Memorandum submitted by the Support to
Safe Motherhood in Nepal
1. SUMMARY
— Concerted efforts have been made
by the international donor community and the Government of Nepal
to improve maternal health.
— There is sufficient evidence in Nepal
to indicate that the maternal mortality rate decline is real and
likely to carry on.
— Strengthening and improving the maternal
health sub-sector has wide reaching impact on the health sector
reform as a whole.
— The DFID-funded Support to Safe Motherhood
Programme working closely with Government of Nepal is making a
vital contribution to the strengthening of maternal and perinatal
health services and decline in maternal mortality.
2. INTRODUCTION
The United Kingdom's Department for International
Development (DFID) has been working with the Government of Nepal
to reduce maternal mortality and improve maternal and newborn
healthcare in Nepal for over 10 years. Since 2004, this has been
in the form of the Support to Safe Motherhood Programme (SSMP),
a £20 million programme funded by DFID, which has been working
closely with the Government to develop and implement an integrated
package of inputs within the national healthcare system. SSMP's
goal is improved maternal and newborn health and survival, especially
of the poor and excluded. The programme follows and builds on
the DFID supported Nepal Safer Motherhood Project (NSMP), 1997-2004,
which together represent a major contribution of DFID's to accelerating
progress towards MDGs 4 and 5.
3. PROGRESS IN
REDUCING MATERNAL
DEATHS
The SSMP story is of particular interest to
the IDC Inquiry into Maternal Health in light of recent evidence
published in the final report of the Nepal Demographic and Health
Survey (NDHS) 2006, that suggests a significant decline in the
maternal mortality rate over this period, from 539 per 100,000
births in 1996 to 281 per 100, 000 live births in 2006. It is
important to examine the evidence suggesting this decline further
and SSMP is currently undertaking this further analysis. Despite
debate over the actual level of the maternal mortality change
and the magnitude of decline, indications are that there is sufficient
evidence to suggest a real decline has occurred. In light of the
investments in strengthening safe motherhood over the past 10
years and continued commitment to Safe motherhood by donors and
the Government Nepal, evidence suggests that the decline is likely
to continue.
This evidence includes:
— An almost three fold increase in
the caesarean section rate between 1996 and 2006 (from 1.0% to
2.7%). These would have been carried out for women with prolonged/obstructed
labour, eclampsia, ante-partum haemorrhage and uterus rupture,
and thus are likely to have been life saving interventions.
— An increase in delivery by health
professionals (doctor, nurse and auxiliary nurse midwife) from
9.0% in 1996 to 18.7% in 2006.
— An increase in the percentage of
deliveries in a health facility from 7.6% in 1996 to 14.0% in
2006.
— A reduction in the total fertility
rate, from 5.1 in 1996 to 3.1 in 2006. In simple terms the total
fertility rate is defined as the total number of live births a
woman has, on average, in her lifetime. A reduction in this is
associated, not only with a reduced exposure to the risks of childbirth,
but also improved overall health status, which reduces the risk
of death.
— The legalisation of comprehensive
abortion care in 2002 (implemented from December 2003) which has
been associated with over 80,000 women accessing safe abortions
between April 2004 and December 2005, representing a huge reduction
in risks from abortion complications.
— A decrease in the percent reporting
to have taken no Antenatal Care (ANC) from 33% to 12% between
1996 and 2006.
— A marked increase in the use of a
safe delivery kit in home delivery in both urban and rural area
between 1996 and 2006; urban: 4.41 times, Rural 10.28 times.
— Increase in equity (across the wealth
quintiles) in the % of women accessing 3+ ANC visits; the % of
births assisted by a skilled attendant and the % of births in
the facility (see graphs below from Demographic and Health Surveys
2001 and 1996).
GRAPHS SHOWING PROPORTION OF BIRTHS PER WEALTH
QUINTILES (2001 AND 1996)
4. WHAT HAS
SSMP HELPED TO
ACHIEVE?
The factors that contribute to high rates of
maternal and perinatal mortality are; a scarcity of skilled human
resources; not enough and poorly maintained physical health infrastructures;
unpredictable and scarce supplies of essential equipment, supplies
and drugs; weak referral systems and inadequate blood supplies.
In addition, health seeking behaviour reflects socio-economic
and cultural inequalities. Even where care does exist the barriers
to access result in delays in accessing health services with many
women and their families not accessing them at all.
SSMP works on all fronts, translating proven
interventions to strengthen the health system and quality of health
service delivery from the foundations while delivering an intensive
programme working with communities to increase demand amongst
the most socially excluded. SSMP supports the implementation and
evaluation of the nationwide maternity incentive scheme, which
provides all women who deliver at a facility with a cash payment
to help cover costs incurred in accessing the facility. The scheme
also pays an incentive to trained health workers who support women
to deliver in facilities and at home and provides free delivery
for complications in the most disadvantaged areas in the country.
Among SSMPs contributions to the strengthening
of maternal and perinatal health services and decline in maternal
mortality are the following:
— Strengthened policy development and
planning, with endorsement in 2006 of the National Policy for
Skilled Birth Attendance, Revised National Blood Policy, Essential
SMNH Package and National SMNH Long Term Plan (2006-17), all of
which are evidence based and reflect recent developments in global
thinking and Nepal experiences. These documents have become the
basis for implementation of district SMNH planning and programming.
— Safe abortion services are now available
in 70 out of the 75 districts from 167 listed sites (89 government
and 78 private). Over 132,205 women have received services since
legalisation, 83% of these from non-government sites and 17% from
government sites.
— The development and strengthening
of 36 comprehensive emergency obstetric care facilities and 40
basic emergency obstetric care facilities, which have been developed
and strengthened across the country.
— Current infrastructure support through
SSMP Financial Aid (FA) to 127 sites, of which 90 are for two-room
additions at 80 Health Posts (HPs) and 10 Primary Health Care
Centres (PHCCs), to enable the provision of locally accessible
24-hour birthing services. So far 27 have been completed and the
rest are expected to be completed soon. The SSMP FA is also providing
support for construction at 18 BEOC sites, 13 CEOC sites, 3 major
CAC sites and 3 minor CAC sites, including new sites planned for
the year 2007-08.
— Working with the Logistics Management
Division (LMD) to establish strict technical inspection of samples
to ensure compliance with the specifications and good quality
before awarding contracts. SSMP has also been exploring opportunities
for co-operation with laboratories in adjoining countries for
quality assessment where such service is not available in Nepal.
— Prioritising support for finalising
and implementing the maintenance strategy, to halt the current
wastage caused by a "crisis maintenance" approach.
— Continuing to support the Department
for Urban Development and Building Construction (DUDBC) in establishing
a co-ordination mechanism between the DUDBC district office responsible
for implementing construction work, and the local facility management
committees (users) to ensure local ownership and involvement.
— Working closely with DUDBC, SSMP
has completed a database inventory of existing government health
infrastructures containing details of their physical condition
and with the capacity to provide information on the number of
different types of facility, quality, land ownership details,
physical condition, size and many other details. This major breakthrough
made it possible to develop a maintenance strategy, which was
presented during the recent Joint Annual Review (JAR). The strategy
has a clear plan and estimated budget for regular maintenance,
repair and reconstruction work required to ensure all government
health infrastructures are functioning, see Annex 19 for extracts
from the strategy document. The inventory will also support planning
of future infrastructure expansion, upgrading, renovation and
reconstruction needs and can be used to support pro-poor (inclusive)
planning and many other purposes.
— Advocating for an equipment maintenance
policy, with the support of other stakeholders. The standard equipment
list will be used to develop a database of equipment at different
facilities, as a base for development of an equipment maintenance
plan. This will save resources currently wasted replacing major
equipment that has been allowed to deteriorate.
— Strengthening government systems
and capacity to improve the supply and procurement systems for
essential drugs and commodities, SSMP is working to ensure year
round availability of SMNH drugs where needed.
— Working to improve infrastructure
tendering practices, which are currently affecting quality by
allowing domination by a few powerful cartels.
— Advocating with the government to
amend regulations that promote the practice of always awarding
contracts to the cheapest bidder, which can compromise quality.
— Addressing Social Inclusion both
in policy development and programme implementation through the
Equity and Access. This involves implementing district level activities
to stimulate demand and increase the access of women to Maternal
and Neonatal Health (MNH) services, with particular emphasis on
those from poor and excluded communities.[173]
The EAP operates through a network of 26 independent Equity and
Access Support Organisations (EASO) in 10 districts[174]
providing intensive support to a total of 120 VDCs and 7 Municipalities.
— Deliveries supported by health workers
have increased 6% since the launch the scheme two years ago and
the increase in the numbers of women delivering at a facility
and with the support of a health worker continues to grow. A total
of 111,745 deliveries between July 2006 and February 2007 involved
the provision of cash incentives under the scheme.
5. THE WAY
FORWARD
In the early years, DfID funded support to safe
motherhood activities focused more directly on the sub-sector
in particular. Today the Government of Nepal Family Health Division
supported by SSMP is driving forward a number of initiatives which
are not only critical to efforts to reduce maternal and perinatal
mortality but also directly benefit the wider health sector.
If you mend the system that supports the delivery
of strong safer pregnancy services, you contribute fundamentally
to building the foundations of the health sector as a whole. All
health services need strong, maintained infrastructure. Issues
of recruitment and retention of human resources are not unique
to safer pregnancy; reliable supplies, quality and well maintained
equipment are needed in all areas of health care. It could be
suggested that maternal mortality be used as a general indicator
of the strength of a health sector. The structures, processes
and mechanisms needed to establish a framework to get this right
are not unique to one sector but maternal and neo-natal death
rates will not decline without strengthening every aspect of health
service delivery unlike many health conditions which can be prevented
or treated with a more vertical approach. In addition in Nepal
as in many parts of the world over 90% of women will quite predictably
become pregnant at least once and every person born was once a
neonate. These services touch more lives than any part of the
health sector. For international aid to concentrate on strengthening
maternal and neonatal health care structures and systems to reduce
maternal mortality, they have the knock on effect of improving
the health infrastructure of a country more widely. What this
programme demonstrates is the extent to which strengthening this
sub-sector has wide-reaching impacts on the health sector as a
whole.
The challenge ahead now is one of long-term
sustainability. How does the Government of Nepal and international
donor community continue this momentum towards achieving MDGs
4 and 5 beyond 2009 when SSMP ends?
173 Socially excluded groups in the context of health
services include: Women in general; the poor; Dalits; Janajatis;
Religious minorities; people living in remote areas; internally
displaced people; PLWA; and Disabled. Back
174
Districts are: Dandeldhura, Dailekh, Surkhet, Baglung, Parbat,
Myagdi, Rupendhi, Nawalparasi, Chitawan, Morang. Back
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