Kurmi, O.

Marahatta, S.B.

Pant, P.R.

Regmi, Pramod

Simkhada, P.

van Teijlingen, Edwin

Bournemouth University Research Online

  Editorial ISSN: 2091-1041 I VOLUME 3 I2017  JMMIHS-1 What can we learn from the Nepal Health Facility Survey 2015? Pramod R. Regmi1, Padam Simkhada2, Edwin van Teijlingen3, Puspa R. Pant4, Om Kurmi5, Sujan B. Marahatta6 1 Lecturer-International Health, Bournemouth University, UK; Visiting Research Fellow, Chitwan Medical College, Nepal; Visiting Fellow, Datta Meghe Institute of Medical Sciences, India  2 Professor of International Public Health, Liverpool John Moores University, UK; Visiting Professor, Manmohan Memorial Institute of Health Sciences, Tribhuvan University 3 Professor of Reproductive Health Research, Bournemouth University, UK; Visiting Professor, Manmohan Memorial Institute of Health Sciences, Tribhuvan University 4 Research Fellow, University of the West of England, UK 5 Assistant Professor, McMaster University, Canada 6 Editor JMMIHS; WHO-TDR Post Doc Research Fellow; Associate Professor, Manmohan Memorial Institute of Health Sciences, IOM-TU Background The Nepal Health Facility Survey 2015 (henceforth NHFS 2015) is a first survey of its kind in Nepal for data acquisition to monitor and evaluate the existing facilities and programmes related to population, health and nutrition. It is a comprehensive and nationally representative survey designed to: (a) establish the availability and delivery of health care services; and (b) examine the ability of facilities to provide quality health services in Nepal [1]. The survey provides rich information, from a large sample of health facilities (n=963) on the availability of  health care services, particularly on child health, maternal and new-born care, family planning (FP), sexually transmitted infections (STI), human immunodeficiency virus (HIV) and acquired immune-deficiency syndrome (AIDS), tuberculosis (TB), malaria and number of other diseases. Findings will be very useful for policy makers, development partners, technical agencies and programme managers to implement evidence-based interventions, in a process to help improve the quality of existing health services. Furthermore, the findings reported from this survey will allow us to compare the existing facilities and services in health sector from Nepal with other South Asian countries or similar low and middle income countries (LMICs) and, more importantly, provide a guideline that will lead to improvement of health care system in Nepal. The survey methods The research methods section is very detailed, describing the mixed-methods approach comprising: (a) quantitative methods during surveys of facilities; and (b) qualitative observation for consultations for antenatal care (ANC), FP and with sick children under the age of five; and (c) qualitative exit interviews to accompany the consultations and postpartum clients. With such range of quantitative and qualitative methods involving   Editorial ISSN: 2091-1041 I VOLUME 3 I2017  JMMIHS-2 representatives from health facilities and service users, we are surprised not to see a paragraph on research ethics, particularly the absence of research ethics approval from the Nepal Health Research Council. The NHFS 2015 obviously involved human subjects in this survey and when conducting health and medical research it is not only important to do the research ethically, but also to apply for prior ethical approval from the relevant authorities. We have noted this missing link in other health studies conducted in Nepal [2, 3]. It would be more informative for the researchers and wider communities to be provided with detailed information such as the tools used in this survey, whether the tools were developed in Nepali and if they were validated prior to conducting the survey. The significance of NHFS 2015 One of the important aspect of this survey is that it has included (and analysed) data from the 14 earthquake affected districts. We observed that in most health facility domains, the 14 earthquake-affected districts are not very different from the national average despite the considerable damage in the health infrastructures following the 2015 earthquakes [4, 5]. Surprisingly, the earthquake affected districts have better infrastructures (e.g. toilet facility, communication, internet facility, emergency transports) compared to the national average. Other services such as having own laboratory facility (21% vs. 25%), availability of child health services including vaccination (11% vs 24%), ANC facilities that provide Prevention of Mother-to-Child Transmission (PMTCT) services (9% vs 18%) in the 14 earthquake-affected districts are relatively poor compared to the national average.  We were interested to see that: "Practically all facilities (99%) reported that they offer some form of temporary modern method of FP; that is, the facility provides, prescribes, or counsels clients on any of the following temporary methods of FP: combined oral contraceptive pills, progestin-only injectable (Depo), implant (Jadelle), intra-uterine contraceptive device (IUCD), and the male condom. Private hospitals are least likely to offer FP services (70%)." Reflecting on this statement we suggest that (a) nearly all facilities offering some form of FP, may simply mean that in the smaller facilities condom are available but not necessarily the other contraceptives mentioned.  Secondly, the contribution made by private facilities on this topic is less that from public ones as is the case for "Antenatal care (ANC) services are equally widely available (98%). Private hospitals are less likely than the other facility types to offer ANC (90%)." Meanwhile, only about 30% health facilities have ANC Guidelines and staff trained for ANC. The NHFS 2015 has clearly shown that the health services in Nepal are not equally advanced across the country and also varied by ecological regions (e.g. mountain, hill, terai)   Editorial ISSN: 2091-1041 I VOLUME 3 I2017  JMMIHS-3 and facility types (e.g. public, private). Similarly, human resources in health care services in Nepal are another important area covered by the survey. Although their number is not clearly stated, stethoscope, sphygmomanometer, and weighing scale are repeatedly referred medical instruments for every service. In all health facility domains, the proportion of trained staff is low. For example, only 8% of private hospitals (against 32% nationally) have a trained service provider* for HIV testing and counselling services. A similar situation was observed in the TB services as only 6% of the facilities reported receiving in-service training during the 24 months preceding the survey. This might raise a question on the quality of services being provided. Implementing agencies should ensure that front-line health care providers are regularly trained and equipped with necessary tools to help facilitate in effective communication and also in developing necessary medication skills as required.  The survey reported that the availability of the national guidelines manual to counsel or treat diseases/ conditions and its use as a reference manual as recommended is poor. Particularly, the existence of these guidelines in the private health facilities is very poor. For example, the guideline for delivery care was available for only 1 in 5 health facilities (21%) on the day of the survey and this proportion for private hospitals is nominal (only 1%). Similarly, less than one-fifth (17%) of the health facilities had HIV testing and counselling guidelines. Treatment wallchart or the national clinical protocol for malaria, and HIV/TB co-infection guidelines were available to only limited facilities on the survey day, 10% and 5% respectively. As these guidelines are often changed in line with changes in technology or medical discovery, they should be regularly updated and their use as ‘guidance document’ should be made mandatory so that both service users and providers can benefit.  Final thoughts This important survey has formed a basis which can be useful for Government of Nepal (GoN), development partners, technical and implementing agencies to initiate discussion on how we improve and distribute specialised quality health services equally where they are most needed so that maximum number of people can benefit. Combined with periodic large population-based surveys such as Nepal Demographic and Health Surveys, the NHFS 2015 findings can help improve the quality of care in health facilities in Nepal by addressing imminent gaps revealed by the data. In the light of bourgeoning non-communicable disease (NCDs) such as diabetes, cardiovascular diseases, cancer and injuries in LMIC including Nepal [6,7], future health facility surveys should also attempt to capture specialised services available to prevent and manage these diseases/conditions. Future facility survey should also collect information around population coverage by these facilities. Such depth and   Editorial ISSN: 2091-1041 I VOLUME 3 I2017  JMMIHS-4  breadth of information will inform policy makers to plan for quality services delivery and required human resources for health in Nepal in the context of changing health needs and priorities under the Nepal Health Sector Programme (NHSP III) and the National Health Policy 2014 [8]. This is very important and timely as the target of Sustainable Development Goals (SDG) to reduce premature mortality by one-third from NCDs [9] will greatly depend on the concerted efforts of health facilities (for both health promotion and management) to provide  early and optimal care. As researchers we value good information. We do realise that good quality data comes at a cost and we appreciate that Nepal is willing to put the resources into important studies like NHFS 2015. *A facility was considered as having trained staff if at least one interviewed provider of HIV testing and counselling services reports that they received training related to their work during the 24 months preceding the survey Conflict of Interest The authors declare that they have no competing interests. Funding The authors received no financial support for the research, authorship, and/or publication of this article. References 1. Ministry of Health, Nepal; New ERA, Nepal; Nepal Health Sector Support Program (NHSSP); and ICF International. Nepal Health Facility Survey 2015 Final Report. Kathmandu, Nepal: Ministry of Health, Kathmandu; New ERA, Nepal; NHSSP, Nepal; and ICF International. 2016. 2. van Teijlingen E and Simkhada P. Failure to apply for ethical approval for health studies in low-income countries. Nepal J Epidemiol 2015; 5(3): 511-515. 3. van Teijlingen E and Simkhada P. Ethical approval in developing countries is not optional. J Med Ethics 2012; 38(7): 428-430. 4. Basnyat B, Tabin C, Nutt C, and Farmer P. Post-earthquake Nepal: the way forward.  Lancet Glob Health 2015; 3(12): e731-e732. 5. Mahato P, Regmi P, van Teijlingen E, Simkhada P, Angell C, and Sathian B. Birthing Centre Infrastructure in Nepal Post 2015 Earthquake. Nepal J Epidemiol 2015; 5(4): 518-519.    Editorial ISSN: 2091-1041 I VOLUME 3 I2017  JMMIHS-5  6. Mishra S, Neupane D, Bhandari P, Khanal V, and Kallestrup P. Burgeoning burden of non-communicable diseases in Nepal: a scoping review. Global Health 2015; 11(1):1. 7. Bhandari G, Angdembe M, Dhimal M, Neupane S, and Bhusal C. State of non-communicable diseases in Nepal. BMC Public Health 2014; 14(1):1. 8. Ministry of Health and Population. National Health Policy 2014. Kathmandu: Ministry of Health and Population. 2014. 9. United Nations. Transforming our world: The 2030 agenda for sustainable development. New York: United Nations. 2015. 

What can we learn from the Nepal Health Facility Survey 2015?

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What can we learn from the Nepal Health Facility Survey 2015?

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