Nepal Health Facility Survey 2021
Final Report
Key Findings of Nepal Health Facility Survey
The 2021 Nepal Health Facility Survey (2021 NHFS) is the second comprehensive assessment of health facilities in Nepal, bringing together the Ministry of Health and Population and health development partners to harmonize various health facilities. (The first occurred in 2015.) The 2021 NHFS was created to provide information on the availability of basic and essential health care services, as well as the readiness of health facilities to provide clients with quality services. The survey collected data on the availability of the following services: child health care, maternal and newborn care, family planning, services for sexually transmitted infections (STIs), HIV/AIDS, tuberculosis and malaria-related conditions, and services for noncommunicable diseases (NCDs) (diabetes, cardiovascular diseases, mental health conditions, and chronic respiratory diseases).
The 2021 NHFS assessed whether components considered essential for quality service delivery were present and functioning for each of these services. The NHFS sample for 2021 was intended to provide national-level representative results by facility type. Hospitals (both government and non-government), primary health care centers (PHCCs), health posts (HPs), community health units (CHUs), stand-alone HIV testing and counseling centers (HTCs), and urban health centers were among the facilities evaluated (UHCs). The survey was also designed to provide results that were representative of each of the seven provinces.
The following key findings of the 2021 NHFS are organized according to the topics of the chapters in this report.
FACILITY-LEVEL INFRASTRUCTURE, RESOURCES, MANAGEMENT, GENERAL SERVICE
READINESS, AND QUALITY OF CARE
· Three-quarters of all health facilities in Nepal provide a comprehensive range of basic client services (outpatient curative care for sick children, child growth monitoring, child vaccinations, any modern method of family planning, antenatal care [ANC], and services for STIs). This is a significant improvement over the 2015 NHFS, when only about 6 in 10 facilities were assessed as having a complete package of basic services.
· In 2021, facilities were slightly more likely (17%) than in 2015 (11%) to have all six basic amenities (regular electricity, an improved water source, visual and auditory privacy, a client latrine, communication equipment, and emergency transport) deemed necessary for providing quality client services. More than three out of ten facilities in Bagmati province (31%) have all basic amenities, compared to less than one out of ten in Madhesh (8%) and Karnali (7%).
· Between the 2015 and 2021 surveys, the availability of personal protective equipment in health facilities improved. For example, the percentage of facilities that had masks on hand increased from 19% to 82%, and facilities were nearly six times as likely to have gowns/aprons on hand in 2021 (53% vs. 9% in 2015).
· With the exception of emergency transport (80%), less than half of all facilities in Nepal have any of the supplies and services considered essential in providing COVID-19 care (self-inflating bag and mask, pulse oximeter, oxygen-filled cylinders, inpatient care, overnight observation beds, communication equipment).
· Most health facilities have limited capacity for basic diagnostic testing; facilities are most likely to have capacity for pregnancy (43%) and malaria (36%), but the least likely to have HIV testing capacity (5%).
· Half of the facilities hold regular management meetings, and a similar percentage of these meetings include members of the community.
· In 2021 (55%) of facilities reported both routine staff training and personal supervision, compared to 69% in 2015.
· Only 6% of facilities reported having an outbreak management plan, 36% had a financial audit completed in the previous fiscal year, and 69% of PHCCs and hospitals use the government's social security health insurance scheme.
CHILD HEALTH AND IMMUNIZATION SERVICES
· Virtually all health facilities in Nepal offer curative care for children, and around 9 in 10 facilities offer growth monitoring and routine vaccination services. Routine vitamin A supplementation is offered in 88% of facilities.
· Outpatient curative care for sick children and growth monitoring services are available 5 or more days per week in almost all health facilities offering these services.
· Very few facilities delivering curative care for children have all of the equipment and trained staff considered necessary to provide quality care for sick children, with facilities most often lacking length or height boards (39%), pediatric stethoscopes (13%), and staff with training in maternal, infant, and young child nutrition (12%).
· Nine in 10 facilities providing child curative care have alcohol-based disinfectant and latex gloves, and 8 in 10 have medical masks. Overall, however, only 1% have all of the infection prevention items needed to deliver services safely.
· Laboratory testing capacity is also limited, with only 12% of facilities able to conduct hemoglobin and malaria testing and stool microscopy.
· Routine vaccinations are available at least 1–2 days per week in more than 8 in 10 facilities that offer vaccinations. Facilities generally obtain the vaccines they administer from a higher-level center and store the vaccines only for a short time as per policy. Only 6% of facilities have all of the components necessary for quality immunization services.
· Around two-thirds of providers of child health services have received recent supervision, and around 1 in 5 providers have received recent in-service training related to child health.
· Providers assessed all three main symptoms of childhood illness (fever, cough/difficulty breathing, and diarrhea) in 28% of observed consultations. They checked for all four major danger signs (ability to eat or drink anything, vomiting, convulsions, and unconsciousness/lethargy) in less than 1% of consultations.
FAMILY PLANNING SERVICES
· A large majority (98%) of health facilities in Nepal offer (i.e., provide, prescribe, counsel, or refer clients on) at least one of the following temporary modern methods of family planning: oral contraceptive pills, male condoms, injectables (Depo), implants, or intrauterine contraceptive devices (IUDs). Around 4 in 10 facilities offer male or female sterilization.
· 95% or more of all facilities offering modern family planning methods provide male condoms, oral contraceptive pills, or injectables to clients at the facility. However, less than half of facilities offering modern family planning methods are able to provide implants (41%) or IUDs (29%). Female or male sterilization services are provided at only 2% of the facilities where modern family planning methods are offered.
· 92% of health facilities that provide temporary family planning methods actually had every method they provide available at the facility on the day of the NHFS visit.
· A majority of facilities offering family planning services have most of the basic equipment required for quality service delivery; however, only around 1 in 5 have the national family planning guidelines available or have staff who received in-service training relating to family planning in the past 24 months.
· Overall, the environment for family planning counseling is poor. Visual and auditory privacy and confidentiality were assured in only 12% of all family planning consultations observed in the survey.
· Method-specific side effects were discussed in only 38% of all observed family planning consultations. There was almost no discussion of STIs or condom use in the consultations.
· Two-thirds of interviewed family planning providers reported that they had been personally supervised during the 6 months before the survey. Less than 1 in 10 providers had had any in-service family planning training in the 24 months before the survey.
ANTENATAL CARE
· Almost all (98%) health facilities in Nepal offer ANC services.
· Three quarters or more of facilities offering ANC have the basic equipment required to deliver quality services, with the exception of a tape to measure fundal height. A majority also have essential infection control items and supplies except for a needle cutter and a waste receptacle.
· Only around one quarter of facilities offering ANC had staff with recent training in ANC available on the day of the assessment, and relatively few had either ANC service (11%) or infection prevention (7%) guidelines.
· More than 6 in 10 ANC providers had received personal supervision in the 6 months preceding the survey.
· Almost all health facilities offering ANC (95%) had essential ANC medicines (iron and folic acid combined tablets and albendazole tablets) available.
· Testing capacity was much more limited, with only around 1 in 4 facilities offering ANC care able to conduct hemoglobin, urine protein, or urine glucose tests. Only 3% of facilities were able to conduct all three tests.
· In the great majority of the ANC consultations observed in the NHFS, the client’s blood pressure (93%) and weight (89%) were assessed. Providers checked the fetal position and listened to the fetal heartbeat in around 7 in 10 consultations.
· Two-thirds of ANC clients were given or prescribed iron or folic acid, and around one-fifth received or were prescribed albendazole.
· Clients mentioned or providers asked and/or counseled about at least one of eight risk symptoms in 63% of the observed ANC consultations, most often severe abdominal pain. All eight risk symptoms were discussed in less than 1% of consultations.
· In general, facilities offering ANC lacked trained staff, diagnostics, and medicines needed for the
provision of malaria services.
· Only 11% of hospitals and PHCCs offering ANC provided any prevention of mother-to-child transmission (PMTCT) of HIV services.
DELIVERY AND NEWBORN CARE
· Just over half of health facilities in Nepal provide normal vaginal delivery services. As expected, cesarean deliveries are available at only a small proportion of facilities (5%), mainly hospitals.
· Eight in 10 facilities that offer normal delivery care services have emergency transport available, and a majority of facilities (66%–99%) have all of the equipment items necessary for providing quality care other than a vacuum extractor (23%) and a vacuum aspiration or manual vacuum aspiration kit (21%).
· Only around one-fifth of facilities offering normal vaginal delivery services had all of the medicines essential for quality delivery care. Facilities were even less likely to have all of the essential medicines for newborn care (2%).
· Around 3 in 10 facilities that offer normal vaginal delivery services had at least one interviewed staff member with recent training in delivery care, and only 13% had guidelines for delivery care available on the day of the assessment.
· Only a minority of hospitals and PHCCs offering normal vaginal deliveries had performed all basic emergency obstetric and newborn care (BEmONC) signal functions (13%) or all comprehensive emergency obstetric and newborn care (CEmONC) signal functions (11%) at least once in the 3 months preceding the survey.
· 90% or more of facilities reported that they routinely carry out a number of essential newborn care functions, including keeping the infant warm, starting breastfeeding soon after birth, and putting the baby skin to skin on the mother’s abdomen.
· 63% of interviewed delivery care providers received personal supervision in the 6 months before the assessment, but only 16% received in-service training during the 24 months preceding the assessment.
· Only a minority of women reported that they received comprehensive checks and advice on key aspects of postpartum (8%) or newborn (19%) care before they were discharged from the facility where they delivered.
· 23% of postpartum women interviewed after their delivery reported that the staff had scolded them or treated them disrespectfully.
HIV/AIDS AND SEXUALLY TRANSMITTED INFECTIONS
· One in 20 health facilities in Nepal have a system to support clients needing HIV testing and counseling. Around three quarters of these facilities are able to offer HIV testing at the facility to clients.
· Relatively few facilities (9%) offering HIV testing and counseling services had all of the items needed for delivering quality services available on the day of the assessment visit.
· Similarly, few facilities offering HIV testing (10%) had all infection prevention items at the service site on the day of the NHFS assessment. In facilities offering laboratory testing, 18% had all infection prevention items available in the laboratory.
· Slightly more than half (56%) of the HIV service providers interviewed in the NHFS reported receiving personal supervision in the 6 months before the survey. However, very few had recent training related to either HIV counseling (3%) or testing (2%).
· 8% of all health facilities in Nepal offer at least one HIV/AIDS care and support services
· 13% of hospitals and PHCCs offer antiretroviral therapy (ART) services.
· More than 8 in 10 facilities offer STI services. A lack of availability of trained staff, STI guidelines,and testing capacity serves as a major constraint on the provision of quality STI services.
NONCOMMUNICABLE DISEASES
· In Nepal, 96% of all health facilities provide services for the diagnosis and/or management of chronic respiratory diseases, and 90% offer services for cardiovascular diseases.
· Almost three-quarters of all health facilities provide services for diabetes diagnosis and/or management, which is more than three times the proportion of facilities providing these services during the 2015 NHFS (21%).
· The availability of guidelines for service provision and trained personnel is consistently low in facilities providing services for the three NCDs.
· Basic equipment such as a blood pressure apparatus, stethoscope, or weighing scale is available in most facilities offering services for the three NCDS. Other equipment, such as height boards, peak flow meters, spacers for inhalers, and essential medicines, is less available.
· Only one-quarter of all health facilities in Nepal offer mental health services.
Source: Government of Nepal Ministry of Health and Population, Nepal Health Facility Survey 2021: Final Report, 2022. Available at: Nepal Health Facility Survey 2021.pdf (mohp.gov.np)
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