Overview

The 2021 Nepal Health Facility Survey (NHFS) is the second survey of its kind following the one conducted in 2015. It was designed to provide information on the availability of basic health care services and the readiness of health facilities to provide quality services to clients.

The survey was implemented by New ERA under the aegis of the Ministry of Health and Population (MoHP). ICF provided technical assistance through The DHS Program, which assists countries in the collection of data to monitor and evaluate population, health, and nutrition programs. The survey received funding from the United States Agency for International Development (USAID); UK’s Foreign, Commonwealth & Development Office (FCDO); and the United Nations Population Fund (UNFPA). The data collection was planned for early 2020 but was pushed back by 1 year due to the pandemic.

The 2021 NHFS is an assessment of health facilities in the formal sector of Nepal. It was designed to provide a comprehensive picture of the strengths and weaknesses of the service delivery environment for each assessed service. The 2021 NHFS collected information from all facilities managed by the government and by private not-for-profit nongovernmental organizations (NGOs), private for-profit organizations, and mission/faith organizations in all 77 districts of the country. The survey was also designed to provide representative results for each of the seven provinces and by facility type. In addition, this survey will provide an endline for the Nepal Health Sector Strategy 2016–2022.

Key findings of the 2021 NHFS

FACILITY-LEVEL INFRASTRUCTURE, RESOURCES, MANAGEMENT, GENERAL SERVICE READINESS, AND QUALITY OF CARE

• Three quarters of all health facilities in Nepal offer a full package of basic client services (outpatient curative care for sick children, child growth monitoring, child vaccinations, any modern method of family planning, antenatal care [ANC], and services for STIs). This represents a clear improvement since the 2015 NHFS, when only around 6 in 10 facilities were assessed as having a full package of basic services.
• Facilities were somewhat more likely in 2021 (17%) than in 2015 (11%) to have all six of the basic amenities (regular electricity, an improved water source, visual and auditory privacy, a client latrine, communication equipment, and emergency transport) considered essential for rendering quality client services. More than 3 in 10 facilities in the Bagmati province (31%) have all of the basic amenities, as compared with less than 1 in 10 facilities in Madhesh (8%) and Karnali (7%).
• The availability of personal protective equipment improved at health facilities between the 2015 and 2021 surveys. For example, the percentage of facilities that had masks available increased from 19% to 82%, and facilities were almost six times as likely to have gowns/aprons available in 2021 (53%) as in 2015 (9%).
• With the exception of emergency transport (80%), less than half of all facilities in Nepal have any of the supplies and services (self-inflating bag and mask, pulse oximeter, oxygen-filled cylinders, inpatient care, overnight observation beds, communication equipment) considered essential in providing COVID-19 care.
• Basic diagnostic testing capacity is limited in most health facilities; facilities are most likely to have the capacity for pregnancy (43%) and malaria (36%) testing and least likely to have HIV testing capacity (5%).
• Half of facilities conduct regular management meetings, and a similar percentage involve the community in these meetings.
• The percentage of facilities reporting both routine staff training and personal supervision was lower in 2021 (55%) than in 2015 (69%).
• Only 6% of facilities reported having an outbreak management plan, 36% of facilities completed a financial audit in the last fiscal year, and 69% of PHCCs and hospitals implement the government’s social security health insurance scheme.

CHILD HEALTH AND IMMUNIZATION SERVICES

• Virtually all health facilities in Nepal offer curative care for children, and around 9 in 10 facilities offer growth monitoring and routine vaccination services. Routine vitamin A supplementation is offered in 88% of facilities.
• Outpatient curative care for sick children and growth monitoring services are available 5 or more days per week in almost all health facilities offering these services.
• Very few facilities delivering curative care for children have all of the equipment and trained staff considered necessary to provide quality care for sick children, with facilities most often lacking length or height boards (39%), pediatric stethoscopes (13%), and staff with training in maternal, infant, and young child nutrition (12%).
• Nine in 10 facilities providing child curative care have alcohol-based disinfectant and latex gloves, and 8 in 10 have medical masks. Overall, however, only 1% have all of the infection prevention items needed to deliver services safely.
• Laboratory testing capacity is also limited, with only 12% of facilities able to conduct hemoglobin and malaria testing and stool microscopy.
• Routine vaccinations are available at least 1–2 days per week in more than 8 in 10 facilities that offer vaccinations. Facilities generally obtain the vaccines they administer from a higher level center and store the vaccines only for a short time as per policy. Only 6% of facilities have all of the components necessary for quality immunization services.
• Around two-thirds of providers of child health services have received recent supervision, and around 1 in 5 providers have received recent in-service training related to child health.
• Providers assessed all three main symptoms of childhood illness (fever, cough/difficulty breathing, and diarrhea) in 28% of observed consultations. They checked for all four major danger signs (ability to eat or drink anything, vomiting, convulsions, and unconsciousness/ lethargy) in less than 1% of consultations.

FAMILY PLANNING SERVICES

• A large majority (98%) of health facilities in Nepal offer (i.e., provide, prescribe, counsel, or refer clients on) at least one of the following temporary modern methods of family planning: oral contraceptive pills, male condoms, injectables (Depo), implants, or intrauterine contraceptive devices (IUDs). Around 4 in 10 facilities offer male or female sterilization.
• 95% or more of all facilities offering modern family planning methods provide male condoms, oral contraceptive pills, or injectables to clients at the facility. However, less than half of facilities offering modern family planning methods are able to provide implants (41%) or IUDs (29%). Female or male sterilization services are provided at only 2% of the facilities where modern family planning methods are offered.
• 92% of health facilities that provide temporary family planning methods actually had every method they provide available at the facility on the day of the NHFS visit.
• A majority of facilities offering family planning services have most of the basic equipment required for quality service delivery; however, only around 1 in 5 have the national family planning guidelines available or have staff who received in-service training relating to family planning in the past 24 months.
• Overall, the environment for family planning counseling is poor. Visual and auditory privacy and confidentiality were assured in only 12% of all family planning consultations observed in the survey.
• Method-specific side effects were discussed in only 38% of all observed family planning consultations. There was almost no discussion of STIs or condom use in the consultations.
• Two-thirds of interviewed family planning providers reported that they had been personally supervised during the 6 months before the survey. Less than 1 in 10 providers had had any in-service family planning training in the 24 months before the survey.

ANTENATAL CARE

• Almost all (98%) health facilities in Nepal offer ANC services.
• Three quarters or more of facilities offering ANC have the basic equipment required to deliver quality services, with the exception of a tape to measure fundal height. A majority also have essential infection control items and supplies except for a needle cutter and a waste receptacle.
• Only around one quarter of facilities offering ANC had staff with recent training in ANC available on the day of the assessment, and relatively few had either ANC service (11%) or infection prevention (7%) guidelines.
• More than 6 in 10 ANC providers had received personal supervision in the 6 months preceding the survey.
• Almost all health facilities offering ANC (95%) had essential ANC medicines (iron and folic acid combined tablets and albendazole tablets) available.
• Testing capacity was much more limited, with only around 1 in 4 facilities offering ANC care able to conduct hemoglobin, urine protein, or urine glucose tests. Only 3% of facilities were able to conduct all three tests.
• In the great majority of the ANC consultations observed in the NHFS, the client’s blood pressure (93%) and weight (89%) were assessed. Providers checked the fetal position and listened to the fetal heartbeat in around 7 in 10 consultations.
• Two-thirds of ANC clients were given or prescribed iron or folic acid, and around one-fifth received or were prescribed albendazole.
• Clients mentioned or providers asked and/or counseled about at least one of eight risk symptoms in 63% of the observed ANC consultations, most often severe abdominal pain. All eight risk symptoms were discussed in less than 1% of consultations.
• In general, facilities offering ANC lacked trained staff, diagnostics, and medicines needed for the provision of malaria services.
• Only 11% of hospitals and PHCCs offering ANC provided any prevention of mother-to-child transmission (PMTCT) of HIV services.

DELIVERY AND NEWBORN CARE

• Just over half of health facilities in Nepal provide normal vaginal delivery services. As expected, cesarean deliveries are available at only a small proportion of facilities (5%), mainly hospitals.
• Eight in 10 facilities that offer normal delivery care services have emergency transport available, and a majority of facilities (66%–99%) have all of the equipment items necessary for providing quality care other than a vacuum extractor (23%) and a vacuum aspiration or manual vacuum aspiration kit (21%).
• Only around one-fifth of facilities offering normal vaginal delivery services had all of the medicines essential for quality delivery care. Facilities were even less likely to have all of the essential medicines for newborn care (2%).
• Around 3 in 10 facilities that offer normal vaginal delivery services had at least one interviewed staff member with recent training in delivery care, and only 13% had guidelines for delivery care available on the day of the assessment.
• Only a minority of hospitals and PHCCs offering normal vaginal deliveries had performed all basic emergency obstetric and newborn care (BEmONC) signal functions (13%) or all comprehensive emergency obstetric and newborn care (CEmONC) signal functions (11%) at least once in the 3 months preceding the survey.
• 90% or more of facilities reported that they routinely carry out a number of essential newborn care functions, including keeping the infant warm, starting breastfeeding soon after birth, and putting the baby skin to skin on the mother’s abdomen.
• 63% of interviewed delivery care providers received personal supervision in the 6 months before the assessment, but only 16% received in-service training during the 24 months preceding the assessment.
• Only a minority of women reported that they received comprehensive checks and advice on key aspects of postpartum (8%) or newborn (19%) care before they were discharged from the facility where they delivered.
• 23% of postpartum women interviewed after their delivery reported that the staff had scolded them or treated them disrespectfully.

HIV/AIDS AND SEXUALLY TRANSMITTED INFECTIONS

• One in 20 health facilities in Nepal have a system to support clients needing HIV testing and counseling. Around three quarters of these facilities are able to offer HIV testing at the facility to clients.
• Relatively few facilities (9%) offering HIV testing and counseling services had all of the items needed for delivering quality services available on the day of the assessment visit.
• Similarly, few facilities offering HIV testing (10%) had all infection prevention items at the service site on the day of the NHFS assessment. In facilities offering laboratory testing, 18% had all infection prevention items available in the laboratory.
• Slightly more than half (56%) of the HIV service providers interviewed in the NHFS reported receiving personal supervision in the 6 months before the survey. However, very few had recent training related to either HIV counseling (3%) or testing (2%).
• 8% of all health facilities in Nepal offer at least one HIV/AIDS care and support service.
• 13% of hospitals and PHCCs offer antiretroviral therapy (ART) services.
• More than 8 in 10 facilities offer STI services. A lack of availability of trained staff, STI guidelines, and testing capacity serves as a major constraint on the provision of quality STI services.

NONCOMMUNICABLE DISEASES

• 96% of all health facilities in Nepal offer services for the diagnosis and/or management of chronic respiratory diseases, and 90% provide services for cardiovascular diseases.
• Almost three quarters of all health facilities offer services for the diagnosis and/or management of diabetes, which is more than three times the proportion of facilities providing these services at the time of the 2015 NHFS (21%).
• The availability of guidelines for provision of services and trained staff is consistently low in facilities offering services for the three NCDs.
• Basic equipment such as a blood pressure apparatus, stethoscope, or weighing scale is available in most facilities offering services for the three NCDS. Other equipment, including height boards, peak flow meters, spacers for inhalers, and essential medicines, is less available.
• Only one quarter of all health facilities in Nepal offer mental health services.
• Only a minority of facilities offering mental health services have guidelines (27%) or a staff member with recent training in mental health care (16%). Half or less of facilities have any of the essential medicines for treating mental illnesses.

TUBERCULOSIS

• Nationally, around two-thirds of all health facilities offer any tuberculosis (TB) treatment services, and 23% offer any TB diagnostic services.
• Just over half of all facilities have treatment protocols in which TB drugs are delivered to the patient by a health worker at the facility, and 25% provide treatment to clients in the community.
• 31% of facilities offering TB services had the TB management guideline 2019 available.
• 17% of facilities that offer TB services had staff with recent in-service training related to TB.
• TB smear microscopy was available at 12% of facilities offering TB services, while 13% had X-ray services for screening and diagnosis of TB.
• Only 4% of facilities offering tuberculosis diagnosis and/or treatment services also had HIV diagnostic capacity.
• Seven in 10 facilities offering TB services had medicines available on the day of the NHFS visit for the continuation phase of the TB treatment regimen.
• More than 8 in 10 facilities offering TB services had in place a system to track whether TB clients were following the recommended treatment regime.

MALARIA

• Just under half of Nepal’s health facilities (49%) offer malaria diagnosis and/treatment services.
• Health facilities in the terai region (74%) are more likely to have malaria services available than facilities in the hill (40%) and mountain (19%) regions.
• By province, malaria services were available most often in Madhesh and Lumbini (64% each).
• With respect to diagnostic capacity, 74% of facilities offering malaria services had the ability to diagnose malaria on-site, primarily using rapid diagnostic tests (RDTs).
• Only a minority of facilities had staff with recent training in malaria diagnosis (12%) or treatment (10%) or malaria service guidelines (13%) available at the time of the NHFS visit.
• Chloroquine (31%) and primaquine (21%) tablets were the most commonly available antimalarial medicines.
• Only 9% of health facilities providing malaria services had long-lasting insecticide-treated mosquito nets (LLINs) in stock for distribution.

Recommended reading

• Nepal Health Facility Survey 2021 Preliminary Data Tables
• Preliminary Findings: Nepal Health Facility Survey 2021
• Second Round Seroprevalence Survey for SARS-COV-2
• The 2nd National Sero-prevalence Survey of Nepal for COVID-19
• Waste Management Baseline Survey of Nepal 2020
• National Mental Health Survey, Nepal-2020 Fact Sheet
• Nepal Multiple Indicator Cluster Survey 2019 (NMICS 2019): Key findings
• National TB Prevalence Survey, 2018-19 Key findings
• Nepal STEPS Survey 2019- Province wise Fact Sheets
• NEPAL–NCDs risk factors STEPS Survey 2019 – Tobacco Factsheet
• Nepal STEPS Survey 2019 Alcohol Consumption and Policy Fact Sheet
• National NCD Risk Factor Survey (WHO-STEP Survey) 2019,Nepal
• Nepal National Micronutrient Status Survey 2016
• The 2015 Nepal Health Facility Survey: Further Analysis Reports
• Key Indicators: The Nepal Demographic and Health Survey (1996 NDHS- 2016 NDHS)
• Key Findings (Nepali & English) – The 2016 Nepal Demographic and Health Survey (2016 NDHS)
• Nepal Demographic and Health Survey 2016 Key Indicators Report
• Nepal Demographic and Health Survey 2016 Key Indicators Report (Short Notes)
• The 2016 Nepal Demographic and Health Survey (2016 NDHS)
• Key findings – The 2015 Nepal Health Facility Survey (2015 NHFS)
• Nepal Health Facility Survey (2015 NHFS) Preliminary Report
• Nepal Multiple Indicator Cluster Survey (MICS 2014) Final Report