Service Provision Quality
assessment studies of 16 health facilities in Nepal
between 1997 and 2000 identified many problems with the
quality of care in services provided in the country's
maternal health sector. The quality of midwifery and
obstetric care fell below WHO's standard 'Ten Elements
of Quality of Care'. Facilities and infrastructure were
poor, essential drugs and supplies were lacking, hospital
management and support systems were weak and staff morale
was low. The technical competence of staff was seen to
be below the level specified in national clinical protocols
and there was a shortage of good quality training sites
for midwifery and emergency obstetric care (EmOC).
The 'Whole-Site Support Package'
The Nepal Safer Motherhood Project's (NSMP) approach to
improving EmOC services
recognises that training and a supply of 'hardware' inputs
are not, alone, enough to bring about the social and managerial
dynamics required for meaningful change. Accordingly, the
concept of 'whole-site support package' was developed.
- Improvements to infrastructure (such
as safe electricity, running water, building renovation
and waste pits) being designed in consultation with service
- Appropriate equipment, that is simple to operate
and maintain, being provided for operating theatres
and maternity wards. Examples include incubators and
lights that can run on car batteries.
- Foundation For Change training
for the staff team, from directors and support staff to sweepers
and peons (ie across the whole workforce).
- Infection control training for all staff.
- A 24-hour blood transfusion
service, in conjunction with the Nepal Red Cross Society (NRCS).
- Updating the technical skills of all service providers, from
doctors to front-line workers and support staff.
- Promoting clinical
standards using the national Reproductive Health Guidelines.
- Effective monitoring
of service utilisation by both service providers and NSMP project staff.
- Adoption of a Quality
of Care (QOC) model that promotes quality through team effort
and addresses critical management issues. This can also be
used to monitor the quality of services.
Supporting Maternal and Child
Health Workers (MCHWs)
Below the district hospital and Primary Health Care Centre (PHCC)
level, the midwifery and Essential Obstetric Care (EOC) skills
of other workers also needed strengthening. MCHWs are
the group of staff responsible for promoting skilled attendance
at delivery and, in turn, NSMP has placed
a strong emphasis on providing training and
support to them.
and Primary Health Management Committees
Before the start of NSMP,
pre-1997, Hospital Management Committees (HMCs) in project districts
were largely ineffective. This was because:
- Members were not sufficiently
aware of the support mechanisms available.
- There were insufficient
resources to support the hospital's
- Members did not believe that improving the quality of care
would be cost-effective.
In general, the public expected His
Government of Nepal (HMGN) to manage hospital needs
and blamed service providers for the poor quality of care.
Since 1998, HMC members
have worked to help create an enabling environment at health facilities. NSMP has
helped to boost the morale and confidence of service providers
by providing improved physical facilities, training and regular
on-site support. Skill areas that have been enhanced include midwifery
care, neonatal care, anaesthetic provision, post-abortion care, BEOC, obstetric
first aid, interpersonal communication skills, equipment maintenance
and repair and infection prevention practices.
As a result of
these inputs, many HMC members
have seen the quality of services improve, built confidence in
service providers and recognised the importance of the committee's
role as a complement to HMGN inputs.
HMC now report increases in the amount of money raised
directly from user fees and indirectly from additional income
generation activities. These funds tend to be used for exempting
the poorest and most needy patients from charges, meeting the
costs of purchasing additional drugs and supplies and paying
the salaries of extra locally recruited staff. In addition,
this support model has helped to improve the overall sustainability
of hospital systems and the access of the poorest to EOCservices.