Surya Bhatta is the Executive Director of One Heart Worldwide. Bhatta, who also represents the Steering Committee of the Association of International Non-Government Organizations of Nepal, has over a decade of experience working in health development leadership roles strengthening Nepal’s public health system through several public health interventions. Nepal Live Today caught up with him to discuss the works and priorities of his organization.
What is One Heart Worldwide? What are the areas the organization covers?
For over a decade, One Heart Worldwide (OHW) has had an active presence in Nepal, improving access and quality of Maternal and Newborn Health (MNH) services for 414,000 pregnancies across 24 rural districts in support of the Government of Nepal’s national plan to provide quality MNH services to rural pregnant women and their newborn infants. Our goal is to improve access to quality MNH care for 250,000 pregnancies annually by the end of 2030 (one-third of all annual pregnancies in Nepal) with programs focusing on the more vulnerable populations of 36 rural districts.
In 2022, OHW will be active in 20 districts. We will have 12 districts in the full implementation phase including a partial program in our previous district of Dolpa, four districts in the transition phase and most importantly, we are accelerating our program roll-out, adding four districts per year over the next three years to achieve our goal in Nepal.
The stated mission of One Heart Worldwide is to save lives and promote the well-being of mothers and their newborns in underserved areas of rural Nepal. Why do you think this is needed in Nepal?
Nepal has made stride progress on human development indicators over the last decade but still, it has one of the highest maternal mortality ratios and newborn mortality rates in the region. For example, 239 women die for every 100,000 live births and 21 newborns die for every 1,000 live births. Within the country, rates are significantly higher in rural areas.
In Nepal, the rural healthcare system is struggling due to shortages of appropriately trained health workers to manage pregnancy, childbirth, and newborns. Additionally, the health facilities are facing poor structural conditions with limited equipment, essential drugs, and supplies.
In rural communities of Nepal, people are poorly informed about the life-saving benefits of accessing quality MNH care and continue the traditional practice of birthing at home instead of delivering at a birthing center under the care of a Skilled Birth Attendant (SBA) or the trained providers.
‘In Nepal, the rural healthcare system is struggling due to shortages of appropriately trained health workers to manage pregnancy, childbirth, and newborns.’
In this situation, the path to life-saving referrals can be very challenging at the community and hospital levels. Municipal governments, healthcare providers and community stakeholders must work together to create an effective MNH strategy if they want to improve maternal and neonatal health outcomes. We work to close the equity gap in Nepal in partnership with the government of Nepal at various levels by increasing access to quality care for pregnant women and their newborns.
Your organization advocates for a locally-led health system. What does this mean? How is the organization working on this approach?
At the core of OHW’s success is our in-depth collaboration with the local communities we serve. We design each district’s six-year transformation plan with local health and community leaders, keeping respect for local cultural norms at the forefront of all we do.
We transfer knowledge, technology, systems, facilities, and competencies to local governments, allowing the government of Nepal to fully take over the costs of running each OHW-transformed district after just six years and maintain impacts indefinitely.
We co-invest with the local government and leverage existing community channels to strengthen the public Maternal and Newborn Healthcare Delivery System to establish a continuum of care, known as the Network of Safety, that increases access to safe delivery and extends both the reach and readiness of the local health system.
Our self-sustaining community-centric model addresses critical gaps in rural MNH service delivery, ensuring that every pregnant woman and newborn can access quality care from a well-trained medical provider no matter where she lives. We spend six years in each district working in partnership with local municipalities, local NGOs and local communities to strengthen the local health infrastructure by upgrading government health facilities, improving the skills and expertise of local health providers, and fostering community empowerment to create meaningful change that is locally driven.
If so, how is this approach embedded in the activities of your organization?
Over the course of a six-year implementation period, OHW works in partnership with both the Nepali government and local stakeholders to strengthen existing public MNH infrastructure and build local capacity. Instead of establishing “parallel” systems in competition with the existing government healthcare systems, our Network of Safety model aligns itself with local governmental priorities, policies, and curricula, receiving endorsement at the national, provincial, and local levels. Our model includes local stakeholders as well as other local organizations including, but not limited to, female community health volunteers, health facility management committee, and health mothers’ groups in the planning, implementation, and long-term maintenance of the Network of Safety.
How do you prioritize and select working districts?
OHW uses publicly available latest data sources to select the priority districts. The major sources are routine health information systems, population-based surveys like demographic health surveys, multiple cluster indicator surveys and human development reports. OHW does several layers of consultations and discussions with the different agencies including federal, provincial and local governments. We also consult with major MNH key players on top of consultations with the government agencies so there is no duplication in program implementation. Then, districts are ranked based on scores they obtain. After that, we select the districts which are in need of support for OHW programs. Once we are in the districts, we run a population-based survey and do facility assessment as a baseline to identify the local gaps so our program and investment plans are aligned with the local needs.
It is said reproductive, maternal, newborn, and child health received much less attention during the Covid-19 pandemic. What was the situation during the pandemic? Is the situation improving now?
During the beginning phases of the pandemic, our field team frequently reported what was happening out in the field. We soon learned that the women we serve were skipping health facility antenatal check-ups and that healthcare providers feared that they would be infected by patients coming into the facilities. Moreover, all quarantine and isolation centers lacked the necessary supplies, equipment and technical resources for Covid management and prevention. We were worried that if we did not act fast, we could lose everything that we’d achieved in the last decade.
‘Social and economic breakdown caused due to the pandemic can have a detrimental impact on health service utilization and the ability to pay for the health services.’
In response to the situation, we realigned our priorities to mobilize the distribution of PPE, supplies and services to our program districts in collaboration with our government partners. Because there was no infrastructure in place for virtual meetings in the early days of the pandemic, we ran several in-person meetings—masked and physically distanced—with the Ministry of Health and Population, the Department of Health Services, Nepal’s Social Welfare Council, the Ministry of Women, Children and Senior Citizens, and the Association of International Nongovernmental Organizations (AIN) in Nepal, which laid the groundwork for an effective roll-out for Covid response plan and for the ultimate programmatic success that One Heart had down the line.
OHW had conducted a rapid assessment of Reproductive, Maternal, Newborn and Child Health service utilization status with the IRB approval from Nepal Health Research Council (NHRC) at 268 birthing centers in 14 districts of Nepal where One Heart Worldwide was rolling out the program activities. Our team collected the service utilization data of three months of the Covid lockdown period and compared it with the corresponding three months’ data of the previous year. There has been a 19 percent increase in institutional delivery, almost no change in antenatal service utilization, and 21 percent increase in postnatal service utilization compared to last year’s corresponding months’ data. But, the use of family planning services has declined during the lockdown. Abortion service users have increased by 13 percent. Interviews with health workers and women who delivered during lockdown showed that the major reason for increased institutional delivery in birthing centers was the travel restrictions which caused women to choose nearby facilities to receive service rather than traveling far.
We have not done any post-Covid assessment on service utilization and impact on MNCH health outcomes. So there is no research evidence to share at this moment. However, life is back to normalcy and several public health measures are lifted. As Covid cases dropped significantly, the public health services are fully resumed and that should have a positive impact on reproductive, maternal, newborn, and child health outcomes. Another determinant we need to take into account is the social and economic breakdown that has been caused due to pandemic and this can have a detrimental impact on health service utilization and the ability to pay for the health services.
Do you feel that the Covid-19 pandemic has posed a serious threat to the achievement Nepal has made in the area of institutional delivery and other neonatal and new mother health issues?
Covid-19 has been a global threat to maternal and newborn health. Of course, this also impacts the progress that has been made in Nepal. At this time, we don’t have enough data to evaluate to what extent this has impacted MNH outcomes in Nepal and there is still the possibility of other Covid variants affecting the world within the next months and years. But there has been a 19 percent increase in institutional delivery in rural birthing centers where we have a programmatic intervention during the lockdown period.
How do you ensure that your organization’s activities are aligned with the government’s priorities?
Before OHW launches the program activities officially, we run population-based surveys to find out the existing gaps within the districts. That gives us an idea of where we should make our investment with the local government. On an annual basis, the annual program and activities development process begin at the field level. In the districts where OHW currently has a field team, our field team conducts quality of care and needs assessments for the local healthcare systems, collecting pertinent information from the community stakeholders and health facilities. OHW team also prepares a Palika profile in order to see the local gaps and then our team meets with elected representatives from each Palika and health facility collaboratively to prioritize the needs for which OHW would be able to provide support and have the most impact. In the districts where OHW has not yet launched a program, the Kathmandu-based team visits key community stakeholders and health facilities before meeting with the local government, mostly at the municipality/rural municipality level, but also at the district level. These visits allow OHW to harmonize and align our activities with existing governmental programs, ensuring there is no overlap.
You have also been conducting programs related to mobile Health. Can you share with us what is m-Health and what are your activities?
mHealth, in other words, mobile health, is a general term for the use of mobile phones and other digital technologies in medical care. Over the past year, the emergence of Covid-19 required us to rapidly and aggressively adapt our programs to ensure the continuity of essential maternal and newborn care (MNH) during the pandemic. New virtual solutions are now possible in rural Nepal thanks to the tremendous growth in the local telecom’s infrastructure in recent years. Given the difficult logistics for travel both for our team and providers in remote locations, we are finding that some programs, particularly in terms of training and refreshers, could feasibly be conducted and even benefit from virtual delivery even beyond the pandemic. Over the next year, OHW will aim to expand the use of digital tools in our programs.
There should be self-regulative and efficient working administrative procedures for civil societies and government partners during the time of emergencies so that we can reach the most vulnerable people and communities before they suffer.’
The MNH Helpline is designed to assist rural MNH service providers in clinical decision-making when faced with an MNH emergency in which referral to a higher facility might be delayed or not be possible at all. OHW had 530 birthing centers enrolled in this program across all OHW districts in 2021. Program results show a decrease in referrals from rural birthing centers as a result of increased local case management, improved confidence among rural MNH providers, and improved communication between rural providers and referral hospitals. These findings have been shared with government partners and relevant stakeholders in the hope that the intervention might be adapted and scaled nationwide.
The Telehealth Program supports rural healthcare providers in adapting in-person consultations to cellphone-based consultations for antenatal care and postnatal care, ensuring continuity of service delivery while limiting unnecessary potential exposure to Covid. The Government of Nepal formally adopted the telehealth program into their official service delivery guidelines during the pandemic. OHW had 762 health facilities enrolled in this program as of the end of 2021. Program results show positive feedback from pregnant and recently delivered women with regard to improved access to ANC/PNC information and relationships with their providers, but also revealed gaps in providers’ awareness of national guidelines for delivering MNH services during Covid, as well as an appropriate distribution of Misoprostol. These findings were also shared with government partners and stakeholders to improve service delivery at the rural health facility level.
In 2022 and 2023, OHW is aiming to launch a program to integrate the use of a Geographic Information System (GIS) within the Network of Safety model, developing our internal capacity to identify, predict, and effectively respond to the unique MNH needs of underserved populations. Following the integration of GIS into our own systems and informed by our own experiences, we will prepare to pilot a GIS skills-building and technology transfer with local government at the Palika level in 2023. Applying the appropriate use of specialized geospatial data collection, presentation, and analysis will provide OHW and our government partners with improved information with which to target resource allocation and program services to ultimately improve the health equity outcomes of pregnant mothers and their newborns.
Finally, how can we build a resilient health care delivery system for the country?
International Development Partners and Civil Societies have played an important role in supporting the government of Nepal in times of emergencies and disasters. Being an early responder in the 2015 mega earthquake and Covid pandemic, the resilient health care delivery system is something we all have to build together. We often tend to forget the learnings and best practices till another disaster hits us. This shouldn’t happen in the days to come. There needs to be preparedness and clarity on roles and functions among the three tiers of government. Lastly, there should be self-regulative and efficient working administrative procedures for civil societies and government partners during the time of emergencies so that we can reach the most vulnerable people and communities before they suffer.