Monitoring health inequalities is essential for achieving Universal Health Coverage because it enables populations that are being left behind to be identified and helps to inform equity-oriented policies, programmes and practices. Such monitoring requires various forms of disaggregated data, which are currently lacking in many countries (ref World Health Statistics 2020).
This elderly woman has had more time to spend with her granddaughters since the COVID-19 pandemic, Nepal. ©WHO/A. Maharjan
Nepal expressed early interest in receiving intensified support from GAP agencies in 2019 when the Government worked with them and other partners to develop a country roadmap and action plan setting out the country’s support needs for implementation of its National Health Sector Strategy (NHSS) 2015-2020 (extended to 2021) and the 2019 National Health Policy. These are focused on improving the quality of primary health care, strengthening health information systems and improving equity of access. A new NHSS planned for 2021-2025 will reinforce these approaches. To build upon District Health Information Software 2 (DHIS-2) for health data management implemented since 2016, an Integrated Health Information Management System Roadmap for 2021-2030 has been developed outlining ways of improving health information, monitoring systems and digital health programs.
A results framework with indicators for SDG 3 and nutrition aspects of SDG 2 (zero hunger) developed to support the current and next National Health Sector Strategies in Nepal showed significant data gaps in key areas. Nepal uses routine data sources (facility-based HMIS reporting, logistics and others), vital statistics and population-based surveys to monitor health trends. However, these systems currently have significant limitations. Routine data sources cannot be interpreted at the population level. Hospital service records in the country reflect a large share of available mortality and morbidity data but quality and coverage need improvement and data from hospitals in different jurisdictions are not well linked. Vital Statistics coverage and timeliness of registration of events need to be improved and causes of death more systematically recorded. Significant investments are also needed in electronic patient records across the system.
Recent surveys have also shown discrepancies in service utilization by sex, age, education level, geography and wealth quintiles and a better understanding is needed of the overall impact of health services on morbidity and mortality by equity stratifiers. Availability of disaggregated data, data analysis capacity for equity monitoring and improved visualization and access to information are core areas requiring further work to ensure that no one is left behind.
During the last quarter of 2020, the government requested joined-up support from multilateral and bilateral agencies and other partners in the Heath Data Collaborative to help tackle these health information challenges. Working across its headquarters, regional and country offices, WHO has played a key role in convening members of the GAP Data and Digital Health accelerator working group (Gavi, UNDP, UNFPA, UNICEF, WFP and WHO) and the Health Data Collaborative, all of which have worked together with the Ministry of Health to agree on three major priority areas including catalytic interventions where the partners will support strengthening health information systems in Nepal over the shorter term:
- Strengthening routine health information systems (RHIS) for UHC and other health-related SDG reporting, with focused interventions for hospital information system improvement in 22 hospitals, including standardization, medical certification of cause of death and outpatient service recording. Strengthened hospital reporting will also enable better information on patient population sub-groups and contribute to evidence-based equity analysis, planning and decision making;
- Establishment of learning centres on RHIS in all seven provinces in collaboration with academia, including targeted capacity building in the public and private sectors; and
- Strengthening health information systems and M&E coordination mechanisms at provincial level to enable better evidence-based planning and more equitable service delivery.
Over the longer term, the agencies aim to support Nepal to invest in and implement further digital solutions and mobile technology to expand coverage of health information systems, vital statistics, electronic medical records and telemedicine in order to increase health equity and accelerate progress towards UHC.