation, with SBA forum functioning as                                                                          The SBA Forum played a role during
   a multi-partner body for coordination and                                                                               policy and strategy development, but is
   technical advice, by September 2007                                                                                     not currently active.

4. At least 12 in-service SBA training sites             4. Achieved. 15 training sites now accredited and are
   accredited and providing training, with at least         providing training. Further sites are under development.
   200 SBAs trained by June 2008, and an                    Total of 1,132 SBAs trained since Jan 2007 (559 in
   additional 3 training sites functioning with 400         2008/09).
   additional SBAs trained by June 2009
                                                                                                                          Need support for medical and nursing
5. SBA training incorporated into pre-service            5. Achieved. Pre-service education strategy finalised and         councils for proper implementation
   MBBS, PCL nursing and BSc nursing curricula              endorsed by IoM. All pre-service nursing and medical          Additional 24 teachers from private
   in training institutions affiliated to IoM, with at      courses revised to include SBA and being implemented           institutions trained on cost sharing basis
   least 8 of these accredited and providing SBA            at IoM campuses. NAMS has also revised and
   training by June 2008.                                   implementing. CTEVT has committed to implementing
   3 private pre-service institutions also accredited       the IoM revised curriculum for certificate nursing
   and providing training June 2009                         courses. Around 50 pre-service faculty staff trained in
                                                            SBA core skills.

6. At least 3 in service CAC training sites              6. Achieved. Six training sites (MH, LZH, MSI, FPAN, Seti
   accredited and providing training by June 2007,           zonal hospital and Bharatpur hospital) accredited and
   and CAC training incorporated into pre-service            providing training.
   MDGP and Ob/gyn curricula by June 2008.                  Three medical schools (BPKIH, IoM and NAMS) have
                                                            incorporated the NHTC approved CAC curricula in MD
                                                            course.




                                                                                                                                                                        48
Output 6: Information
Indicator                                           Progress                                                     Comments

1. SMNH related data (including CAC) available      1. SSMP is continuing to support HMIS Section in revising       Piloting was delayed by procedural
   within HMIS, analysed and disaggregated by          the HMIS to include monitoring of EOC, SBA, CAC and           issues; hence this activity is running later
   ethnicity and caste from 3 pilot districts and      newborn care, disaggregated by ethnicity and caste.           than anticipated. SSMP/ Options provided
   findings used to support scaling up of revised      Piloting of the revised HSIS tools and system is              substantial TA to supplement FA,
   HMIS in all 75 districts November 2009              continuing in 3 districts.                                    especially to enhance capacity of GoN
                                                                                                                     staff
2. SMNH website has received over 1,000 visits by   2. Exceeded. 19,466 visits recorded in 2009. New design         All major reports are now placed on the
   June 2008 and over 3,000 visits by November         in process as part of SSMP closeout dissemination.            website and regular news updates.
   2009

3. Consensual and evidence based SMNH related       3. Achieved. SMNH long term plan 2006-2017, SBA
   policy and strategy developed reflecting best       policy, strategy, blood policy and Aama programme
   practices. June 2007                                developed, based on evidence and consensus
                                                       (workshops and meetings). Annual joint national SMNH
                                                       and RH review and planning workshop conducted in
                                                       December, and these events increasingly reflect
                                                       evidence based planning. SSMP/Options is also
                                                       supporting the planning process for the next phase of
                                                       health sector planning, NHSP II.

4. SSMP disseminates, and supports government       4. SSMP/ Options continues to support GoN in
   and other stakeholders to disseminate, key          dissemination of learning. During this reporting period
   SMNH evidence and learning at inter/national        this has included participating in the annual PESON
   and regional levels at least once each year         conference, supporting ActionAid Nepal in organising
                                                       the EAP final dissemination meeting and organising a         EAP end-line KAP study contracted out by
                                                       national level dissemination meeting for the results of       SSMP/Options under TA funds.
                                                       the MMM study.

5. SMNH research (3 studies) carried out in line    5. Targets for 2007 and 2008 achieved. For 2009: GIS            GIS outsourced under SSMP/ Options TA
   with agreed priorities of FHD by June 2007, an      based SMNH atlas and Target Population Projection             funds
   additional 3 by June 2008, and an additional 3      completed; SSMP/ Options is supporting FHD in                Field work and analysis for community
   by November 2009, under FA and TA                   executing a community obstetric morbidity study under         study completed and report will be ready
                                                       FA. SSMP/ Options and                                         in the next reporting period.
                                                       USAID supported the MMM Study, for which field work
                                                                                                                                                                    49
                                                           was completed in April 2009. Summary report was                  MMM study field work used some FA
                                                           compiled during this reporting period and disseminated            funding, Final report will be ready within a
                                                           at a national stakeholder meeting.                                few weeks

6. Critical analysis and review of maternal perinatal   6. Previously achieved. Maternal perinatal death review
   death review completed by December 2007                 system commissioned and report completed and
                                                           disseminated.


Output 7: Physical Assets
Indicator                                               Progress                                                         Comments

1. Comprehensive physical assets management             1. Infrastructure database (HIIS) previously developed              Government staff trained to use and
   policies and need based planning under                   and efforts initiated to decentralise and integrate with         update HIIS.
   implementation by June 2008.                             equipment inventory.                                            This system must be
                                                           Maintenance strategy and prioritisation model (6 levels)          integrated/coordinated with KFWs
                                                           for infrastructure being implemented to support rational          PLAMAHS system at MD.
                                                           allocation of maintenance budget. Money sent to all              Reduced maintenance budget this year
                                                           districts for repair and maintenance. Maintenance                 will impact work
                                                           guidelines sent to D/PHOs. Monitoring of construction            Good governance is essential for
                                                           increased by contracting technical people at district             successful implementation of reforms.
                                                           level under FA.                                                  Institutionalisation of HIIS is very
                                                           Budget allocated for e-bidding for construction                   important; Infrastructure Management Unit
                                                           contracting, coordination with DUDBC ongoing                      in MD essential
                                                                                                                            E-bidding recognised by Government as
2. Government initiates supply system for essential     2. LMIS now functional. Budget allocated for                         effective and all legal entities (eg Public
   drugs and commodities based on commodity                strengthening throughout the country by contracting               Procurement Monitoring Office) and LMD
   forecast reporting by June 2008.                        staff to support LMIS updating on regular basis.                  want to make it regular practice.
                                                           Consultative workshop to initiate e-bidding to ensure fair       Direct procurement through DfID initiated
                                                           participation in procurement of heath sector goods.               by GoN request,

3. At least 85 birthing centres, 12 CEOC facilities,    3. 86 Birthing centres; 10 CEOC sites; 15 BEOC sites                 and equipment is on its way. Sites will be
   50 BEOC facilities constructed (based on                completed.                                                        equipped in the next reporting period.
   standard prototype designs) and equipped by             Functions for health posts, PHCCs and district hospitals
   June 2009                                               defined and standards developed. Development of
                                                           designs in process. Prioritisation list of health posts for
                                                           construction, upgrading or addition of birthing centre


                                                                                                                                                                            50
                                                       and list of PHCCs requiring addition of BEOC identified.
                                                       Average costs of different health facilities worked out.

4. At least 3 minor CAC sites and 3 major CAC       4. Four out of 6 completed.
   sites constructed and fully equipped completed
   by June 2009


Output 8: Finance and the Safe Delivery Incentives/ Aama Programme
Indicator                                           Progress                                                      Comments

1. Annual joint SMNH planning, budgeting and        1. Achieved. Annual RH/ SMNH joint planning meetings             Resource allocation, mobilisation and
   reviews in place, based on SMNH long term           conducted each year, led by FHD. All stakeholders              implementation heavily dependent on
   plan by June 2007                                   participate (UNFPA, USAID, NFHP, UMN, EA                       political decisions at Ministry of Finance
                                                       programme, ADRA, NSI) and send their final                     and National Planning Commission.
                                                       programmes to FHD, who submit the total plan for next         Need to strengthen technical capacity of
                                                       year to MoHP and National Planning Commission. This            DoHS finance section to ensure proper
                                                       is in process for 2010/11.                                     financial monitoring of Aama.
                                                                                                                     Need focal person for Aama in FHD to
2. Monitoring guidelines for the safe delivery      2. Achieved for SDIP. New monitoring guideline                    whom technical support/ training can be
   incentives programme (SDIP) developed, tested       developed for Aama programme, which includes                   given.
   and endorsed by MoHP by September 2007              requirement for social and public auditing. Claims for        Need documentation to enable FHD to
                                                       home delivery incentives require signature of VDC              link achievements with GoN free health
                                                       secretary.                                                     care policy.
                                                       Social audit manual developed, field tested and               FHD needs to strengthen implementation
                                                       approved by FHD                                                of additional safeguard measures (as
                                                                                                                      submitted to DfID).
3. Standardised reporting for SDIP by December      3. SDIP financial monitoring software developed and pre-
   2007                                                 tested. Installed in FHD, DoHS finance section and all
                                                        regional health directorates.
                                                       Integration of Aama/ SDIP recording and reporting tools
                                                       into the national HSIS in process.
                                                       Analytical report of Aama expenditure prepared and
                                                       submitted to MoHP and DFID each year.




                                                                                                                                                                   51
ANNEX 1: Key Findings of the Maternal Mortality and Morbidity Study

 The overall Maternal Mortality Ratio (MMR) for the eight study districts is 229 per 100,000 live
  births, ranging from 153 to 301 by district. This is consistent with the pregnancy related mortality
  ratio calculated by the 2006 Nepal Demographic and Health survey (NDHS), of 281 per 100,000
  live births.
 MMR variations: The MMR was lowest amongst women in their twenties, with increased risk for
  those aged under 20 and between 30-34. The figure for those aged over 35 was considerably
  higher (962 per 100,000 live births). There were also differences between ethnic groups, with
  higher rates among Muslims, Terai / Madhesi and Dalits.
 Maternal causes accounted for 93% of pregnancy related deaths, giving an overall pregnancy
  related mortality ratio of 247 per 100,000 live births and making this a good proxy indicator for
  maternal mortality.
 Maternal causes accounted for 11% of all deaths of women of reproductive age, in third place
  by ICD-X chapter; down from 21% in 1998, when it was the leading cause.
 There has been a dramatic increase in the contribution of suicide (16%) to deaths of women of
  reproductive age, compared with 10% in 1998. This makes it the leading single cause of death,
  whereas in 1998 it was third.
 Direct causes accounted for 69% of all maternal deaths and 31% were due to indirect causes.
  The proportion of direct deaths is considerably higher when only hospital deaths are considered
  (89% direct; 11% indirect).
 The percentage contribution of haemorrhage (24%) to maternal causes been dramatically
  reduced, from 41% in 1998. However, it remains the leading cause of maternal death, and the
  decline reflects a reduction in postpartum (from 37% to 19%), rather than antepartum.
 The percentage contributions of eclampsia, abortion related complications, gastroenteritis and
  anaemia to maternal causes have increased, while those from obstructed labour and puerperal
  sepsis have more than halved since 1998. Heart disease did not even feature in 1998, but now
  accounts for 7%.
 Place: There was an increase in the proportion of maternal deaths occurring in a health facility,
  to 42%; with 41% occurring at home; and 12% in transit. In 1998 just 14% of deaths occurred in
  facilities and 70% at home.
 Timing: All non-maternal pregnancy related deaths occurred during the ante-partum period.
  Many were unwanted pregnancies, suggesting the pregnancy status of the women may have
  placed them at greater risk. Of the maternal deaths, 34% occurred in the antepartum period;
  39% during the intrapartum period and up to 48 hours afterwards; and 28% in the postpartum
  period. The fact that 61% of deaths occurred outside the intrapartum period suggests that
  interventions should not focus solely on this period.
 Over 80% of women who died from maternal causes were emergency admissions and in a
  critical state on admission: 18% died within four hours of arrival, 39% within the first twelve
  hours and 53% within the first 24 hours.
 Supply side factors contributing to poor maternal outcomes included continued use of practices
  which are not evidence based, lack of appropriate staff; lack of essential drugs; weak referral
  systems and lack of blood.
 Community factors contributing to poor maternal outcomes included delays in recognising a
  problem and deciding to seek care; long distances to a health facility; lack of finance and/ or
  transport or time taken to make arrangements; seeking care from the informal sector; not being
  able to or not wanting to seek care alone or needing permission to seek care.




                                                                                                   52
ANNEX 2: Summary of Key Points for EAP End of Contract Report


1.    Summary of key achievements
     (These are documented in more detail in the end-line survey)

a.   Increased SMNH knowledge and healthy practices among targeted groups
b.   Empowerment of women within families and society
c.   Positive impact on health service, both quality of services and utilisation
d.   Establishment of emergency funds, and utilisation by poor and excluded people
e.   Establishment of emergency transport schemes and their utilisation by poor and excluded
     people
f.   Capacity building of local NGOs
g.   Use of “Voice for Action” (or voice capturing) to empower people to demand and achieve better
     services and to improve mutual understanding between service users and providers.

2. Reflections on the partnership process

a. Partnership with EASOs at implementation level

A rigorous process was used for selection of the EASOs, to ensure their acceptability and
effectiveness at community and district levels. Since the target communities comprised the most
excluded people, it was essential for the success of the whole programme that the EASOs be able
to reach and work with these groups. The criteria used for initial screening of potential partners laid
the foundations for selecting the right partners. These criteria included: inclusive structure in terms
of leadership; membership and staffing representing marginalised groups such as women, dalits
and janjatis; experience in social mobilisation and community empowerment group activities, rights-
based and social inclusion approaches, conducting awareness raising and advocacy activities.

EASOs were not required to submit proposals, but EAP worked with the selected partners from the
very beginning in all components of programme cycle, such as social mapping, community
selection, KAP survey, planning and budgeting, implementation, monitoring, review and evaluation.
One EAP district coordinator was placed in each district to facilitate and support EASOs, which has
ensured linkage on SMNH issues between rights-holders, duty bearers/service providers and the
other stakeholders. Investment in capacity building through mentoring, training, workshop, coaching
and cross visits enhanced the competencies of the EASOs. Joint participatory review and reflection
process (PRRP) and planning and social audit strengthened the credibility of EASOs among the
community and stakeholders in the district. EAP intervention and work process inspired EASOs to
reform the board where dalit, poor and marginalised people were included.

EAP has learned that working closely in partnership with district level NGOs from poor and
marginalised constituencies is more effective than just providing financial resources.

b. Partnership with SSMP/Options

The SSMP/ Options approach of working together to provide support as a team member of EAP,
rather than simply as a donor has been very helpful. SSMP/ Options played a very supportive
proactive role in terms of providing initial guidance, orienting EAP staff on the SMNH technical
contents/model, concepts of increasing access, equity and access, voice capturing and its uses,
behaviour change communications (BCC), transforming and building the NSMP learning into equity
and access programme. The provision of national and international technical support inputs when
required was important in programme planning, implementation, monitoring, voice capturing and
participatory review



                                                                                                    53
SSMP also played important role in coordinating with different government agencies (MoHP, FHD,
NHEICC) and non-government agencies to collect and feed back information and learning into EAP,
for example in strengthening services in EAP areas where the demand was created, providing BCC
and reference materials. SSMP provided a forum for cross sharing and learning among partners
which was very helpful for EAP. All these initiatives helped in achieving EAP objectives. It was
partnership in true sense.

3. Equity and Access Programme learning

During its three plus years of implementation, EAP gathered the following experiences and learning:

   •       Targeting the poor and excluded is essential even within a universal coverage approach, if
           they are to be reached to the poor and excluded regardless of the resources available. This
           is fundamentally a moral argument.
   •       In absence of poverty mapping data, disaggregation using (six) caste/ethnicity groupings is
           an effective means to track equity related changes in MNH knowledge and service
           utilisation.
   •       Demand creation without concurrent service strengthening can de-motivate communities for
           care seeking. So service strengthening and demand creation should go hand in hand.
   •       Raising awareness of rights and social inclusion among both right holders (service users)
           and duty bearers (service providers) is effective in improving service delivery and
           accountability.
   •       Working through women’s groups and networks is effective in increasing equitable demand
           for, and equal access to, MNH services. Developing a sustainability plan for these groups
           and networks (e.g. group strengthening and planning) is essential if gains are to continue.
   •       Voices of community members/groups and service providers, used skilfully, can be effective
           in improving local policies and service quality.
   •       Localisation of behaviour change communications’ materials, including into local languages,
           increases local ownership and impact.
   •       Social empowerment through women’s groups impacts on other sectors notably education,
           livelihoods and social justice (e.g. addressing gender based violence).
   •       Tracking other empowerment indicators in groups e.g. responses to gender based violence,
           school enrolment of girls is important to track all the changes.
   •       Due diligence partnering and working through district level NGOs from poor and
           marginalised constituencies is highly effective – particularly in addressing social
           empowerment and rights issues. It is also cost effective.
   •       Empowering women to claim their health rights and redefine social norms around pregnancy
           and childbirth is a long-term agenda, 3 years is too short time period.

4. Summary of recommendations for future DfID support.

EAP has been successful in increasing access to and utilisation of SMNH services for the poor and
excluded through its targeted demand side approach. Its socially inclusive and right based approach
helped to empower the right holders and made them able to claim their rights. Other sectors, such
as livelihood, education etc. are equally important in contributing to better results in maternal and
newborn health. However EAP's effort was very limited in these sectors due to its design and limited
resources. EAP recommends the following points for DfID consideration in its support in the next
safe motherhood programme phase:

           Scale-up targeted equity and access activities across the country in all 75 districts.
           Ensure rights based, socially inclusive, empowering approaches are at the core of
            community mobilization processes. Also ensure the linkages of programme with other
            sectors, particularly livelihood and education.
           Ensure disaggregated monitoring is rolled out across the country for all major health
            indicators.

                                                                                                   54
       Ensure demand creation and service strengthening go hand in hand.
       Use networks of demand side agencies to promote free care and support social auditing of
        demand side financing schemes.
       Support group, network, co-operative strengthening as a discrete programme goal.
       Explore the potential of a national Equity and Access Agency from the private sector to
        provide technical support to local “demand side agencies”. The agency could be from
        private or local government sector, and possibly working beyond health sector alone.
       Draw learning from other targeted demand side programmes (e.g. UNFPA PARHI; Unicef
        WRL/DACAW; MIRA) and consolidate in EAP model.

5. List of learning products

   a. Experience and Learning documents:
          Community emergency funds for saving lives of mother and newborn (Annex 2A)
          Using REFLECT tools for group discussion: EAP experience (Annex 2B)
          Voice for action and for change (Annex 2C)
          Dialogue process: EAP experience (Annex 2D)
   b. EAP Briefing notes- English and Nepali
   c. EAP bi-annual progress reports (volume 1 to 7)
   d. Knowledge, Attitude and Practice (KAP) survey reports- Baseline and End-line.
   e. EAP final evaluation report - by Social Welfare Council (SWC)
   f. Voice for action time-line and learning workshop proceeding
   g. Voice reports – 1st round by Dr Madhu Devkota and team, and 2nd round by Uddhav Rai
   h. "Voice for Action" implementation guideline
   i. EAP Advocacy- Reflection and Recommendation- by Dr Marry Manandhar
   j. EAP Advocacy Strategy- Excerpt from KIM data Round 2- by Dr Marry Manandhar
   k. Positive Changes (voice evidences), EAP District Profiles – by Dr Marry Manandhar
   l. Review of the Equity Access Programme – by Deborah Thomas
   m. EAP advocacy strategy – based on issues identified from voice capturing
   n. Capacity building need assessment report
   o. EAP brochure - English and Nepali
   p. Need assessment report




                                                                                             55
ANNEX 3: Equity and Access Programme KAP Study: Summary of Findings

 “A woman died in that village. Her family was poor and not able to meet basic needs for food and
clothing. She lives with her husband, mother-in-law, sister-in-law and brother-in-law. They didn’t
permit her to go for antenatal checks in her pregnancy. They didn’t let her go out to attend meetings
or discussions in the community. They made her do heavy work at home. She experienced a long
and difficult labour of four days but the family didn’t take her to the health post. Finally she was
taken to the PHC where she was referred to the district hospital. But they didn’t take her there.
Instead they took her home. After some time she died.”6

Headline Achievements

What is the Equity and Access Programme (EAP)? Launched in 2006, EAP is a community
mobilisation programme aimed at improving maternal and newborn health (MNH) among the poor
and excluded. Operational in full in 8 districts spread across the country, covering the Terai and
Hills, it has been implemented by ActionAid Nepal and New Era in partnership with district level
NGOs, and through close coordination and the support of the Department of Health Services
(DoHS), and district authorities. In 2008, DoHS funded and rolled out the equity and access model
to 2 additional districts, and in 2009, has scaled up its Financial Aid to support a further 8.
    “Women are aware of their rights. They go to groups and participate in savings. They have
    developed the confidence that they can make a difference.”7

The EAP takes a rights based approach to raise demand for maternal and newborn health services,
and in pursuit of greater equity and social inclusion, targets the poor and socially excluded. Built on
a “tried and tested” package of inputs that work together – women’s groups, community based
emergency funds and transport schemes, localised behaviour change communications, and the
social mobilisation of family members and local stakeholders – the programme aims to empower
women and create an enabling environment for improved MNH. With a strong focus on building
local capacity and fostering local change agents, the programme works with existing institutional
structures and actors, including district health officers and health providers, district administration,
village development committees, political parties, private providers, NGOs, CBOs, FCHVs and
women’s groups, to forge coalitions for change at district level and below.

What impact has it had and who has benefited? Implemented between September 2006 and
June 2009, the programme has achieved impressive results in forming VDC and district level
women’s networks and cooperatives. In terms of health outcomes, Baseline and End-line household
surveys, service records, and qualitative research capturing the voices of women, health service
users, and health providers, line up to show dramatic increases in MNH knowledge, attitudes and
practices; headline messages are presented below.

While all social groups have benefited from improved MNH indicators, Dalits and Disadvantaged
Janajatis, two social groups that have lagged behind national level health improvements, have
benefited particularly well.




6
    Dailekh, Paduka VDC; KIM 2009.
7
    Chitwan, Kalyanpur VDC, KIM 2009, see Manandhar, Mary, 2009, “Positive changes EAP district profiles”.

                                                                                                             56
                                         Increase in ANC 4+ by Social Group



                Brahmin/Chhetri

            Advantaged Janajatis

         Disadvantaged Madeshi
                                                                                     Endline
             Religious Minorities                                                    Baseline

         Disadvantaged Janajatis

                            Dalits

                                     0              20            40          60      80




Antenatal care: Take-up of 4 or more ANC visits has increased from 45% to 60% at end-line and
equity has increased. Service records from EAP areas show similar levels of increase as the
baseline and end-line surveys, with 4+ ANC rising 36% over the first 2 years of the programme. The
equity gap between use of ANC by Brahmin/Chhetris and Dalits, Disadvantaged Janajatis and
Disadvantaged Madeshis respectively, has declined. Notably women exposed to EAP have a
significantly higher ANC use rate than others.
Hand in hand with increasing ANC has been a massive increase in the use of iron tablets for 90
days or more during pregnancy, rising from 12.3% at Baseline to 65.5% at the end of the
programme, with Dalits, Disadvantaged Janajatis, and Muslims increasing up-take more than 5-fold.

Knowledge of the danger signs in pregnancy, labour and the post-partum period is fundamental to
timely and appropriate care seeking. Among recently delivered women, their husbands and
mothers-in-law, knowledge has more than doubled over the programme period, with the largest
knowledge gain among Relatively Disadvantaged Janajatis. Moreover, women exposed to EAP
have significantly better knowledge than others, confirming women’s groups as effective channels of
information.



                      Increase in knowledge of 3 or more danger signs in labour




               Brahmin/Chhetri
            Advantaged Janajati
         Disadvantaged Madeshi
             Religious minorities                                                  Endline
         Disadvantaged Janajatis
                                                                                   Baseline
                           Dalits

                                     0             20            40           60      80

                                                                                                57
Delivery practices: while the programme mobilised women, their families and communities to reflect
and act upon the social norms, traditional practices and cultural beliefs that work against safe
motherhood, policy and service level improvements have synergistically increased access to
services. Improvements in district level obstetric services, the introduction of the Safe Delivery
Incentive Programme (SDIP) and the more recent introduction of free delivery services, have all
contributed to increased access to obstetric care, and provided a conducive environment for EAP to
work with the district health team to foster community participation in the management of health
services, and generate demand.


                                     Institutional delivery rate for EAP areas
                                                  and nationally




                                45
                                40
                                35
                                30
                                25
                                20
                                15
                                10
                                 5
                                 0
                                                  2006/7                         2008/9
                         HMIS                      15.3                           14.8
                         EAP areas                 20.8                           39.5




By the end of the programme a staggering 85% of respondents reported that women should deliver
in a facility, including 80% of mothers-in-law, one of the target groups of EAP, and a key stakeholder
in shifting birthing practices. The Endline household survey found 40% of recently delivered women
gave birth in a health facility, up from 21% at Baseline and over double the national rate of 15% in
2008-98. Correspondingly, the number of women delivering with a skilled provider doubled from
19% to 41% with the vast majority delivering in a facility and only a small minority in the home 9.
Service records from the programme areas chart the same upward trend in institutional deliveries,
with an average increase of 29% during the first 2 years of the programme.

Broken down by social group, the rise in facility based deliveries has been greatest among Dalits
(123%). Rapid gains have also been made by Advantaged Janajatis (99%) and Disadvantaged
Janajatis (91%), with lower improvements among Brahmin/Chhetris (62%), and Disadvantaged
Madeshi (57%), and lowest gains among Muslims and other religious minorities (21%).

Nevertheless, advantaged groups continue to have higher institutional delivery rates than the
socially disadvantaged, and we find that while demand and supply interventions have significantly
increased access to, and use of institutional deliveries for some socially excluded groups, they have
yet to overcome the strong bias that the better-off and advantaged have higher rates of facility
based deliveries, a bias that persists across the world10.

8
  HMIS, DOHS.
9
  This correlates with the findings of the SDIP Impact Evaluation, 2008.
10
   Gwatkin D., Rustein S., Johnson K., Pande R., Wagstaff A., 2000, Socioeconomic differences in health, nutrition, and
population – 45 countries. Washington DC: World Bank.

                                                                                                                    58
                             Facility based delivery rates in EAP districts

                                                                                   Endline

                   Dadeldhura                                                      Baseline

                       Dailekh
                        Parbat
                       Myagdi
                    Rupendehi
                   Nawalparasi
                       Chitwan
                       Morang

                                 0         10     20        30      40        50    60




                                 Facility based delivery rates in EAP districts


                      Brahmin/Chhetri

                   Advantaged Janajati

                Disadvantaged Madeshi
                                                                                              Endline
                    Religious minorities
                                                                                              Baseline
                Disadvantaged Janajatis

                                  Dalits

                                           0           20            40            60          80




Regional and district variation is evident with institutional delivery rates much higher in Terai districts
than Hills. Various factors appear to contribute to this situation, better availability and physical
accessibility of obstetric services in the Terai, lower Human Development Indicators in the Far
Western and Mid Western regions, and stronger traditional and religious beliefs and practices
surrounding pregnancy and birthing in the West. Nevertheless, across all EAP districts, facility
delivery rates have increased over the course of the programme, and all have higher rates than the
national average of 14.8% for 2008-9.

With tradition the primary factor for women choosing to deliver at home, tipping the institutional
delivery rates calls for greater focus on communication and mobilisation approaches to support

                                                                                                         59
women, their families and communities to challenge harmful practices and redefine the social norms
that underpin pregnancy and childbirth behaviours.

Emergency obstetric care: better informed, better prepared, and better availability of emergency
obstetric care has translated into more rational care seeking and increased treatment of obstetric
complications, rising by 32% within the first 2 years of the programme.

Contribution or attribution? From the end-line survey we find that women exposed to EAP have
better knowledge of the danger signs, higher ANC rates, better knowledge of SDIP, and are more
likely to use an emergency transport scheme. Although in the absence of control sites, it is not
scientifically possible to attribute changes in health outcomes, without doubt EAP has made an
important contribution both in raising demand and in supporting local health services to be more
responsive.

Greater social equity? What more needs to be done: EAP has contributed to reducing the social
inequities in use of MNH services but unevenly. While Dalits and disadvantaged Janajatis, have
benefitted particularly well, disadvantaged Madeshi castes and Muslims and other religious
minorities have fared less well. Future programming will need to place stronger emphasis on
reaching disadvantaged Madeshi castes and Muslims and other religious minorities through more
tailored communication and mobilisation approaches, and addressing supply side barriers such as
social discrimination. Success of EAP in the Hills and Terai also calls for the programme’s
adaptation to mountain districts where development indicators of remote communities trail behind.

The road ahead: coherent with Government goals of public-private-partnership, and the Ministry of
Health and Population’s draft Gender Equity and Social Inclusion Strategy, the equity and access
approach fits neatly into the policy frame and political landscape. With past investments in design
and development, it is estimated that scaling the approach up nationally will cost approximately
Rs40 million or US $540,00011 for 3 years of support per district; this includes support for
implementation of the community and social mobilisation approach at VDC and district level plus
centrally led mass media, behaviour change communications, and advocacy activities. Such
targeted investments will lever significant returns both for MNH and women’s development, and
make an important contribution to realising the MDGs.
   “Women have formed groups. They have started to speak about their rights. They help by
   providing money to those in need. They don’t feel shy going for pregnancy check ups and tell
   about this. They take iron pills daily, collect the money in the group and make decisions of
   who should get money. Numbers of groups have increased. After forming the group, they
   decided to build temporary toilets and later built a permanent toilet. Earlier they could not even
   tell their names and introduce themselves but now they can share many things. They can tell
   about not to get pregnant immediately after marriage, and to take the 3 month injection. …
   Women have become leaders and nowadays things have changed. Women can also read
   and write, learn after tours to different places and learned from observing from other
   villages.”12




11
     US$1:NRs74
12
     Myagdi, Okharbott VDC: KIM 2009.

                                                                                                  60
ANNEX 4: CEOC Sites established and functioning by Region: July to December 2009

                                                    Medical
SN    Region/District     Government          No.   College           No.    Others                      No.   Comments

      Eastern Region
                          Ilam     District                                  Singfring       community
 1    ILAM                Hospital             1                             hospital                     1    GoN yes
                          Mechi         Z.
 2    JHAPA               Hospital             1                             Lifeline hospital Damak      1    GoN yes
                                                                             Amda Hospital                1
                                                    Novel Medical            Abodhnarayan Nursing
 3    MORANG              Koshi Z. Hospital    1    College            1     Home                         1    GoN yes
                                                                             Saptakoshi     Nursing
                                                                             Home                         1
                                                                             Birat Nursing Home           1
                                                                             Okhaldhunga       Mission
 4    OKHALDHUNGA                                                            Hospital-1                   1    Mission only
 5    PANCHTHAR*          District Hospital    1                                                               GoN yes
                          District
 6    SANKHUWASABHA       Hospital(new)        1                                                               GoN yes
                          Sagarmatha Z.
 7    SAPTARI*            Hospital             1                                                               GoN yes
                          Lahan    District
 8    SIRAHA              Hospital                                           Lahan Nursing Home           1    GoN no
 9    SOLUKHUMBU          District Hospital                                                                    GoN no
                                                    {BPKIHS
 10   SUNSARI             BPKIHS (GoN)         1    (GoN)}**           (1)                                      GoN yes
 11   UDAYAPUR*           District Hospital                                                                     GoN no
      Sub-total 11 CEOC                                                                                         7       GoN
      districts                                7                       2                                  8    functioning

      Central Region
                          District
 12   BHAKTAPUR           Hospital                                                                             GoN no
                                                    Bharatpur
                          District                  Medical
 13   CHITWAN             Hospital             1    College            1                                       GoN yes
                                                                             Dhanusha         Nursing
                          Janakpur                  Janaki Medical           Home
 14   DHANUSHA            Zonal Hospital       1    College            1                                  1    GoN yes
 15   DOLAKHA             Jiri Hospital                                      Gauri Sankar Hospital        1    NGO only
                          Maternity                 Teaching                 Kathmandu      Model
 16   KATHMANDU           Hospital             1    Hospital (GoN)     1     Hospital                     1    GoN yes
                                                    Kathmandu
                                                    Medical
                                                    College            1     Kathmandu Hospital           1
                                                    Nepal Medical
                                                    College            1     Om Nursing Home              1
                                                    Kist    Medical          Valley Maternity Nsg
                                                    college            1     Home                         1
                                                                             Capital Hospital             1
                                                                             Everest Nursing Home         1
                                                                             MonmohanMemorial
                                                                             Hospital                     1
                                                                                                                GoN no -
      KAVEREPALANC                                                           Shree           Memorial          community
 17   HOWK*                                                                  Hospital                     1    only
                                                                             Dhulikhel    Community
                                                                             Hospital                     1
 18   LALITPUR            Patan Hospital       1                                                               GoN yes
                                                                             B&B Hospital                 1


                                                                                                                    61
                                                   Medical
SN   Region/District     Government          No.   College         No.   Others                      No.   Comments
                                                                         Alka Hospital                1
                                                                         Star Hospital                1
19   MAKAWANPUR          District hospital    1                                                            GoN yes
20   NUWAKOT             District hospital    1                                                            GoN yes
                                                   Birgunj
                         Narayani Zonal            Medical               Advance         Medicare
21   PARSA               Hospital             1    College          1    Center                       1    GoN yes
                                                   National
                                                   Medical
                                                   College          1
22   RAUTAHAT            Gaur Hospital        1                                                             GoN yes
     Sub-total      11                                                                                      8       GoN
     CEOC districts                           8                     8                                15    functioning

     Western Region
                         District
23   BAGLUNG             Hospital             1                                                            GoN yes
                         District                                        Aap Pippal        Mission
24   GORKHA              Hospital             1                          hospital-2                   1    Mission only
                         Western                   Manipal
                         Regional                  Teaching              Fishtail Hospital and
25   KASKI               Hospital             1    Hospital         1    Research centre              1    GoN yes
                                                   Gandaki
                                                   Medical               OM     Hospital   and
                                                   College          1    Research centre              1
                                                                         Aviyan    Community
                                                                         Hospital                     1
                                                                         Kaski Model Hospital         1
                         District
26   GULMI               Hospital             1
                                                                         District      Community           Community/
27   LAMJUNG                                                             Hospital                     1    mission
                         District
28   NAWALPARASI         Hospital                                        Madhyabindu Hospital         1    GoN no
                                                   Lumbini
                                                   Medical               Tansen            Mission
29   PALPA                                         College          1    Hospital -3                  1    Mission only
                                                   Universal
30   RUPANDEHI           Zonal Hospital       1    College of MS    1                                      GoN yes
                                                                         Amda Hospital                1
                                                                         Butwal Hospital              1
31   TANAHU                                                              Laxmi Hospital               1    GoN no

     Sub-total 9 CEOC                                                                                       5       GoN
     districts                                5                     4                                11    functioning


     Mid       Western
     Region
                                                   Nepalganj
                         Bheri    Zonal            Medical
32   BANKE*              Hospital             1    College          1                                      GoN yes
                                                   Kohalpur
                                                   Medical
                                                   College          1
                         Bardia District
33   BARDIA              Hospital                                                                          GoN no
                         District
34   DAILEKH             Hospital                                                                          GoN no


                                                                                                                62
                                                     Medical
 SN    Region/District       Government       No.    College          No.     Others                 No.   Comments
                             District
 35    DANG*                 Hospital          1                                                           GoN yes
                             District
 36    JUMLA*                Hospital                                                                      GoN no
                                                                              Chorjahari   Mission
 37    RUKUM                                                                  Hospital-4              1    Mission only
                             Regional
 38    SURKHET               Hospital          1                                                           GoN yes

       Sub total 7 CEOC
       Districts                                                                                            3       GoN
                                               3                         2                            1    functioning
       Far         Western
       Region
                             Seti     Zonal
 39    Kailali               Hospital          1                                                           GoN yes
                             Mahakali zonal
 40    Kanchanpur            Hospital          1                                                           GoN yes
                                                                              TEAM         Mission
 41    Dadeldhura                                                             Hospital-5              1    Mission only

       Sub-total 3 CEOC                                                                                     2       GoN
       districts                              2                                                      1     functioning
        Total 41 Districts   Grand Total      25                         16                          36

*These 8 districts have UNICEF service strengthening support
**Note: Except in the 2 cases noted (BPKIHS and TUTH) all medical colleges are private, Sunsari therefore
counts as a GoN CEOC site because of BPKIH

Summary: 41 districts have CEOC facilities
         Only 25 of these have functioning GoN sites; 10 have a pvt/NGO/mission CEOC site and 7 have
         no functioning CEOC of any kind.
         There are 76 functioning CEOC facilities in total (25 GoN + 16 med college + 36 NGO/Pvt). Note:
         BPKIHS appears twice, as GoN and as medical college hence the total is not 77 but 76.


Summary of CEOC sites by region

      Region              Districts     Functional             Districts with Non        functional
                          with      any CEOC                   no functional GoN             CEOC
                          functional    facilities             CEOC           facilities
                          CEOC
          EDR                   9             16                     2                     3
          CDR                   10            31                     1                     2
          WDR                   9             20                     0                     1
         MWDR                   4              6                     3                     3
         FWDR                   3              3                     0                     -

           Total               34                   76               7                     9




                                                                                                                63
ANNEX 5: Executive Summary of Appreciative Inquiry Evaluation

Context

It is recognised that Health Facility Management Committees (HFMC) are central to decision-
making at facility level, and supporting them has resulted in improved management of facilities. This
has also led to improved community relations, fostering local ownership and commitment to
supporting health facilities and mobilising community resources to fund physical improvements and
recruitment of additional staff to support 24 hour services. Under Support to the Safe Motherhood
programme (SSMP), Appreciative Inquiry (AI) has been used as a management tool to augment
traditional service development inputs at facility level. Genesis Management was contracted to
conduct participatory planning workshops using the AI approach in selected Basic and
Comprehensive Emergency Obstetric Care (B/CEOC) facilities, and to train teams of district based
facilitators to roll this out to peripheral facilities. A total of 82 persons received training in August and
November 2008, with checklists and guidelines provided for conducting AI workshops. Fifty health
facilities were selected from 28 districts, including health posts (HP), Primary Health Care Centres
(PHCC) and hospitals. The main purpose of the AI process was to enable HFMCs to plan and
establish improved and regular maternal health services, especially 24-hour delivery and B/CEOC,
as appropriate. Four facilitation modalities were used: (1) Genesis Management direct facilitation,
(2) district focal persons facilitating with backstopping from Genesis Management, (3) district teams
facilitating with support from regional coordinators, (4) district teams facilitating without any
backstopping.

Purpose and Objectives of Evaluation

The purpose of the exercise is to evaluate the current model of implementing the participatory AI
process through a master AI facilitator and trainer, with roll-out to lower level facilities through AI
trained district health teams, compare the effectiveness of the various facilitation approaches used,
and make recommendations for sustaining positive change at reasonable cost.

The specific objectives of the evaluation are to:

       Examine the extent to which the AI process has made a difference in the health facilities by
        identifying evidence of change, such as increased service availability and utilisation;
        improved physical working environment and quality of services; team work and positive
        problem solving among health staff and management; improved attitudes among health staff
        towards clients and each other; increased functionality of HMFCs and their support and
        management oversight of health staff; improved frequency and effectiveness of
        communications between facilities and communities.
       Assess the extent to which the facility has been able to establish and maintain functional 24-
        hour delivery or B/CEOC services, in line with the objectives of the participatory workshop
        and as appropriate to the type of facility.
       Investigate and document the positive experiences and barriers experienced by the facility
        staff, HFMC members, district teams and community representatives in implementing the
        facility breakthrough plans developed.
       Assess the implementation of the participatory workshops by the facilitators, including
        whether they were able to use all the tools provided, whether the training they received
        effectively prepared them for the challenges they encountered and whether the workshops
        were successful in achieving their aims.
       Identify any areas in which the AI approach and training could be modified to better equip
        prospective AI facilitators to achieve their objectives, and assess whether further training or
        supervision might be required.
       Explore the potential of other models for scaling up, to increase effectiveness and reduce
        costs.

                                                                                                          64
Evaluation Methodology

Information was gathered and triangulated from: interviews with health facility in-charges and with
chairpersons of HFMCs; review and analysis of facility records; focus group discussions with
breakthrough teams and mothers. A total of 12 health facilities, representing each development
region, type of facility and facilitation modality, were selected for the evaluation. As the AI
workshops only began in December 2008, this evaluation comes at a relatively early stage in
implementation and there are other confounding variables, such as implementation of free health
care services with the provision of incentives, that may have contributed to increased institutional
delivery.

Major Findings

Almost all interviewees said the AI approach was new to them and it had created awareness about
the importance of quality management and built positive understanding between health staff and
patients, health facility managers and health staff. Some participants also mentioned that the AI
workshop had helped them view the people and the activities more positively.

Infrastructure equipment and supplies: Out of the 12 health facilities, only two had all seven
types of infrastructure required, but there were at least minimum levels of physical facilities for
starting normal delivery in all institutions. Only four had all nine specified drugs, with availability
ranging from 3-9. The CEOC site has all nine drugs. Out of the nine birthing centres, only three had
all eight types of supply and equipment expected. The BEOC and CEOC sites had adequate
supplies and equipment. Clear differences were not found with facilitation modality.
Human resources: Four facilities did not have 24-hour availability of a Skilled Birth Attendant
(SBA)13; one had no SBA, four had only one SBA, one had two SBAs, three had three SBAs., one
(the CEOC site) had four SBAs.
Services: Both BEOC sites can provide all eight complication management services and the CEOC
site can provide nine out of the ten expected (lacking blood transfusion).
Transparency: Seven of the facilities (58%) had displayed the names of mothers who received
delivery incentives.
Reporting: Eleven of the facilities (92%) prepared monthly maternity reports, but less than half
(45%) had complete and accurate records.
Service utilisation: After the AI workshop, institutional normal delivery increased by 55% and
newborn care services increased by 21%. Referrals for complications more than doubled. These
figures represent averages, and there was wide variation among the facilities. However, during
community interviews it was found that as a result of lack of human resources in some local health
facilities, women either travelled long distances to give birth in another facility or delivered at home.
The percentage of women receiving four Antenatal care (ANC) check-ups increased by 4% and
those receiving a Postnatal care (PNC) check-up increased by 5%. Clear differences based on the
modality of the facilitation were not found.
Physical environment: After the AI workshop, improvements were seen in most of the facilities in
cleanliness of the ANC/ PNC rooms and waiting areas; toilet facilities for patients and care takers;
drinking water facilities for patients and care takers; and cleanliness of the surrounding environment.
VDCs have been very supportive of improvements in physical facilities, providing small financial
grants. The major reasons for these improvements are the increased levels of activity of
management committees and commitment of health staff.
Attitudes: AI process facilitated team building and understanding among participants, who realised
they could achieve a lot by working jointly. In some facilities, the participants reported stronger
collaboration and commitment, including the formation of a support network through which they
seek advice and feedback from one another.


13
     Doctor, nurse or Auxiliary Nurse Midwife (ANM)

                                                                                                      65
Emergency funds: There was increased awareness of the importance of emergency funds in
almost all health facilities, and among local leaders of political parties, HFMC members and Female
Community Health Volunteers ( FCHV). However, none of the health facilities have established an
emergency fund, but they manage emergency cases on an ad hoc basis. Almost all respondents
said the AI workshop has encouraged them to establish 24-hour delivery services, explore the
availability of local resources and ideas for positive problem solving. They have begun to review
their areas of strengths and capacity for improving health facilities.

The district authorities (DHOs, FPO and PHN) repeatedly mentioned the need for systematic follow-
up visits by the facilitators and suggested that a guide for AI facilitators should be developed and
distributed, with details of resources and tools used in the AI workshops and complete facilitators’
notes. This would serve as a resource and confidence builder for the DHOs and local facilitators.

Lessons Learned

A positive step for change: The AI workshop has resulted in a variety of innovations in health
facilities to support improved quality of services and infrastructure and identify gaps in knowledge,
attitudes and practices at various level of health facility function. The workshop has been a positive
step for change.
Thrust of the programme: The key thrust of the programme has been to enable the community to
realise the problem is theirs and the responsibility to address the problem is also theirs, so that they
should volunteer and start advocating for support and services.
Importance of leadership: Establishing and/or expanding availability of 24-hour delivery services
requires an effective management team. When the members of HFMC are not willing to invest in
management change, it is extremely difficult to move forward. On the other hand, when the HFMC is
committed to making quality changes in the health facility remarkable progress is possible.
Human resources, supply and monitoring: The AI workshop nurtures the leadership qualities of
providers and the community members, but the process should be backed up by increased
provision of trained SBAs, essential supplies and equipment and intensive monitoring.
Follow-up visits: Periodic follow-up visit by facilitators is important for continued learning and
behaviour change. These visits should be organised informally.

Recommendations

   Ensure the AI process is backed up by provision of the required supplies, equipment and
    minimum number of SBAs in each health facility, to enable them to move forward in
    establishing and sustaining 24-hour delivery services.
   Ensure the AI process is further supported by informal follow up visits by facilitators.
   Scale up the AI process, using competent facilitators and the cascade model. District level AI
    coaching should be facilitated by the external consultants and DHO. At the peripheral level
    (PHC, HP, SHP) the AI workshop should be conducted by the DHO and participants from the
    district level workshop.
   The existing facilitator guide should be expanded and distributed, detailing all the resources
    and tools used in the district level workshop and complete facilitators’ notes, to serve as a
    resource and confidence builder for the facilitators at the peripheral level workshops.




                                                                                                     66
ANNEX 6: Hints and Tips for District Safe Motherhood


These suggestions are intended to help district stakeholders, including District/ Public Health
Officers and Health Facility Management Committees, to further develop and improve their safe
motherhood and newborn health services. Simple suggestions for activities and approaches are
provided, with information about why they are recommended and how to do them. There is a list of
case studies at the end to illustrate successful initiatives observed in different districts across the
country.

1.   Participatory joint planning

    Why?
      Ensures local stakeholders have ownership and involvement and will fully support safe
       motherhood activities
      Improves the quality of planning in terms of broadened and inclusive perspective

    How?
      Sensitise local stakeholders about their potential to help – encourage them to be involved
      Include all local stakeholders in planning meetings: health staff, management, local
       politicians, civil society, community leaders and media
      Use a good facilitator experienced in participative and appreciative inquiry approaches

Case study from Achham (SSMP/UNICEF)

2.   Health Facility Management Committee strengthening and support

    Why?
      Empowers local management and leadership, enabling them to see what they can achieve
      Improves quality of management and services
      Improves community relations and thus service utilisation

    How?
      Use appreciative inquiry review and planning process with a trained/ experienced facilitator
      Train local change agents and breakthrough groups to keep the momentum going
      Provide ongoing monitoring support through Public Health Nurses (PHN) and regional
       offices, working with local change agents

Case studies from Rupandehi and Mugu (SSMP/UMN)

3.   Public/ Social Auditing

    Why?
      Creates public awareness and an atmosphere of transparency
      Encourages accountability of public agencies towards their communities
      Encourages further support and investment by community, based on trust


    How?
      Organise public information/ feedback meetings at VDC and district level
      Post reports and audits in public places
      Inform and involve local media/ journalists

Case study from EAP


                                                                                                    67
4.   Community/ health worker interactions

    Why?
      Creates understanding of each other’s perspectives and challenges
      Promotes dialogue by breaking down barriers between health staff and community
      Encourages service utilisation by building public confidence

    How?
      Organise public visits to local health facilities (through facility management committees)
      Arrange interactive public meetings, with skilled facilitation
      Arrange joint activities for a common purpose (eg fundraising/ health awareness raising etc)

Case studies from Dailekh and Myagdi (EAP)

5.   Local recruitment of key staff

(This is especially recommended for Auxiliary Nurse Midwives (ANM) and has been successfully
done in many districts. It could also be extended to doctors and staff nurses)

    Why?
      In particular, ANMs are the mainstay of local services and there are many available locally
       who do not have jobs
      Locally recruited staff are more likely to stay longer, because of family and community ties
      Local staff may be more acceptable to the community
      Locally recruited staff likely to be more accountable to the employer and community, thus
       strengthening management and community relations

    How?
      Identify funding, either from facility income, VDC/ DDC funds, local donor agencies,
       businesses etc
      Sensitise VDCs/ DDCs about safe motherhood so they prioritise this
      Advertise through local media and by word of mouth
      Ensure selection processes are transparent and fair

Case study from Panchthar (SSMP/UNCEF)

6.   Identification and use of local resources to improve services and facilities

    Why?
      Enables local health facilities to improve services without waiting for central inputs
      Creates local ownership for long-term sustainability
      Promotes retention of staff because of better working conditions
      Encourages service utilisation because of improved services and local inputs

    How?
      Lobby VDCs and DDCs, also regional authorities
      Approach local donor and development agencies
      Approach local businesses
      Start small and demonstrate effective use of donations

Case studies from Saptari (UNICEF) and Chitwan and Dadeldhura (EAP)




                                                                                                 68
7.   24 hour delivery services at local birthing centres

    Why?
      Encourages institutional delivery without the need for women to travel to the district hospital
       and incur high transport costs
      Provides a homely but safe environment for delivery
      Women and health staff will know each other
      Easy to provide and encourage use of antenatal and postnatal care

    How?
      Activate PHCC/ health post management committee
      Empower PHNs and give them the responsibility for promoting and supporting services: they
       are key people
      Recruit ANMs locally
      Involve service staff in determining work shifts to enable 24-hour services
      Be innovative in making best use of limited resources: start with minimum of essential simple
       equipment
      Use simple locally available materials and craftsmen to make furniture (delivery beds, tables
       etc)
      Identify local resources to fund improvements needed
      Involve the community and other local stakeholders in improvements
      Start small and build on success: demonstrate initial achievements to potential local donors
       to persuade them to give

Case study from Sankuwasbha

8.   Referral and transport mechanisms

    Why?
      Fast referral of complicated cases is critical for saving lives

    How?
      Identify initial contributions for emergency funds and transport schemes from local sources
       (VDC, DHO, donor agencies etc)
      Establish or use existing savings groups to contribute to emergency funds
      Encourage community groups to identify local transport that can be quickly mobilised
      Lobby local authorities and mobilise the community to improve roads, trails and bridges
      Install telephone (landline, CDMA or mobile) at local health facility
      Make prior arrangements for referral to next level(s) of facility
      Involve FCHVs in identifying high risk cases and encouraging service utilisation
      Promote antenatal care with information about referral mechanisms as this encourages
       women to use professional delivery services and/ or seek help more quickly if they have
       complications

Case studies from Morang, Rupandehi and Chitwan (EAP)

9.   Mobilisation of FCHVs

    Why?
      They are known and respected in communities
      They already have health knowledge and are involved in many programmes
      They are responsible for mothers’ groups

    How?
      Ensure local FCHVs receive all training available under GoN programmes

                                                                                                   69
     Provide them with the required BCC materials
     Provide them with referral slips (especially the pictorial ones)
     Provide additional local level briefings and information as appropriate
     Involve them in all safe motherhood related activities
     Give them a small emergency fund for immediate use when needed and/ or link them to
      local accessible emergency funds
     Involve them and mothers’ groups in health facility improvements and maintenance
     Encourage them (with an incentive) to support female health workers during night work

Case study from Saptari (SSMP/UNICEF)

10. Establishment of emergency services at district level

   Why?
     Life saving services are needed within easy reach of the district – speed is essential in an
      emergency

   How?
     Ensure the presence of a surgically skilled doctor and support (anaesthetics assistant)
     Establish safe blood services
     Establish a community drugs scheme

Case study from Udayapur (SSMP/UNICEF)




                                                                                                70
ANNEX 7: UNITED MISSION TO NEPAL END OF PARTNERSHIP REPORT

SECTION 1: ANALYSIS OF MAIN ACHIEVEMENTS

Health facility activities began in Mugu in December 2005 and in Rupandehi in March 2006.

Achievement 1: Establishment of 24-hour delivery services

All 13 selected health facilities (HF) now provide 24-hour delivery services, including continuous
facility services at all eight supported facilities in Rupandehi and Mugu hospital. The four health
posts (HP) in Mugu provide 24-hour home and institutional delivery services. Mugu hospital
provides all functions of Basic Emergency Obstetric Care (BEOC) services. All Primary Health Care
Centres (PHCC) and health posts in Rupandehi are also providing some functions of BEOC
services. A blood transfusion facility was established in Mugu hospital. (SSMP logframe output 2)

The quality of care provided in these health facilities has improved significantly over the last three
years. Skilled Birth Attendant (SBA) training enabled the staff to function independently and
confidently in their remote locations and improve the quality of care. Most facilities now routinely use
the partograph, standard infection prevention protocols and provide active management of the third
stage of labour. SBA training has also enabled Auxiliary Nurse Midwives (ANMs) to provide, BEOC
services which they previously did not have the skills or confidence to undertake. In areas where
transport is easy, they still prefer to send complicated cases to higher centres with better facilities.

A number of factors have contributed to the success of 24-hour services in these rural health
facilities, among which are good leadership from the health facility in-charge, commitment of ANMs,
commitment and support of Health Facility Management Committees (HFMC) and support from
communities, especially FCHVs. Contributions from communities, including Village Development
Committees (VDCs) and women group members, made it possible to improve buildings and create
an enabling environment for staff to provide services. Frequent visits, encouragement and support
to these facilities were essential to ensure they started and continued to provide 24-hour services.

The needs for delivery care in a facility near a woman’s home cannot be over emphasised, as
transport is one of the major barriers to women using services. Availability of services for
uncomplicated deliveries at local health facilities will also reduce the service load at specialised
hospitals (zonal and above), enabling them to focus on providing specialised care. National policy
should support this pattern of service delivery for improving access and quality of care for all
women, including those with complications.

To increase clinical support for ANMs working in rural health facilities, use of CMDA phones was
piloted in Rupandehi at three health facilities. This has enhanced the confidence of staff in providing
services and also speeded up referral, as transport can be arranged and referral centres are
informed about the situation while the woman is en route to the hospital.

Health facilities were selected for support with the involvement of the district health management
committee in Mugu and Reproductive Health Coordinating Committee (RHCC) in Rupandehi, as an
appropriate participatory approach. A guideline developed at the Family Health Division (FHD) was
applied and facilities were selected on the basis of social inclusion and equitable distribution.
However, these were not necessarily the best located health facilities, which led to difficulties in
starting services and initial low service utilisation. Zoning of health facilities with their catchment
populations followed by district level planning would be more likely to result in selection of
appropriate facilities. Willingness of the staff and HFMCs should also be a criteria for selection.




                                                                                                     71
Achievement 2: Health Facility Management Committee taking their responsibilities

The commitment of HFMCs in all rural health facilities has been commendable, and their
participation and that of other local stakeholders, in the management and support of health facilities
is a crucial component for future sustainability of their functioning. This is especially true in the light
of limited government provision for the required staff at health post and sub-health post (SHP) level
to provide 24-hour services. UMN promoted and supported involvement of the HFMC members
through their participation in planning, training on roles and responsibilities and exposure visits to
functioning community managed health facilities. This provided motivation and learning, producing
more creative management.

The HFMCs in Rupandehi support employment of local staff and provide staff incentives, visiting
their facilities regularly to solve problems as they arise, encouraging staff to create a user-friendly
environment and requesting help for upgrading work from the Regional Health Directorate and
District Development Committee (DDC). They meet regularly and follow their action plans. Thus, it is
likely that most health facilities in Rupandehi will continue to provide 24-hour services after support
from SSMP/ UMN ends. In Mugu, the District Health Management Committee, led by the Local
Development Officer (LDO), established a District Emergency Fund which includes referral for
obstetric complications. Currently HFMCs fund seven ANMs in Rupandehi and one ANM in Mugu
health facilities. The DHO also allocated six ANMs and two staff nurses to health facilities providing
24-hour services.

Understanding of HFMC members about their roles and responsibilities occurred about 6-12 months
after the initial planning for health facility improvement in Rupandehi district. Needs and challenges
that arose in the early stages in all the supported health facilities sometimes delayed start-up of 24-
hour services, but frequent visits to encourage and gently challenge the committees and encourage
community support enabled them to overcome the difficulties. Most HFMC members took on their
responsibilities and are proud of their achievements, moving on to plan further improvements and
upgrading of their health facilities. However, in Mugu this did not happen at district level due to
frequent changes in the district officers (DHO and Chief District Officer), who are secretary and
chairperson respectively of the management committee. A culture of dependency and blame
prevented the DHO from functioning to his optimum level in managing the health facilities.

Strong partnership, ability to raise local funds and contributions from local communities reflected
their participation and ownership and is an indicator for long term sustainability of services. The
HFMCs were able to mobilise local resources ranging from Rs.85,000 to Rs.1,038,000 per facility in
Rupandehi. The total funds raised locally, excluding locally recruited staff salary, material
contributions and labour was Rs.2,664,400 among eight health facilities in Rupandehi district. In
addition, they also acquired an ambulance for Dhakdai PHCC. In Mugu, community participation
and contribution was minimal at rural health facility level. Only one health post was able to mobilise
Rs.100,000 from the VDC.

Achievement 3: Sustained increase in delivery service utilisation

Utilisation of MNH services in all supported health facilities increased tremendously, as shown in
graphs 1 and 2. Utilisation of these services continues to increase in the first quarters of 2009-10
even after direct support from UMN ceased (output 2).

Deliveries at Mugu district health facilities have increased over the last 4 years. SBA deliveries at
hospitals and four health facilities rose from 4.5% in 2005/06 to 14% in 2007/08 and 16% in
2008/09. Total attended home deliveries increased in 2007/08 due to introduction of the SDIP, but
then decreased dramatically in 2008/09 to 55% of the 2007/08 level, probably due to better
monitoring and accountability. More than 30% of maternity admissions at Mugu hospital in 2008/09
were complicated deliveries. EOC met need increased from 4.3% in 2005/06 to 9.9% in 2006/07,
and 20% in 2007/08 and 2008/09. In spite of increased admissions for complications, referrals

                                                                                                        72
remained constant at 10 or 11 per year and most returned safe after major interventions at referral
hospitals. Two maternal deaths occurred during the supported period at the hospital – one due to
ante-partum haemorrhage and the other post-partum haemorrhage. Three health posts provide 24
hour facility delivery services and home delivery, with varying degrees of increased utilisation.
These HPs covered 17 – 34.6% of expected pregnancy in 2008-09.

All eight supported health facilities in Rupandehi are providing 24 hour services, with increased
utilisation, as shown in graph 2. Dhakdai PHCC is providing BEOC services, with complicated cases
increased to 15% of deliveries in 2008-09, compared with 9% in 2007/08. However, referrals from
all health facilities have increased from 13% of total cases to 16%, following their acquisition of a
24-hour ambulance service. The seven other health facilities including four PHCCs refer all
complicated cases to the nearby Lumbini Zonal Hospital.

Graph 1: Deliveries attended by SBA, Mugu District
                                                                Deliveries attended by SBA, 2005-09


                                       250




                                       200




                                                                                                                               2005/6
                                       150
                                                                                                                               2006/7

                                                                                                                               2007/8
               Number of deliv eries




                                                                                                                               2008/9

                                       100                                                                                     2009/10*




                                       50




                                        0

                                             Mugu Hospital   Dhungedada HP            Sreekot HP      Natharpu HP   Kimri HP




* Projected from three months utilisation data. Not available from HP level.




                                                                                                                                          73
Graph 2: Institutional Deliveries, Rupandehi District
                                                                         Institutional Deliveries, Rupandehi, 2005-09

                                             450



                                             400



                                             350



                                             300
                                                                                                                                                               2005/6

                                             250                                                                                                               2006/7

                                                                                                                                                               2007/8
                     Number of deliv eries




                                             200                                                                                                               2008/9

                                                                                                                                                               2009/10*

                                             150



                                             100



                                             50



                                              0

                                                   Dhakdai PHCC   Parroha HP   Motipur PHCC Ryapur PHCC Suryapura SHP Rudrapur SHP Lumbhini PHCC Majegaun HP



*Projected from three months utilisation data

Achievement 4: Enhanced Capacity of District Level Stakeholders

Capacity of the district level staff, including the district Public Health Nurses (PHN), was enhanced.
The PHNs from both districts14 are now able to assess health facilities, conduct planning, training
and follow-up to start 24 hour delivery services and improve service quality. This means they will be
able to scale up MNH service strengthening with support from the Regional Coordinators. The PHN
in Mugu is also able give supervision and regular support to health post staff after receiving SBA
training. However, frequent transfer of the hospital in-charge (doctor) and lack of support from the
management, hampers her activities.

District level stakeholders are fully aware of the importance of safe delivery care. Rupandehi DHO
has incorporated plans for health facility improvement in his annual plan. The DDC of Rupandehi
gives incentives for health facilities to provide 24 hours delivery services by providing 100,000
Rupees per health facility for starting 24 hour services. The District Health Management Committee
of Mugu meets as needs arise and has established a district emergency fund by mobilising local
NGOs/INGOs and getting contributions from of all VDCs.


SECTION 2: REFLECTIONS ON THE PARTNERSHIP PROCESS

The partnership between SSMP and UMN was with mutual respect, trust and two way
communication. This resulted in flexibility in implementing the programme which had benefits at the
community level. UMN was able to respond to community needs and requests from health facilities
as needs arose. The number of health facilities supported in Rupandehi increased from the six
planned to eight actual health facilities.

The partnership enhanced UMN’s capacity to be a national player involved in national level
meetings and discussions. This certainly increased UMN’s ability to represent the needs and
concerns of the community and at district level and also to share lessons learned from remote

14
     Mugu does not have PHN, but a Senior ANM from the hospital takes the responsibility



                                                                                                                                                                          74
areas. Monthly SSMP partners’ meetings were a very important forum for UMN to learn from other
partners, to connect with policy level development, to share experiences and contribute to national
policy. This has contributed to development and endorsement of the “Remote Area Guideline for
Safe Motherhood”.

The partnership was based on an umbrella structure of SSMP supporting the government health
system including various divisions and districts under Department of Health Services (DoHS). This
increased the credibility of UMN and thus promoted its capacity to implement at district level. On the
other hand, inability of the central level divisions to respond the needs of district/facility levels, due
to lengthy procedural requirements, hampered the staff motivation and morale in certain
circumstances. One example was the long duration needed to provide essential equipments as per
a need assessment. This was perceived by facility level health workers as a non-caring attitude by
staff at central level.

SSMP supported for the development of a planning facilitation tool, which combined the strengths of
Appreciative Inquiry (AI) and Client Orientated Provider Efficiency participatory Planning Action
(COPE/PLA). This tool was applied in both Mugu and Rupandehi for planning with health facilities
with great success.

Coordinated planning at Department of Health Service level for long term improvement of health
facilities is essential in order to respond to the needs at local levels. Availability of SBA training
places did not catch up with the number of health facilities starting SBA services. This hampered or
delayed service functioning and seriously affected capacity building and motivation of HFMCs. They
were not able to start services without skilled staff and thus felt they are wasting their precious and
limited local resources. Continued delay in the supply of essential equipment from central levels
also de-motivated staff. They saw this as unresponsive and felt unsupported by the central
administration. Immediate response to requests from health facilities is needed to maintain their
commitment and enthusiasm.


SECTION 3: SUMMARY OF RECOMMENDATIONS FOR FUTURE DFID SUPPORT

   Scaling up birthing centres and BEOC facilities needs intensive initial support, facilitation and
    encouragement. UMN's experience indicates this requires inputs outside of DHO system, with
    active involvement of DHO staff, until the facility is functioning and the HFMC is fully engaged,
    after which it should be handed over to the DHO as soon as possible. The FHD and Regional
    Health Directorate could take this responsibility if strengthened by increasing their staff working
    under the FHD focusing on safe motherhood and newborn health. These staff could be
    responsible for upgrading and supporting HPs and PHCCs to be 24 hour birthing centres and
    BEOC centres.

   Upgrading all health posts and PHCCs to provide 24 hour birthing and BEOC centres
    respectively should continue with flexibility to support SHPs in selected areas. This should be
    supported with transport facilities for referrals. Upgrading all PHCCs to BEOC centres might not
    be the best option, instead it is suggested that upgrading strategically located health posts for
    BEOC would more effectively enhance equitable access.

   Relying only on local capacity to run 24-hour services while the government provision for staff is
    so limited at health post and SHP level is not realistic in remote areas. Support from central
    levels, especially for local staff recruitment will be necessary for long term sustainability. The
    HFMCs need support from central levels to finance the operational costs of 24-hour delivery
    services, including salaries for locally recruited staff and costs such as electricity and telephone
    facilities for the initial 6 months in districts with easy access and continuous support to districts
    where utilisation of delivery services do not support the salary needed for locally recruited staff.


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   The free delivery care and incentives (Aama) programme has greatly increased accessibility of
    maternal health care services for the poor who are near health facilities providing services.
    However, it widens the gap between women in urban areas (where facilities are available) and
    women from remote areas (where there are no facilities),as providing free services and
    incentives where these services are not available does not increase women’s ability to access
    services. Women from remote areas still have to pay for transport and other expenditures if
    they are referred to another district or a referral centres, for complications. This leads them into
    deeper poverty while urban area women can have easy access to such services. The
    government should take this into account when equity related policies are revised and
    implemented.

   The Aama programme also increases utilisation of delivery care services at specialised centres
    (zonal and regional hospitals). This, in some instances, has led to compromise in quality of care
    at these facilities due to increased workload. The national policy on the AAMA programme
    should consider strengthening peripheral health facilities for normal deliveries, keeping
    specialised facilities for women who need special care.

   A comprehensive approach is most effective: service strengthening should be followed by
    increasing access activities in order to increase utilisation of services.

   Lack of an ANM sanctioned post in Mugu (Kalnali zone) has greatly affected provision of 24
    hour service. These health facilities provide services to the most poor and vulnerable
    population in the country, and thus it has little capacity to raise local financial resources.
    Moreover, due to sparse population and limited awareness of the population, utilisation of these
    services is low compare to health facilities in Teria. All these factors have resulted in the
    HFOMC not being able to provide a needed ANM for their community.

   Approaches to service provision and referral in mountain districts such as Mugu need to be
    reviewed in the light of the very difficult nature of the terrain with associated access problems,
    and the cost of establishing and running 24-hour services for small populations. The Remote
    Area Guidelines formulated with the leadership of FHD and SSMP/ Options has the potential to
    improve access to MNH care in these remote locations, but needs to cover not only service
    provision and referral, but also preventive measures. The HFMCs in remote areas also need
    additional financial support to sustain 24-hour delivery services. This guideline should also
    consider provision for referral support for women who need a Caesarean Section.

   Frequent transfer of officers in district line agencies, including the DHO, and the perception of
    Mugu as a “punishment posting” make continuity and sustained strengthening of the HFMC of
    Mugu hospital almost impossible. Hospital services can only be sustained if all sanctioned
    posts are filled and there is regular supervision and monitoring visits from central/ regional
    levels.

   The approach of many development and humanitarian organisations in providing aid to Mugu
    for the past few years has created a dependency attitude. Future programmes funded by
    bilateral and multilateral donors need to consider such issues and seek to create local
    empowerment.

SECTION 4: LIST OF LEARNING PRODUCTS

Video – Maya (MNH focused)
AI/COPE/PLA planning tool




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ANNEX 8: UNICEF END OF PARTNERSHIP REPORT

SECTION 1: ANALYSIS OF ACHIEVEMENTS

Achievement 1: Review and planning workshops and AI approach

   Planning workshops at district and VDC levels, based on the Appreciative Inquiry (AI)
    approach, have proved effective in creating an enabling environment for Skilled Birth
    Attendance (SBA) and improved quality of SMNH care. This approach helps the community to
    develop ownership of the health facility. HFMCs have been empowered to plan and manage
    human resources, equipment, recording/reporting, monitoring, and improvements in
    infrastructure.
   The focus on local resources and demand has increased the accountability of local service
    providers.
   The best results were seen at the human resources level with the local recruitment of staff by
    birthing centres to ensure functionality as a 24-hour delivery service site.
            o 59 ANMs, 2 MCHWs and 1 staff nurse were recruited in seven districts.
            o In three districts, communities donated land for birthing centres.
            o In six VDCs, money was allocated to construct a full birthing centre.
            o In seven districts, bhoto topi (vest and cap) for newborns, to prevent hypothermia
               were provided through local funds to women delivering at facilities
            o NRs 50–100 were provided as an incentive to FCHVs accompanying women for
               institutional delivery.
   Local communities provided matching funds for EOC funds.
   The quarterly SMNH district review is included in the district work plan, showing the acceptance
    of the review and planning meeting by the DHO and DDC.
   FHD has begun scaling up the AI approach using GoN funds, indicating that FHD has
    acknowledged the importance of this process.

Achievement 2: Increase in health facilities providing 24-hour delivery services

   During the project, 109 sites (hospitals, PHCCs, HPs and SHPs) have been made functional;
    this is 15 more than planned.
   Institutional deliveries increased in all eight MNH project districts from 5,681 in 2005/06 to
    14,928 in 2008/09, an increase of 163%. Mobilisation of communities, creating awareness of
    the availability of trained SBAs and SMNH services and rapid expansion of birthing centres at
    peripheral level have contributed to this, especially for marginalised and remote communities.
    Implementation of Aama Programme has also acted to increase institutional deliveries.
   There has been a significant increase in the capacity of health facilities for managing
    emergency newborn and obstetric complications. Met need for EOC increased from 24% in
    2005/06 to 28% in 2008/09.
   There is also an increasing trend of met need for Caesarean Section (CS), from 15% in
    2005/06 to 31% in 2008/09. In 2006, there were only three CEOC sites providing CS services;
    by 2009, there were six functional CEOC sites.
   A total of 167 service providers from the UNICEF districts have received SBA training, 134
    supported by UNICEF and 33 under government funding. Many of the 24-hour delivery services
    sites now have at least one trained SBA.
   UNICEF’s refresher training on safe delivery and newborn care for ANMs, Staff Nurses and
    MCHWs promoted learning of key life-saving skills (use of partograph, active management of
    third stage of labour, use of MgSO4 for prevention and management of pre-
    eclampsia/eclampsia). After training, most birthing centres started using the partograph, and
    ensuring active management of third stage of labour at every birth.
   Whole-site Infection Prevention (IP) training has substantially improved quality of care at
    birthing centres and hospitals. Involvement of HFMC members resulted in investments in

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    improving IP, such as construction of waste disposal and placenta pits, incinerators, and IP
    equipment and supplies in many facilities. HFMC members carried out monitoring and
    supervision to ensure good IP practices were in place, creating increased accountability of
    health workers.
   A total of 65 health facilities constructions were completed in the eight SMNH project districts
    and some renovation in two CEOC sites. New construction included three CEOC sites, six
    BEOC sites, 46 birthing centres and nine new health posts.
   Five CEOC sites, seven BEOC sites and 32 birthing centres received equipment from the
    Government fund, after strong advocacy from SSMP/ Options and UNICEF.

Achievement 3: Establishment of SBA training sites

   UNICEF supported NHTC to develop four SBA training sites (Dhulikhel hospital, Kavre;
    Sagarmatha Zonal Hospital, Saptari; Dang Hospital; and Bheri Zonal Hospital, Banke).
   To date a total of 113 SBAs have been trained at these sites.

Achievement 4: Partnerships

   UNICEF has been a regular contributor to monthly SSMP partner meetings, and is a member of
    the BCC Working Group and the Service Delivery Group.
   UNICEF’s strong working relationship with other SSMP partners enabled the development of
    standard guidelines for initiating and operating 24-hour birthing centres, and the Remote Area
    Guidelines for increasing access to EOC services for communities in remote areas and
    continues to advocate strongly with partners for wider implementation of these guidelines.
   UNICEF shared all materials it developed, and assisted in upgrading the SMNH content of the
    FCHV training manual and developing an AI training manual for the Safe Motherhood
    Programme.
   UNICEF is also a member of the FHD-led technical assistance group for scaling up of
    misoprostol for prevention of postpartum haemorrhage at home births and has provided
    technical assistance for the development of a guideline.
   MNH project consultants were effective in developing strong partnerships with DHOs/DDCs and
    other district partners for improved planning, implementation and monitoring of the programme.
    Involvement of district administrators, community leaders, service providers, HFMC members
    and the community resulted in positive outcomes.

Achievement 5: Establishment of watch groups and safe motherhood action group

   Watch groups and Safe Motherhood Action Groups have effectively mobilised the community
    and increased demand for services. They have also helped to address the three delays by
    encouraging pregnant and postnatal women and their families to use peripheral facilities, been
    instrumental in establishing EOC funds and promoted timely referring pregnant women with
    complications.
   Under the leadership of the Ministry of Local Development and Local Development Offices, a
    national operational guideline for watch groups was developed based on field experiences in
    UNICEF districts.

Comments

The following factors have influenced achievements towards MDG 4 and 5:




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   UNICEF adopted a strategy of mobilising the community to create demand as well as
    strengthen the service sites to fulfil the demand. It is important to work on demand and supply
    simultaneously to achieve better utilisation of services.
   Empowering the community to plan for service sites in their own locality was instrumental in
    making the sites functional.
   Availability of trained human resources is the most crucial and difficult factor to keep a site
    functional. This was partially solved by communities through local recruitment.
   AI review and planning workshops have been instrumental in empowering communities to
    make health facilities functional.
   Strengthening existing SBA training sites and establishment of other new sites is essential to
    produce the required 5,000 SBAs to achieve the target of 60% of deliveries attended by an SBA
    by 2015.
   Watch groups and Safe Motherhood Action Groups established at ward level have been vital in
    mobilising women and communities to utilise services, monitoring the health of pregnant
    women and supporting them when needed. Watch groups should be scaled up nationally.

Challenges

   Lack of human resources:
    At service sites: Lack of SBAs and doctors is a severe constraint to fulfilment of EOC and 24-
    hour delivery service needs. Despite commendable local efforts, these issues cannot be
    completely solved at district and community levels. While ANMs are available and can be hired
    locally, highly skilled human resources such as doctors can only be posted through the MoHP.
    Although filling ANM posts is reasonably easy, paying salaries through local community
    resources demands continuous effort and sustainability is not assured. Furthermore, the current
    number of sanctioned posts for ANMs is only half of the requirement for SBAs calculated on a
    population basis.
    At training sites: Sufficient SBA trainers must be available at the training sites. Trainers are also
    key service providers for EOC. As a result of work pressure, conflicts can develop between
    efficient service delivery and responding to training needs.
   SBA training opportunities for locally hired staff: It is NHTC’s responsibility to provide SBA
    training to all doctors, staff nurses and ANMs currently in the government system; therefore,
    they are given priority and locally hired staff have a lower chance of receiving training. This is a
    hindering factor for community commitment, especially as health facilities are being handed
    over to local authorities within the devolution process.
   Sustainability of peripheral birthing centres: Recruiting and retaining local staff is important
    for 24-hour delivery services at health facilities where only one or no posts are sanctioned for
    SBAs. In the terai region, well-performing birthing centres with high population coverage have
    generated enough revenue from the Amaa Programme to easily cover salary and investments
    for the service. In hill and mountain regions, however, revenue collected from normal deliveries,
    even for a well-performing birthing centre, is not sufficient to cover salary expenses. There is a
    risk that the incentives scheme, meant for equity, will create inequity between regions, as
    incentives are given on caseload and large differences exist between targets according to
    geographic region.
   Placing and posting of SBAs at inappropriate service sites: Frequent transfer of SBAs to
    other health facilities rather than birthing centres, and to irrelevant units within hospitals, has
    been a challenge for continuing 24-hour delivery services.
   Lack of proper supervision and monitoring: To ensure quality of care, it is essential to have
    periodic supervision and monitoring of service providers and service sites.
   Lack of advanced newborn care: Although C/BEOC sites and birthing centres should have a
    component for newborn care, this has not been taken into account. Not even CEOC sites have
    a well-established newborn care unit. Standard quality care services are lacking for newborns;
    this should be an area for government investment.


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SECTION 2: REFLECTIONS ON THE PARTNERSHIP PROCESS

The SSMP/ UNICEF partnership generally went well and improved with time. A few observations
are:

   Being the partner of SSMP, it was easier to advocate and this brought success in influencing:
      - The government for constructing birthing centres, C/EOC sites and HP in the UNICEF SMNH
      districts and supplying equipment.
      - NHTC to plan SBA training at the four SBA training sites.
   However, SSMP/Options support did not always take into account initiatives implemented by
    other SM partners.
   It was often perceived that SSMP/Options and FHD coordination needed to be strengthened,
    having separate office space could have been responsible for this.
   SSMP/Options hired former FHD capable human resources as advisers. These advisers
    influenced FHD but weakened its capacity. SSMP did not address this.


SECTION 3: SUMMARY OF RECOMMENDATIONS FOR FUTURE DFID SUPPORT

   Continue focusing on service strengthening. Many agencies are working on demand creation
    and community based interventions, but these need to be accompanied by strengthening of
    health facilities to provide 24-hour delivery services to meet the demand. However, if the EAP
    programme had been implemented in the UNICEF supported districts, better and more holistic
    outcomes could have been achieved. Either way, the two types of intervention (demand and
    supply) need to go together
   Continue using and supporting the AI review and planning process, including scaling it up to all
    districts
   Continue support for human resource development, which is a major system weakness.
   Ensure support for family planning, as this is a major factor in maternal mortality reduction.
   Ensure work in improving maternal care is complemented by newborn care, rather than leaving
    it be addressed by a separate package.


SECTION 4: LIST OF LEARNING PRODUCTS

   Pictorial FCHV training manual on SMNH services
   Appreciative Inquiry training manual for the Safe Motherhood Programme.




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ANNEX 9: SBA Follow Up Recommendations

From the Report of Post Training Follow-up for Skilled Birth Attendants: Review of Implementation
Experiences, September 2009

Conclusions and Recommendations

Discussion of Conclusions

1.   Scaling up: Overall, the follow up exercise proceeded smoothly, adequately covering a
     significant number of trainees (119) in a relatively short period of time (about two months in the
     field). This is a very positive indicator of the practicability of scaling up sustainably under the
     GoN system, especially as NHTC was supportive and involved throughout. However, if all SBA
     trainees are to be followed up, as should be the case, creative approaches will be needed to
     ensure availability of the necessary human resources. Trainers should certainly carry out a
     proportion of visits, in the interests of developing their own professional skills by seeing the
     results of their training, but cannot be expected to cover all. Other options to consider include:

        Assignment of other qualified SBAs working at training sites to carry out visits
        Recruitment of additional SBAs at training sites, so that follow up visits can be rotated
         amongst all qualified SBAs without disrupting services
        Involving district based Public Health Nurses (PHN), as the GoN designated safe
         motherhood point persons. However, since they are not qualified SBAs, their support role
         would be limited to environmental and management issues, rather than technical skills
        Involving the five regional training coordinators that NHTC plans to recruit for 2009/10
         under SSMP Financial Aid
        An additional support strategy, already practised by some of the trainers, is to maintain
         telephone contact with the newly trained SBAs, enabling them to request immediate advice
         in handling complicated cases or addressing other problems. This is particularly important
         for SBAs working alone in small and/ or remote health facilities.

     The fact that so many SBAs and their supervisors commented on the lack of trainer follow up
     as a significant barrier to optimum development of the SBA skills and confidence further
     reinforces the importance of this activity.

2.   On-site coordination: Follow up is also important as a mechanism for improving coordination
     among key stakeholders at site level, to ensure the SBA has the necessary support from
     management and other staff. To further promote this understanding, the trainers have
     recommended providing a structured SBA orientation for facility in-charges and/ or SBA
     supervisors, in the form of interactive meetings at regional or national level.

3.   Trainer orientation: During review of the tools while compiling the data, some inconsistencies
     were noted in the way the trainers interpreted and used the tools. This is not surprising in view
     of the fact that their orientation on the tools was carried out in a rather ad hoc manner, rather
     than at a joint workshop at which issues could be fully discussed and any confusions brought to
     light and corrected. Under the circumstances the course taken was probably an acceptable way
     to get the exercise completed in time, but the findings confirm the desirability of using a
     workshop approach in future. It is reported that some of the issues were discussed and
     addressed at the trainers’ interactive meeting held in June, confirming the usefulness of this
     event.

4.   Visit objectives: There may be a tension between the two main objectives of follow up visits,
     both of which are valid and should not be mutually exclusive. At the outset it should be clearly
     understood that supporting the SBAs, providing coaching and advice, including intervening with


                                                                                                     81
     the supervisors as necessary to address management and environmental issues, is the primary
     aim of the visit, making follow up an integral part of training. Data collection is also important to
     inform improvements in the training and support of SBAs, enable trainers to learn more about
     the workplace realities of the SBAs they train and as a basis for discussion. However, there is a
     danger that the specificity of the tools may affect the balance of the visit, with trainers focusing
     on completion of forms to capture data, rather than spending more time informally talking and
     “drawing out” the SBAs. Careful consideration was given to addressing this balance when the
     tools were revised after initial assessment of the follow up results. Proper orientation of the
     trainers before future visits will also be important to ensure the different objectives are met.

5.   Trainer learning: One of the key aims of the exercise was to help trainers understand
     importance of follow up in helping them to improve their training, and to motivate them to
     continue following up trainees in the future. They commented that they had indeed learned a
     great deal from trainees during their visits, in particular the difficulties the SBAs face at their
     normal place of work, where the equipment and supplies they had access to during training
     were either not available or very limited. As a result they recommended steps be taken to
     ensure that at least MVA sets and vacuum delivery equipment are made available at PHCCs
     and health posts where a trained SBA is working. In reality, it may be better to ensure these are
     available before the SBA goes for training, so that on return she can immediately use the skills.

6.   Tools design: As this exercise was in essence a pilot, the effectiveness and user-friendliness
     of the tools and process was evaluated. Discussions are ongoing about the tools design, and
     achieving a balance between closed, “multiple choice”, ticking the box and yes/ no style
     questions, which are less prone to inconsistency but also less likely to yield detailed
     information, against more open analytical questions that may be harder and more time
     consuming to record accurately. In particular it has been agreed that the tools for the supervisor
     discussions be revised as many supervisors are not trained SBAs and therefore cannot
     comment on technical issues. It is also worth noting that when asked about their caseloads and
     the skills most recently used, SBAs are most likely to remember the busiest periods and most
     dramatic cases and therefore not give accurate figures. It was therefore agreed that the tools
     be adjusted so that hard data are sourced from the facility records and the tool for the SBA
     perspective on skill utilisation is more discussion based.

     At the trainers’ interactive meeting in June, the trainers commented that many of the tools were
     difficult to administer and ambiguous, covering too much in one question. They suggested
     simplification by separating each factor to be addressed, and this has been done. They also
     confirmed their preference for a mix of open and closed question styles.

     It is recommended that some kind of SBA evaluation of the usefulness of the visit be included,
     such as post visit anonymous completion of a form or a follow up telephone call from a neutral
     person (not the trainer who carried out the visit).

7.   Logistics: Other process issues to consider are the length and timing of visits, whether visits
     are done in batches or one at a time, logistics management, realistic budgeting and ensuring
     the right people carry out follow up. The trainers indicated they would like more autonomy so
     that they are given a reasonable, but not too tight, timeframe and a lump sum budget, enabling
     them to make arrangements to fit in with their other commitments and the characteristics of the
     area they are visiting. NHTC and their training team may wish to develop guidelines in
     collaboration with supporting partners, such as Nick Simons Institute, for the current year’s
     planned follow up.

8.   Skill use: Overall it appears that most of the SBAs are using their new skills and are confident
     about doing so. The most commonly used life-saving skills were MVA, vacuum delivery,
     newborn resuscitation, and management of post partum haemorrhage. Management of
     shoulder dystocia and breech positioning, although less commonly seen, are also important as

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     both can be easily managed after training (skills easily learned), but without professional help
     these conditions can be fatal.

9.   Competency: Generally most of the SBAs were assessed as competent and confident in
     performing the samples of key skills observed, with the only major exception being IUCD
     insertion. This problem appears to be due to lack of opportunities for clinical practice during
     training, as most training sites do not have clients for IUCD and there is generally not a family
     planning clinic on site. Thus most of the SBAs had only practised on models, which is a serious
     concern as the potential for uterus perforation in unskilled hands is high and model practice is
     not adequate for developing this skill. Although IUCD insertion appeared to be the skill for
     which clinical practice is most lacking, this was also said to be an issue for other skills, such as
     MVA, vacuum delivery and breech births, at least at some training sites, and this needs to be
     addressed.

10. Skill retention: It is difficult for ANMs posted in remote health posts to retain all their skills, as
    caseloads may be low and they may be the only person with SBA training and therefore have
    no professional support. Strategies for addressing this need to be developed, perhaps by
    providing rotational posting at the district hospital.

Recommendations

1.   Scale up: Set in motion procedures for scaling up post SBA training follow up training under
     GoN work plans, to ensure all trained SBAs receive a visit, ideally within three to six months of
     completing their SBA training. (NHTC to plan and manage, with partner support).

2.   Human resources: Review and implement possible options for ensuring the availability of
     sufficient and appropriate human resources to carry out follow up. (NHTC, using SSMP
     Financial Aid).

3.   Orientation: Ensure all personnel carrying out follow up visits receive an initial formal
     workshop orientation on the tools, and issues arising during the course of the follow up,
     including adjustments required in the training, are discussed at regularly organised trainers
     interactive meetings. (NHTC to plan at trainers interactive meeting).

4.   Objectives: Ensure those carrying out follow up visits are clear about the objectives of the visit
     and particularly the importance of providing adequate technical support to the SBAs and not
     allowing the visit to be over dominated by completion of forms. (NHTC at trainers interactive
     meeting).

5.   Supervisor orientation: Arrange regional or national orientation meetings for in-charges/
     supervisors from facilities where trained SBAs are working. Ideally this should coincide as
     closely as possible with the timing of the concerned SBAs’ training. (NHTC working with FHD
     and Regional Health Directorates).

6.   Equipment: Selection of trainees should include the criterion that the facility has/ will receive
     the required equipment for SBA services (at least MVA sets and vacuum delivery equipment)
     and the trainee will be assigned to delivery care after training. (NHTC, LMD and FHD).

7.   Tools: Continue with the process of reviewing the completed forms at trainer interactive
     meetings, adjusting the tools as needed to ensure they provide clear, unambiguous and
     consistent information and are easy to administer. Include a question on length of time since
     training and provision for SBA evaluation of the usefulness of the visit. Simplify the questions so
     that only one factor is addressed at a time. Ensure a mix of open and closed style questions, as
     appropriate. (NHTC at trainer interactive meetings).


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8.   Logistics: Make the system as flexible as possible to make it easier for trainers to manage the
     visits; consider providing a lump sum budget with reasonable timeframe and guidelines.
     (NHTC, working with the accounts department).

9.   Clinical practice: Address the issue of lack of skills in IUCD insertion, either ensuring training
     sites develop links with nearby family planning clinics for clinical practice or, if this is not
     possible, removing this skill from the training. Also ensure sufficient clinical practice is available
     for all key skills. (Trainers at training sites; NHTC to consider omitting from the training
     competencies for which clinical practice cannot be assured).

10. Skill retention: Develop strategies for helping SBAs in remote postings to retain their skills (for
    example rotational posting in the district hospital). (Trainers explore with individual SBAs and
    discuss with District Health Officers during follow up).




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ANNEX 10: Terms of Reference for Regional Training Coordinators

Government of Nepal, Ministry of Health and Population, National Health Training Centre


1. Background

The National Safe Motherhood Programme (SMP) is a priority within the Government of Nepal's
(GoN) Health Sector Strategy, which serves towards meeting three years special plan and health
sector targets set out in the Millennium Development Goals (MGD). The goal for maternal health is
to reduce the maternal mortality ratio by three quarters between 1990 and 2015. The framework for
implementation of the SMP is the National Safe Motherhood Plan 2002-2017 (revised in 2006).
Based on the SMP, a National Policy on Skill Birth Attendance 2006 and National In-service
Training Strategy on Skilled Birth Attendance was endorsed and is under implementation.

The Maternal Mortality Ratio (MMR) in Nepal continues to be high (estimated at 281 per 100,000
live births, NDHS 2006). To address this, the Skilled Birth Attendance (SBA) training programme
was initiated in 2007, and the Aama programme was launched in early 2009, combining the Safe
Delivery Incentive Programme with free delivery services.

2. Purpose of the Assignment

The main purpose of this assignment is to provide support to the quality implementation of the
national SM related training programmes specifically skill birth attendance core skill training,
Operation Theatre Techniques and Management (OTTM) and Infection Prevention (IP) training at
training sites at central, regional, zonal and district hospitals. The successful candidates will be
assigned to cover NHTC safe motherhood related training in or near their assigned regional training
sites and the districts the sites cover for training. The posts will be located at regional training
centres to facilitate travel and management coordination. The assignment will include planning,
capacity building of trainers, supervision and new activity development. The Regional Training
Coordinator will also be responsible for facilitating the implementation of the QI tool to improve the
quality of the service and training at each training site to assure use of evidence based clinical
practice standards, infection prevention practices and management. The coordinator will also
assure the timely reporting from assigned training sites.

3. Specific Tasks

Planning
 Working with assigned SBA training sites, prepare annual training plan based on 5-year
   Operational Plan for In-service SBA training and include plans for trainee follow-up and use of
   QI tool
 Develop annual training plans for OTTM and IP based on NHTC’s Annual Plan and submit to
   NHTC’s Director and Regional Directors.
 Prepare Regional Training Coordinator annual work plan to provide support and monitor the
   SMNH training at different training sites and as assigned to establish new training sites. Submit
   to NHTC Director

Training strengthening
 Strengthen the planning capacity of SBA trainers and clinical supervisors through support for
    annual planning for SBA training and training follow-up.
 Guide trainers to use “self assessment quality improvement tool” on a bi-annual basis. In
    addition, using SBA trainer’s skill check list conduct annual assessment of each trainer and
    provide supportive coaching to improve their training performance



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   Work with NHTC and their partners to plan annual Interactive Trainer’s meeting for professional
    development and exchanging amongst trainers training experience.
   To strengthen training quality and trainees capability, work with each training site to plan and
    implement training follow-up to assure that the trainees are able to perform to standard after
    training and to learn from the exercise what skills are not adequately mastered at the training
    site.

    1.   Identify SBA trained follow-up staff (including trainers) to follow up to 100% of trainees
         trained previously and trained in current programme year and coordinate to assure the
         follow-up is conducted and the findings written clearly and submitted within 1 month of
         follow-up date.
    2.   Assure each trainer conducts 2-10 training follow-ups annually and discuss with the
         training team what the findings mean for improving training.
    3.   To ascertain success of training and to support the trainees, conduct independently 15-25
         follow ups of trainees in your assigned districts each year.
    4.   Review follow-up reports quarterly (including your own) and analyse training problems
         which the trainees performance suggest must be improved. Discuss and submit
         recommendation for training improvement to training coordinators and to NHTC.

   Coordinate with the training site hospital staff, RTC, RHO and DPHO for linkage within the
    system to improve training and to assure trainees return to utilise their new skills, and to gain
    support for the trainers and training programme.
   Coordinate with safe motherhood partners and government authorities to obtain needed
    training equipment and supplies and to provide necessary support to the trainers.
   Support training management committee by coordinating and motivating the committee to
    conduct meetings and to support and monitor the training events and strengthen the training
    quality.

Service strengthening
 Support the selected SBA training hospitals to improve quality of services and training and
   support initiatives to improve client load through effective use of safe motherhood programmes
   such as Aama. As needed to assure required clinical practice, advocate for placement of SBA
   staff at relevant ward and clinics.
 Work with hospital and training staff to conduct 6 monthly or at least annual Quality
   Improvement assessments using the QI tool.
 Coordinate with the training hospital’s in-charge and staff at MCH and NGO clinics and satellite
   clinics so that SBA trainees can have supervised practice in ANC, PNC and FP counselling and
   IUCD insertion and removal.
 Based on QI tool findings support hospital team to prepare a plan for future improvements
   particularly for low performing training sites. Review implementation of the plan with Hospital
   and training heads. Report findings of QI Tool and subsequent reviews with NHTC director. If
   necessary together identify plan to assure problems can be effectively addressed and if not
   possible consider closing training site until addressed.

Management and Reporting
 Support NHTC in annual review, planning and budgeting.
 Coordinate with the accounts sections and technical teams at NHTC and the SMNH training
  sites to ensure the appropriate, timely release and reporting of the SBA training budget and
  recommend any revisions needed.
 Support to organize training committee meetings within the institution to ensure every member
  support quality improvement of SBA training program and service in the SBA training sites. .
 Prepare a quarterly report and submit it to NHTC SMT focal person and SSMP about the status
  of the SBA training sites and financial issues.


                                                                                                  86
    Review the maternity registers at assigned training sites and compare with HMIS EOC reporting
     and provide feedback to NHTC to discuss with Management Division.

4. Outputs

            Implement SBA 5 year implementation plan effectively to meet objective of the National
             policy for SBA and National in-service training strategy to meet MDG 5
            Regular field visits in at least one training site, one hospital, one PHC and one health post
             for post training follow up in each month.
            Quarterly progress report to SM training coordinator at NHTC and to RHD.
            Participate in NHTC annual review and planning meetings.
            Data analysed after post training follow up and report on findings.
            Timely fund released of SBA training.
            Increased number of trained SBA focused at the number of CEOC/BEOC and birthing units.
            Improved IP and evidence based standard practice.
            Training site implementation of SBA training plans
            Evidence of use of QI Tool to improve training sites service and training quality
            Significant progress of 100% trainees undergoing post training follow up by the trainers and
             others as assigned

    5. Time Frame: One Year, from July 2009 to June 2010 (If budget is available there is a
    possibility of extending this contract for three consecutive years)

    6. Reporting: The SM Regional Coordinators will report directly to NHTC’s SM training focal
    person/NHTC Director and concern advisers from SSMP.

    7. Qualifications: Bachelor in Nursing (BN) or MBBS with SBA training, data analysis and
       report writing skills .

    8. Professional Experience and Skills

    Essential

               Knowledge of Nepal's safe motherhood programme.
               Knowledge of Nepal's national in-service training system.
               Working knowledge of EOC monitoring and reporting.
               Minimum one year of working experience in SBA training or safe motherhood maternity
                service.
               Ability to work in difficult and remote areas.
               Experience of working with different stakeholders and partners and field work.
               Fluent in Nepali and able to prepare report in English.
               Working knowledge in MS word and MS Excel.
               Facilitation, negotiation and team building skills.
               Leadership and networking skills.
               Willingness and ability to travel including to remote areas.

    Desirable

                Experience in post training follow up.




                                                                                                        87
ANNEX 11: Standard Function and Space Allocation for all levels of Health Facility


                                                         Space            Terai   Hills   Mntn

                                GA.01   Admin Room                                     
                                GA.02   Public Toilets                                 
                                GA.03   General Store/Future Laboratory                
                                GA.04   Multipurpose Hall                              
                                                                                       
              General




                                GA.05   Staircase
                                GA.06   Store/Water pump                               
                                GA.07   First Floor Lobby                              
                                GA.08   First Floor Verandah                           
                                GA.09   Flexible Use Room 1                            
                                GA.10   Flexible Use Room 2                            
                                GA.11   Flexible Use Toilet                            

                                MS.01   Waiting Area                                   
                                MS.02   Admission/Registration/Office                  
              Medical Section




                                MS.03   EPI/MCH/FP Room                                
                                MS.04   Examination Room                               
                                MS.05   DOTS Clinic                                    
                                MS.06   Dispensary/Store                               
                                MS.07   Dressing/Treatment Room                        
                                MS.08   Staff Toilet                                   

                                OB.01   Delivery Room - 1 table                        
                                OB.02   Ante- and Post-Natal Beds                      
              Birthing Unit




                                OB.03   Patient Toilet                                 
                                OB.04   Counselling                                    
                                OB.05   Neo-natal Corner                               
                                OB.06   Autoclave                                      
                                OB.07   Sluice                                         
                                OB.08   Staff Utility Area                             
                                                                                          
           ANM Quarters -




                                AQ.01   Living/Dining/Bedroom                          
                                AQ.02   Bedroom                                        
               2no




                                AQ.03   Small Kitchen                                  
                                AQ.04   Toilet/Shower                                  




                                                                                                 88
ANNEX 12: Summary of Points from Field: August and September 2009

Summary of Points from Field Visits, August and September 2009

Districts visited: Rupendehi, Palpa, Dang, Bardiya, Kailali, Chitwan, Nawalparasi, Baglung

Purpose of visits

   Facilitating handover of completed buildings and establishing reasons for delays
   Monitoring ongoing construction work, identifying and supervising improvements and
    corrections

Summary of Analysis

   It was realised that more frequent monitoring
    of sites by expert DUDBC technicians and
    dissemination of knowledge is required to
    ensure site engineers understand health
    facility design, functions and flow. The lack of
    knowledge and care observed on use of
    natural light, ventilation and air flow in design
    was shocking. It was realised monitoring and
    supervision from the centre and districts is
    weak, and even the district supervisors
    complained about it during the visit. SSMP
    allocated FA each year for this purpose, but
    much remains to be done.
   Practical approaches more suitable to local conditions, use of natural resources such as solar
    power needs to be given higher priority and use of electrically powered equipment reduced.
    This seems to have been totally neglected by DUDBC despite repeated requests
   Continuous site supervision seemed to be rare, and “distance supervision” had often resulted in
    poor quality of work and careless faults.
   Standard form needs to be adopted for all concrete work. Curved RCC works were clearly
    visible in many of the sites.
   It is sometimes necessary for the local office to adjust the design, without disturbing the
    principle flow and functions and standard sizes, to suit local conditions. This is not often done,
    although there is a pool of technicians in the DUDBC division offices, often leading to
    inappropriate location of birthing centres, B/CEOC sites. Another major factor for inappropriate
    location was inability of the DUDBC technician to understand the functions and requirements of
    health facility constructions, and their consequent inability to convince local people and users
    about the best location. A good need assessment can help them to understand this, but
    although the principle of need assessment has been agreed between DUDBC and FHD and
    budget allocated through SSMP FA, there seems to have been little response from DUDBC.

Recommendations for future programming

   All the DUDBC field staff should be oriented on health infrastructures design and detailing and
    more health infrastructure related experts should be developed.
   Staff at all levels should receive practical exposure on health infrastructure design and
    construction methods, standard fitting of fixtures and the latest technologies, such as UPVC
    frames and fixtures.
   An increase in human resources is needed to meet site supervision needs
   Monitoring by central staff, who understand about the construction of health facilities, should be
    increased.

                                                                                                   89
Examples of errors observed




Unreachable ventilator                    Poor workmanship of fittings




Incorrect positioning of fittings         No counter in the sluice area




       No wall skirting, poor finishing




                                                                          90
      ANNEX 13: Distribution of New Facilities


                                      TABLE SHOWING DISTRIBUTION OF NEW HEALTH FACILITY CONSTRUCTION BY YEAR AND REGION

                                                             2061/62 (2004/05)                        2062/63 (2005/06)                        2063/64 (2006/07)                       2064/65 (2007/08)                        2065/66 (2008/09)




                                              Region
SN




                                                                           MWDR




                                                                                                                    MWDR




                                                                                                                                                            MWDR




                                                                                                                                                                                                     MWDR




                                                                                                                                                                                                                                             MWDR
                                                                                        TOTAL




                                                                                                                                 TOTAL




                                                                                                                                                                         TOTAL




                                                                                                                                                                                                                  TOTAL




                                                                                                                                                                                                                                                           TOTAL
                                                                    FWDR




                                                                                                             FWDR




                                                                                                                                                     FWDR




                                                                                                                                                                                              FWDR




                                                                                                                                                                                                                                      FWDR
              Types of Facilities




                                                                                  WDR




                                                                                                                           WDR




                                                                                                                                                                   WDR




                                                                                                                                                                                                            WDR




                                                                                                                                                                                                                                                    WDR
                                                       CDR




                                                                                                CDR




                                                                                                                                         CDR




                                                                                                                                                                                 CDR




                                                                                                                                                                                                                          CDR
                                                              EDR




                                                                                                       EDR




                                                                                                                                               EDR




                                                                                                                                                                                        EDR




                                                                                                                                                                                                                                EDR
                                                                                                             1      2                          1
1    Birthing Units in HP/PHCC                                                                  6      6                   4     50      5           5      3      3     30      4       7    5      4      1     21      2 2         3      7      8      22
                                                                                                             2      2                          4
2    BEOC                                                                                       0      1     0      2      2     5       1 3         2      2      0     8       1       0    1      2      0     4       1 1         0      2      0      4
3    CEOC                                                                                       0      3     1      1      0     5       3 0         0      0      1     4       0       1    1      0      2     4       1 2         0      0      1      4
                                                                                                                                                                                                     1      1               1
4    HP new infrastructure                             2       1    2      2      2     9       0      1     0      0      0     1       3 7         5      5      5     25      7       8    4                   42      8           6      8      4      40
                                                                                                                                                                                                     3      0               4
                                                                                        1
5    PHCC                                              4       4    3      3      5             0      0     0      0      0     0       3 4         2      3      3     15      6       8    2      9      7     32      3 4         0      0      3      10
                                                                                        9
6    District Hospital                                 1       2    0      2      2     7       0      0     0      0      0     0       1 0         0      0      0     1       1       2    0      0      1     4       4 2         0      0      1      7

     District  Hospital     major         repair
7                                                      1       3    0      2      2     8       0      1     2      2      2     7       0 1         0      1      0     2       1       1    0      1      1     4       0 0         0      0      0      0
     /improvement or expansion

8    Zonal/Regional/Sub-regional Hospital              0       0    0      1      0     1       1      0     1      0      0     2       0 0         0      2      1     3       0       0    0      0      0     0       0 0         0      0      0      0


     Zonal/Regional/sub regional Hospital
9                                                      0       1    0      1      0     2       1      0     0      1      2     4       0 0         1      0      0     1       0       2    1      1      0     4       0 0         0      0      0      0
     repair and improvement or expansion



      Totals
      Birthing units:               123
      BEOC:                         21
      CEOC:                         17
      New HP:                       107
      New PHCC:                     76

                                                                                                                                                                                                                                                          91
ANNEX 14: Progress of Construction Work by Facility Type

CEOC sites
 SN   CEOC         Construction       Numbers   Base Year       Progress Status             Remarks
      Status
  1       Dang District Hospital         1        62/63     Completed
  2                    Udaypur           1        62/63     Completed
  3                      Siraha          1        62/63     Completed
  4     Accham Distrcit Hospital         1        62/63     Completed
  5                    Nuwakot           1        63/64     Completed
  6                       Gulmi          1        63/64     Completed
  7               Makawanpur             1        63/64     Completed
  8                     Morang           1        62/63     Completed
 10                     Bhojpur          1        64/65     Completed
 11                     Syangja          1        64/65     Completed
                                                                                           VERY SLOW
  9                      Sarlahi         1        63/64     Finishing works remaining       PROGRESS
 12                Arghakhanchi          1        64/65     Finishing works remaining    SLOW PROGRESS
 13                      Baitadi         1        64/65     Finishing works remaining    SLOW PROGRESS
 14                      Gorkha          1        65/66     Work upto sill level
 15                        Ilam          1        65/66     Work upto DPC level
 16                     Khotang          1        65/66     Work Ordered
 17                        Sindhuli      1        65/66     Work Ordered



 SN   Summary                           No.
  1   Completed                         10
  3   Near Completion                    3
 4    Under Construction                 4
                           TOTAL        17


BEOC sites
 SN   Status   of           BEOC      Numbers                         Status                Remarks
      Construction
  1          Kadarbona, Saptari          1        62/63     Completed
  2        Dhakdhai, Rupandehi           1        62/63     Completed
  3        Jogbuda, Dadeldhura           1        63/64     Completed
  4             Rajapur, Bardiya         1        63/64     Completed
  5      Tikapur Hospital, Kailali       1        64/65     Completed
  6            Mugu, Gamgadhi            1        62/63     Completed
  7            Shreegaun, Dang           1        62/63     Completed
  8              Bahuni, Morang          1        63/64     Completed
  9               Rampur, Palpa          1        63/64     Completed
 10      Raniban, Okhaldhunga            1        63/64     Completed
 11             Sindhupalchowk           1        63/64     Completed
 12         Rayapur, Rupandehi           1        63/64     Completed
 14                     Pyuthan          1        63/64     Completed
 15         Magargadhi, Bardiya          1        64/65     Completed
 16         Holleri PHCC, Rolpa          1        64/65     Completed
 13       Bulingtar, Nawalparasi         1        62/63     Finishing work in Progress   SLOW PROGRESS
 18         Kanchanpur, Saptari          1        65/66     Finishing work in Progress
 17   Bagauda PHCC, Chitawan             1        64/65     Worked upto sill level
           Chandra Nigahapu,
 19                 Rautahat             1        65/66     Worked upto DPC
 20             Lamahi Dang              1        65/66     Worked upto DPC


                                                                                                         92
 SN   Status     of         BEOC      Numbers                          Status             Remarks
      Construction
 21          Dist. Hospital, Dolpa        1         65/66    Worked upto DPC




 SN   BEOC Status                     Number


  1   Completed                          15
  2   Near Completion                     2
  3   Under Construction                  4
      TOTAL                              21


Birthing Centres

      Status    of         Birthing     Centre
 SN                                                Numbers   Base Year           Status
      Construction
  1              Darchula (Pasti and Dethala)         2        62/63            Completed
  2      Solukhumbu (Nele and Chulakhraka)            2        62/63            Completed
                  Rasuwa (Laharepauwa and
  3                                Shyafrubesi)       2        62/63            Completed
  4                    Doti (Daud and Dankot)         2        62/63            Completed
              Sankhuwasabha (Mamling and
 5                                  Tumlingtar)       2        62/63            Completed
 6             Bajhang (Khiratadi and Rayal)          2        62/63            Completed
 7          Taplejung (Hampang and Sinang)            2        62/63            Completed
 8             Pyuthan (Okharkot, Khawang)            2        62/63            Completed
 9           Salyan (Bazhkot, Lekhapokhara)           2        62/63            Completed
 10                         Bajura (Kolti, Tate)      2        62/63            Completed
 11                Mustang (Zarkot, Charang)          2        62/63            Completed
 12                      Jajarkot (Dalli, Sima)       2        62/63            Completed
 13                  Dolakha (Namdu, Fasku)           2        62/63            Completed
 14                Jumla (Chumchaur, Hasija)          2        62/63            Completed
 15                     Dolpa (Kaigaun Dolpa)         1        62/63            Completed
 16          Baitadi (Shreekot, Joshibungma)          2        62/63            Completed
                     Sindhupalchowk( Jalwire,
 17                             Dandapakhar)          2        62/63            Completed
 18        Dailekh (Naumule, Danda Parajul)           2        62/63            Completed
 19                        Kadarbona, Saptari         1        63/64            Completed
 20                             Aurahi, Siraha        1        63/64            Completed
 21               Trivuwan Basti, Kanchanpur          1        63/64            Completed
 22                           Bhumlutar, Kavre        1        63/64            Completed
 23                      Bodebarsain, Saptari         1        63/64            Completed
 24                          Rampur, Udaypur          1        63/64            Completed
 25                         Murkuchi, Udaypur         1        63/64            Completed
 26                          Sisniya HP, Dang         1        64/65            Completed
 27              Pokharinarayamsthan, Kavre           1        64/65            Completed
 28                             Dapcha, Kavre         1        64/65            Completed
 29                          Charikot, Dolakha        1        63/64            Completed
 30                      Kamlbazaar Achham            1        63/64            Completed
 31                           Pali Nawalparasi        1        63/64            Completed
 32                                Syuja, Dang        1        63/64            Completed
 33                            Letang, Morang         1        63/64            Completed
 34                        Madhuban, Sunsari          1        63/64            Completed
 35                                Kavre, Dang        1        63/64            Completed


                                                                                                    93
     Status    of    Birthing     Centre
SN                                          Numbers   Base Year             Status
     Construction
36                          Fulbari, Dang      1        63/64             Completed
37                   Santdanda, Achham         1        63/64             Completed
38                  Kafalbote, Panchthar       1        63/64             Completed
39                    Yashok, Panchthar        1        63/64             Completed
40                      Limba, Panchthar       1        63/64             Completed
41              Chyangthapu, Panchthar         1        63/64             Completed
42                   Yangam, Panchthar         1        63/64             Completed
43                   Embung, Panchthar         1        63/64             Completed
44                      Olane, Panchthar       1        63/64             Completed
45                  Thambuche, Rasuwa          1        63/64             Completed
46                   Parchyang, Rasuwa         1        63/64             Completed
47                       Bhutar, Udaypur       1        63/64             Completed
48                     Phattepur, Saptari      1        63/64             Completed
49                    Lekhgaun, Surkhet        1        63/64             Completed
50                     Barla HP, Achham        1        64/65             Completed
51              Majegaun HP, Rupandehi         1        64/65             Completed
52                       Mugu (Shreekot)       1        64/65             Completed
53                   Natharpu HP, Mugu         1        64/65             Completed
54               Dhungedhara HP, Mugu          1        64/65             Completed
55                   Shreekot HP, Mugu         1        64/65             Completed
56                       Pato HP, Saptari      1        64/65             Completed
57               Mayankhu HP, Udaypur          1        64/65             Completed
58     Sakhada HP (Chinnamasta), Saptari       1        64/65             Completed
59                       Shivalaya,Kavre       1        64/65             Completed
60                 Ravi PHCC Panchthar         1        64/65             Completed
61               Pathargada, HP, Saptari       1        64/65             Completed
62            Hanumannagar,HP, Saptari         1        64/65             Completed
63                  Chaimandu, Achham          1        63/64             Completed
64                    Dubarkot, Dhanusa        1        63/64             Completed
65                  Turmakhad, Achham          1        63/64             Completed
66                 Jayagath HP, Achham         1        64/65             Completed
67                   Kuchhi HP, Achham         1        64/65             Completed
68                  Mallekh HP, Achham,        1        64/65             Completed
69                 Pangu Bhugdeu,Kavre         1        64/65             Completed
                      Total Completed a       86
70                  Bairaban HP, Morang        1        65/66        Work upto RCC level
71                Paroha HP, Rupandehi         1        65/66         Worked upto RCC
72             Motipur PHCC, Rupandehi         1        65/66         Worked upto RCC
                        Near completion        3
73                   Golbazar HP, Siraha       1        65/66           Work ordered
74                    Viman HP, Sindhuli       1        65/66           Work ordered
75               Ram Gopal HP, Mahottari       1        65/66           Work ordered
76              Kolhuwa HP, Nawalparasi        1        65/66           Work ordered
77         Arthar Dandakharka HP, Parbat       1        65/66           Work ordered
78                 Pakhapani HP, Myagdi        1        65/66     Worked upto sill level & Wall
79                    Takam HP, Myagdi         1        65/66         Worked upto DPC
80              Madan Pokhara HP, Palpa        1        65/66           Work ordered
81                      Puja HP, Pyuthan       1        65/66           Work ordered
82                     Liwang HP, Rolpa        1        65/66           Work ordered
83                   Baraula HP, Pyuthan       1        65/66           Work ordered
84                 Jagannath HP, Dailekh       1        65/66           Work ordered
85                    Tribeni HP, Dailekh      1        65/66         Worked upto DPC
86                 Mehalmudi HP, Kalikot       1        65/66         Worked upto DPC


                                                                                                  94
      Status    of     Birthing    Centre
SN                                               Numbers   Base Year              Status
      Construction
87              NabaDurga HP, Dadeldhura            1        65/66             Work ordered
88              Ganeshpur HP, Dadeldhura            1        65/66             Work ordered
89                    Daiji HP, Dadeldhura          1        65/66       Finishing Works remaining
90           Chormara PHCC, Nawalparasi             1        65/66              Work ordered
92                Awalching PHCC, Surkhet           1        65/66              Work ordered
                          Under Construction       19



SN    Birthing Centre Status                     Number
 1    Completed but not yet handed over            86
 2    Near Completion                               3
 3    Under Construction                           19
      TOTAL                                        108



      Safe Abortion (CAC) Units

SN                                               Numbers     Base Year        Progress Status             Remarks
     CAC Construction Status
1    CAC building (Minor) Seti Zonal Hospital       1         2064/065           Completed
     CAC building (Major) Pohara Regional           1         2064/065
3    Hospital                                                                    Completed
     CAC building (Minor) Sindhuli Distrcit         1         2064/065
5    Hospital                                                                    Completed
     CAC building (Minor) Mahottari Distrcit        1         2064/065
6    Hospital                                                                    Completed
2    CAC building (Major) Koshi Zonal Hospital      1         2064/065    Up to first floor roofing     Slow Progress
     CAC building (Minor) Siraha Distrcit           1         2064/065    Finishing              work
4    Hospital                                                             remaining


SN   Summary                                       No.
1    Completed but not yet handed over              4
3    Near Completion                                1
4    Under Construction                             1
                                         TOTAL      6




                                                                                                                95

				
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