Overview
Good quality health data are indispensable for strengthening health systems, particularly to identify and address disparities experienced by marginalized subpopulations, as emphasized in the 2021 case study on Nepal. The decentralized governance system in Nepal contributes to fragmented data production. An assessment of data gaps for health-related SDGs showed significant limitations in the availability of disaggregated data to monitor equity and understand the health situation at local levels.
Signatory agencies of both the Global Action Plan for Healthy Lives and Well-being for All (SDG3 GAP) and the Health Data Collaborative (HDC), such as Gavi, the Global Fund, UNAIDS, UNFPA, UNICEF, WHO and the World Bank, as well as other members of the HDC, like the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), have collaborated with the Government of Nepal to strengthen routine data sources, vital statistics, and population-based surveys. The agencies are also supporting capacity building on data management at national and subnational levels. This case study focuses on activities aimed at strengthening data on births, deaths, cause of death and access to and utilization of health services. The outcome will strengthen the autonomy of subnational decision makers and allow planning of health interventions for those most in need.
Female Community Health Volunteers recording and administering vaccine for an infant in rural Nepal and maintaining the records to support SDGs and UHC monitoring in communities. ©WHO Nepal/Paban Ghimire.
Situation in Nepal
Between 2017 and 2019, Nepal’s Universal Health Coverage (UHC) service coverage index increased from 48% to 53%1; less than 50% of the required rate to attain the Sustainable Development Goals (SDGs). Consequently, the government prioritized health data availability at all levels to support more equitable health service delivery, with a particular focus on those left behind. A cost-free, basic health care package (BHCP) was to be delivered through local governments as a gateway to achieving UHC. With SDG3 GAP as the roadmap and support from SDG3 GAP agencies, the government developed a National Action Plan for 2020-2022. In line with the plan, the Ministry of Health and Population (MoHP) placed primary health care and health data accelerator solutions high on the agenda.
Nepal’s primary data sources include:
- Routine data sources: facility-based integrated health information management system (IHIMS), logistics management information system (LMIS), civil registration and vital statistics (CRVS), and program specific reporting systems.
- Population-based data sources: census, health surveys and small-scale studies.
The census data are being used to determine health programme coverage and population characteristics; however, discrepancies occur over time due to large internal and foreign migration. While almost 25% of SDG indicators related to mortality can be provided through robust CRVS, absence of cause of death is a major issue in the system. Furthermore, coverage and timeliness of birth registration are suboptimal, and infants unregistered at birth are often from marginalized communities, which adds to inequities of service access, use of inaccurate denominator estimations, and - as recently demonstrated during the pandemic - underestimated vaccination targets. Hospital service records need to be improved for completion, compliance, quality, and digitization. Inadequate coordination of information management systems leads to siloed approaches and poor interoperability.
Under the leadership of the Government of Nepal and with support from the SDG3 GAP Data and Digital Accelerator Working Group, HDC and SDG3 GAP member organizations have strengthened their collaboration and aligned political, technical, and financial resources to address these challenges.
Nepal has developed a Digital Nepal Framework 2019, an eHealth Strategy 2017 followed by an e-Health Implementation Roadmap 2019 and an Integrated Health Information Management System Roadmap 2021-2030 to govern, guide, and improve health information, monitoring systems and digital health programmes. Implementation of these frameworks requires smart investments by governments, development partners, health policy makers, statisticians, community-based organizations, and the private sector.
While COVID-19 has impacted the country, primarily by disrupting continuity of regular health services, integration of surveillance systems with systems tracking service delivery supported a cohesive and efficient pandemic response. The pandemic also highlighted the need to advance towards digital systems for uninterrupted health data flow during emergencies.
Collaborative efforts for strengthening data on births, deaths, cause of death and access to and utilization of health services at all levels
International Classification of Diseases (ICD) is instrumental for standardizing the information on morbidity and mortality in the health facility-based data and CRVS. The Medical Certification of Cause of Death (MCCoD) system supports death audits. These are components of the digital health interventions for interoperability and standardization. MoHP has coordinated with the Department of National ID and Civil Registration and relevant stakeholders to strengthen birth and death data using digital platforms as well as the use of ICD and MCCoD for setting the standard.
The government has witnessed strengthened collaboration among SDG3 GAP agencies through the Data and Digital Health Accelerator Working Group to tackle its health information challenges, particularly during the pandemic. MoHP has formed a Technical Working Group to support CRVS’ coordination mechanism.
The World Bank is supporting the Department of National ID and Civil Registration in infrastructure and capacity building for data management at all levels. UNICEF continues to provide technical assistance and ICT support to strengthen HMIS and LMIS at national and subnational levels. In addition, UNICEF and the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) are providing technical guidance to strengthen birth registration and digital health. WHO and the United Nations Economic and Social Commission for Asia and the Pacific (ESCAP) are supporting the development of Business Process Improvement for birth and death registration and vital statistics. MoHP developed a guideline covering all the aspects of MCCoD from collection to use and sharing of data on mortalities. Federal and provincial public health entities have been brought together for better data on mortalities and cause of death.
UNICEF, WHO and the World Bank Group are supporting to strengthen capacity in all federal and provincial public hospitals for recording and reporting of services using ICD11. This is expected to enable hospitals to manage standardized, disaggregated data and allow interoperability among the systems. Working with WHO through the SDG3 GAP Data and Digital Accelerator Working Group, UNFPA has selected Nepal as a priority country for geospatial analysis to map and expand SRH coverage and expand CRVS completeness and coverage.
HMIS tools have been revised to address the federal context, data requirements for UHC, the SDGs, and national health plans. Compliance for quality and timeliness will be monitored once implementation begins.
With support from MoHP, HDC and SDG3 GAP Data and Digital Accelerator Working Group partners, local governments are supported through federal and provincial levels to improve and use routine health information systems and vital statistics in health care planning, management, and monitoring. This offers potential for more equitable health service delivery as local governments are primarily responsible for implementation of the BHCP. Better data will lead to better understanding of inequalities and allow deployment of an efficient health insurance program for equitable care to minimize impoverishment, however, a validated social registry is crucial to implement targeted interventions.
Results and way forward
Key achievements include:
- 55% of health facilities have computers with internet connectivity 2 and use of digital technology continues to grow.
- Digital birth and death registration system has rolled out, with 82% of local registrars’ offices using it.
- Implementation of the Birth Registration Management System is underway in 50 health facilities with plans for a nationwide scale up.
- Legal provisions have been amended for CRVS to facilitate timely registration and simplify the registration process.
- Coordination mechanism for CRVS has been established.
- National ID has been rolling out.
- 70% COVID-19 vaccination target was reached by April 2022.
- Capacity building on standardization of health data and digital health has been initiated with health facility registry, ICD11 and MCCoD.
- Monitoring and evaluation mechanism has been established at provincial levels, including monitoring of SDGs and UHC.
The partnership among SDG3 GAP agencies and the Government of Nepal is producing valuable technical solutions, preventing duplication, and promoting advocacy messages in meaningful ways. Collaboration increases efficiency by minimizing time, cost and administrative burden for monitoring, evaluation, and reporting, and enables joint perspectives on the way forward. For example, a joint annual review is conducted every year through a participatory approach to evaluate the health sector’s progress and develop plans for the next year.
Due to competing priorities and the specific focus of each agency, it is arduous to always align partners’ activities. Guidance from the global level is essential to expedite the local level partnership and resource pooling for implementation.
For accurate monitoring of BHCP and SDG progress, continuation of technical assistance and capacity development is needed until local levels gain full efficiency on data management. Further advocacy and budget allocation for implementing GAP and NAP at subnational level are essential for local ownership and progressing in an equitable manner.
Partners, led by UNFPA, UNICEF and WHO, will continue to explore current CRVS needs in Nepal, promote alignment with ongoing CRVS strengthening initiatives, engage new partners as needed, and integrate CRVS within stronger overall health and population data systems, digitization, UN cooperation frameworks and national development priorities and plans.
Female community health volunteers as initiators of routine health data collection for SDGs and UHC monitoring in communities
In Nepal, efforts to improve health-related data begin at the local level with female community health volunteers (FCHVs). With support from health care workers, 52 000 FCHVs are engaged in the provision and recording of basic health services. Their contributions to CRVS on health service utilization and birth and death registration facilitate local level health planning. For example, improved recording of pregnant women and newborns enables better tracking and provision of antenatal care and immunization.
Furthermore, because the FCHVs are from the community, they have local insight which is of value to health programme managers for health promotion activities.
Key and vulnerable populations affected by HIV, Nepal. ©The Global Fund/Sarah Hoibak.
What is the SDG3 GAP?
The Global Action Plan for Healthy Lives and Wellbeing for All (SDG3 GAP) is a set of commitments by 13 agencies that play significant roles in health, development and humanitarian responses to help countries accelerate progress on the health-related SDG targets. The added value of the SDG3 GAP lies in strengthening collaboration across the agencies to take joint action and provide more coordinated support aligned to country owned and led national plans and strategies. A “recovery strategy” (Oct 2021) serves as a strategic update on the SDG3 GAP in the context of achieving an equitable and resilient recovery from the COVID-19 pandemic to the health-related SDG targets.
The purpose of GAP case studies is to monitor SDG3 GAP implementation at country level.
The Health Data Collaborative (HDC) convenes multiple global health partners for efficient alignment of investments to empower countries for planning, implementing, evaluation of progress and standardizing processes for data collection and analysis to achieve the SDG3 targets. SDG3 GAP and HDC are interlinked through the SDG3 GAP Data and Digital Accelerator Working Group and the support provided to countries on strengthening data systems is fully aligned and integrated.
References
- Source: Tracking universal health coverage, 2021 global monitoring report
- Nepal Health Facility Survey 2021