Improving outcomes for children under two in rural Nepal

Sachit Pandey, MS, Mobile Systems Engineer & David Citrin, PhD, MPH, Director of Impact

Improving child mortality rates is imperative to building robust maternal and child healthcare delivery systems globally. Indeed, there is perhaps no clearer measure of the inability to deliver on equitable and accessible healthcare than children dying from preventable deaths.

Globally, the mandate to do better for children around the world is clear. As the global health and international development communities transition from the United Nations 2015 Millennium Development Goals to the Sustainable Development Goals, ensuring healthy lives and wellbeing for women and children remain central to the new framework. However, in settings where births and deaths are not recorded with regularity, the measurement of child mortality is still a key challenge. In the absence of such vital registration systems, new ways to assess child health are needed.

In rural Nepal, where Possible operates an integrated healthcare delivery model in partnership with the Government of Nepal, we have developed an innovative approach to measuring under-two mortality (U2M) that integrates surveillance with the routine delivery of longitudinal care carried out by a network of Community Health Workers (CHWs). CHWs run an Android-based mobile application developed in collaboration with our innovation partner Dimagi, which allows for the geo-tagging of households and unique identification of patients in order to deliver longitudinal care, while also prospectively collecting key population health data over time, including institutional birth rate and U2M.

Tara, a Community Health Worker Leader, geo-tagging a home.

While, under-five mortality (U5M) is a more frequently reported indicator of child health globally — used largely for cross-country comparisons — the accurate estimation of this indicator requires repeated surveys of mothers asked to remember the dates of birth and deaths of children over the course of several years, and thus is subject to recall bias as well as other methodological and analytical constraints. Furthermore, as overall childhood mortality declines worldwide, as it has in Nepal, deaths tend to concentrate in the first two years of life. In discussions with our government partners and local Community Advisory Board, we felt we needed to understand child mortality at a finer-grain spatial and temporal level if we were to improve quality of care in our catchment area population. Together with the Government of Nepal, we are committed to developing a national delivery science program that can aid in district and national-level public sector healthcare system strengthening. The near-real-time measurement of child mortality is central to these improvement efforts.

Each home gets a Household ID number.

The results from our most recent census indicate a 12% observed reduction in U2M (from 36.9 per 1000 live births to 32.5) in our catchment area since the last measurement in February 2015. While we believe this represents a true reduction in actual child death, here we resist “immodest claims of causality,” in the words of one of our organization’s advisors, Dr. Paul Farmer. Instead, we are guided by the notion of humility in the face of complexity, acknowledging that our approach to building this sensitive surveillance system is still undergoing refinement, and that we have a ways to go to further drive down this number. As Adams et al (2015) remind us, new ways of collecting data can create a greater sense of commitment around more accurate reporting and innovation around metrics, but more importantly these efforts re-center the mission of keeping every woman and infant alive.

Notably, we have also increased our ability to detect stillbirths by 150%, which reveals both a more sensitive survey instrument, as well as the increased trust between our Community Health Workers and the families they serve. It will be the deepening of these relationships with government partners and local communities that will further our ability to deliver high quality care to women and children, and assess our overall impact to ensure we continue to strive to do better.