From Committee to Care

Supporting Communities in Nepal to Manage Local Health Systems

Text by RTI staff, photos by Jacob Kasell, USAID Health for Life project

It’s one of the busiest days of the month at the local health facility in Raniyapur, a village in the marshy plains of southern Nepal. The first floor of the green cement building bustles with mothers, fathers, children, and babies who have come for a bi-monthly vaccination clinic.

Circulating between different consultations rooms while holding their medical records and vaccination cards, parents take this opportunity to seek health advice for themselves and their children.

For Sahira Khan, a female community health volunteer in Raniyapur for the past 25 years, such clinic visits by locals were unheard of just a few years ago. “Before, people did not come to this health facility,” she says. “And women didn’t even want to take simple things like iron tablets because they were afraid it would cause infertility.”

Sahira Khan (left); a mother brings her child in to get vaccinated at Raniyapur health post (right)

Perceptions are changing; the availability of quality health services combined with increased community outreach activities have helped improve the health of mothers and children . It’s a change that Khan credits to transformational work by Raniyapur’s Health Facility Operations and Management Committee (HFOMC), a local committee led and managed by community members.

***

As part of an ongoing process in Nepal to decentralize the powers of the government, a framework agreement was signed in 2013 that provides local authorities with greater responsibility and decision-making power regarding health in their communities.

That framework details the roles and responsibilities of village-level HFOMCs. Representative of all community members, these decision-making groups work with local government to identify health service gaps, oversee health planning, and mobilize funds and resources. The goal is to ensure local communities take greater responsibility in managing local health facilities and health programs.

Raniyapur’s HFOMC gathers upstairs in the Raniyapur Health Post

USAID’s Health for Life project — implemented by RTI International — has supported the revitalization of HFOMCs in vulnerable and disadvantaged communities. Health for Life is a key part of USAID’s efforts to strengthen the Government of Nepal’s capacity to plan, manage, and deliver high-quality family planning and maternal, newborn, and child health services (read more on our project and impact below this story).

***

As vaccination day continues downstairs at Raniyapur Health Post, the HFOMC’s nine members gather upstairs to review last year’s plan and discuss the upcoming health planning process for this year.

In April 2015, Health for Life familiarized Raniyapur’s HFOMC with their roles and responsibilities, and also ensured that the group established itself according to guidelines in the national framework.

“The HFOMC follows policies set up by the government, but Health for Life provides the support to translate those policies into reality,” says Devi Lal Chaulagain, HFOMC chairperson.

The framework requires including members of marginalized and disadvantaged groups, who are much less likely to go for antenatal and postnatal checkups, deliver at a birthing center, or use family planning.

Two girls play badminton outside Raniyapur’s madrasa

Raniyapur is one of the most disadvantaged villages in its district in terms of the health status of its 6,500 residents — about three-quarters of whom are Muslim, a minority group that has historically been marginalized in Nepal.

Health for Life also worked with the HFOMC to create a five-year strategic health plan, which provided much-needed prioritization and resources to the facility’s operations, according to the head of the health facility, Prithvinath Yogi. The plan was endorsed by local government in 2014, and as a result, the local health budget increased from USD 490 in 2014/15 to USD 1,090 in 2016/17.

The plan was underpinned by the results of a quality improvement self-assessment conducted in the health facility — an effort also supported by technical assistance from Health for Life.

Gaps identified in the assessment and addressed in the plan have already produced very practical outcomes. For instance, the HFOMC partnered with an organization that provided a delivery bed for the birthing center. And through a partnership with UNESCO, they recently carried out a project to improve the health facility’s water supply.

“We have been mobilizing the community to seek care, but what we really needed to do was improve quality in the health facility — and we did. We trusted that if services are good, people will motivate others to come and also receive health services,” says Chaulagain.

As part of its new and improved services, the health facility provides 24-hour delivery services for pregnant women, offers comprehensive family planning counselling and services, and has established outreach clinics in remote communities.

****

Statistics show that their work is paying off.

Sahijaha Khan and her children

Since 2013, when the local health governance framework was implemented, the percentage of institutional deliveries conducted by skilled birth attendants at Raniyapur Health Post more than tripled from 22 percent to 79 percent of all live births. And pregnant women who attended all four antenatal checkups more than doubled from 39 percent to 91 percent in 2015/16. DPT3 and measles vaccinations are above 85%.

For Khan, who represents female community health volunteers on the HFOMC, behind these numbers lie the stories of real women in her community — women like Sahijaha Khan, who brought her healthy 16-day-old girl to the health post for vaccination. She attended all four of her antenatal checkups and delivered her child at the same facility.

“I no longer have to send pregnant women all the way to the hospital to receive quality care,” says Khan. “Bad things used to happen more often.”

For Maulana Akil Ali Sheikh, a religious leader and schoolteacher who represents teachers on the HFOMC, family planning is where he has seen the biggest impact — since 2013/14, the contraceptive prevalence rate has increased by more than 30 percent.

Maulana Akil Ali Sheikh, outside the madrasa where he teaches.

“This would have been unheard of years ago,” Sheikh says outside the madrasa where he has taught Arabic and Urdu for 28 years. Family planning was once strictly prohibited among the Muslim community, but now both men and women come to him for family planning advice. “Now people listen. They didn’t before,” says Sheikh.

His family has lived in Raniyapur for five generations, and his standing in the community makes his voice a powerful one. His tactics are varied and mostly interpersonal — for example, he says women in the community are still reticent when it comes to discussing contraceptives, so he incorporates family planning tips into traditional storytelling sessions at mealtimes.

Raniyapur is not alone in seeing improvements in local health. In its last reporting period, Health for Life found that about 96 percent of HFOMCs in the 141 high-priority areas the project supports met key functionality criteria — most were non-functional at the start of Health for Life support.

****

The HFOMC in Raniyapur has high ambitions to accelerate progress

“We aim to make Raniyapur a community that is fully-immunized, with zero mothers delivering at home, and with no open defecation,” says Yogi. “We can only meet these goals with a strong, integrated, and democratic HFOMC.”

When asked how the HFOMC will continue to function when Health for Life support ends, Chaulagain is optimistic. “We think it we can maintain our progress because a certain level of capacity, confidence, and a good image among the community has already been built.”

For Khan, there is no question that the HFOMC must continue its work. “There are no closing hours for us community health volunteers. Before, it used to feel like we were working on our own, but now we have people who work with us. We are not alone anymore.”

Sahira Khan and members of her family

About Health For Life & it’s impact

As a key part of its efforts to strengthen the Government of Nepal’s capacity to plan, manage, and deliver high-quality family planning and maternal, newborn, and child health services, USAID’s Health for Life project — implemented by RTI International — directly addresses key health system constraints in local health systems governance; data for decision making and evidence-based policy development; human resources management; quality improvement systems; and knowledge and behavior change. In addition to contributing to Nepal’s next 5-year health sector strategy, the project works at the district level in 14 districts in the Mid-Western and Western regions, where it’s equity-based approach strengthens district and village health systems and helps identify and implement best practices. After the devastating earthquakes in April and May 2015, H4L began supporting the MoH in 10 of the 14 most-affected districts to improve health system governance, improve evidence-based planning, budgeting and policy making, and to institutionalize a national system for quality assurance and improvement.

Health for Life has helped develop a Collaborative Framework for Local Health Governance between the Ministry of Health and Ministry of Federal Affairs and Local Development and helped mobilize and allocate USD 783,500 to improve access to and use of quality health services in 344 villages in FY 2016–17. HFOMCs have been revitalized and made functional to improve health facility performance. In high-priority VDCs 92% of health facilities have expanded services and 96% have upgraded quality of services. The project’s support has led to developing, piloting and scaling up a nationwide quality improvement system for peripheral health facilities, and revised curriculum for Auxiliary Nurse Midwives to improve Skilled Birth Attendant competencies, strengthened implant and IUCD services, increased use of uterotonics among pregnant women, and introduced tracking of pregnant women by mobile technology in selected sites such that 65.2% received ANC per protocol, 88.5% of post-partum women decided to use FP method and the percentage of Dalit (marginalized and disadvantaged) women that delivered at HFs increased from 26.4% to 42.3%.

To improve health seeking behaviors, Health for Life helped develop and launch a text messaging initiative, m4ASRH, that reached 181,577 adolescents and youths with sexual and reproductive health messages (2,683,250 messages from users and 4,932,664 responses to users), reached more than 26,000 students in 141 schools and aired a 12-episode serial, Smart Sathi, to improve their sexual and reproductive health knowledge. The project also supported 1,404 radio program episodes resulting in improved awareness and demand for health services (FP/MNCH), and held over 300 public hearings conducted in VDCs to strengthen accountability. Most recently, Health for Life has revitalized HFOMCs in the most damaged villages of 10 earthquake-affected districts, prepared village health recovery plans and established quality improvement teams at health facilities