Table 3 Additional contextual factors associated with implementation of evidence-based interventions to decrease amenable under-5 mortality in Nepal
Contextual Factor | Facilitator, Barrier, Both, or Neither | Description |
|---|---|---|
Economic development | Facilitator | Nepal’s steady economic growth during the study period was identified as an important contributor to health sector successes. Key informants observed that a growing number of Nepalese people working overseas improved economic status and increased financial access to health care through remittances; further, their exposure to other health care systems led families to have higher expectations of care and demand better quality |
Female empowerment | Facilitator | During the study period efforts to increase female empowerment included education, addressing poverty, improving asset ownership, increasing women’s economic rights, and targeting women for microcredit programs to increase financial opportunities. In the health sector, efforts included government-sponsored village mothers’ groups, and granting authority and importance to FCHVs in communities |
Focus on universal health care and equity through national leadership | Facilitator | Nepal committed to access to health care as a fundamental right of the people, prioritizing gender equality and social inclusion in health policy and delivery through policies including its Second Long Term Health Plan (1997–2017) which prioritized Nepal’s most vulnerable groups including women and children, rural populations, and underprivileged and marginalized people [41]. Following the people’s movement of 2006, a free health care policy was introduced in 2006 which provided essential health care services free of charge to the poor, disabled, elderly, and FCHVs up to primary healthcare centers and 25-bed hospitals. The following year this was expanded to all citizens at the health post level [42]. The 2007 interim constitution of Nepal enshrined health as a fundamental human right [43], and free basic primary care was extended to all citizens between 2008–11 – the same time period as the national IMCI rollout [41, 44] |
Health system strengthening | Both | Nepal’s work to strengthen health systems broadly, including efforts to address geographic access, infrastructure, and human resources for health, was essential for facilitating IMNCI implementation and U5M reduction EBIs more generally. For example, the ability to integrate new IMNCI programming into existing community-level health systems structures was important its successful scaling across the country. However, health system strength was also a barrier to EBI implementation, such as human resources in more remote areas which grew at a slower pace compared to national increases. While the country made efforts to meet these needs, this left goals for training workers unmet, for example challenging the ability to achieve a goal of 7,000 trained maternal health workers by 2015 |
Conflict | Neither | Surprisingly, this was not a major barrier to EBI implementation including IMCI. While Nepal experienced a decade of armed conflict between the Government of Nepal and the Maoist insurgency between 1996 and 2006, neither side disrupted access to health services, and KIs reflected on policies which encouraged ongoing primary care. Most key health metrics including EBI implementation improved during this time, including U5M, vaccination rates, and antenatal care visits. Much of the pilot work for Nepal’s IMCI programming took place during this period |