Improving quality of care

The quality of health care is just as important as being able to access it. In developing countries such as Nepal, priority tends to be given to making services accessible to the entire population rather than improving service quality. Further challenges such as a fragmented health sector, limited equipment and supplies and a lack of trained health staff all act to limit the quality of services available.

We applied a number of innovative strategies to tackle this problem. Evidence has shown that while there have been improvements in providing institutional deliveries, the number of people accessing these services has been inconsistent. An analysis of data on service use in 2010/11 showed that of the 17 higher level hospitals providing Comprehensive Emergency Obstetric and Neonatal Care (CEONC) services in Nepal, 12 were overcrowded, with patient numbers consistently exceeding the number of available beds.

We conducted a study in six referral hospitals which found that delivery services were mostly overcrowded while the services in many birthing centres were under-used. To overcome this imbalance we recommended extending the provision of, and improvements in, the quality of maternity services at the referral hospitals, and strengthening strategic birthing centres to relieve the loads on referral hospitals.

We helped the Family Health Division to produce its 2013/14 annual work plan and budget, addressing overcrowding by producing guidelines on the hospitals’ uses of funds. This included sustainable funding for improvements in all referral hospitals across the country. We supported the role out of these guidelines through site visits and remote support to improve quality of care.

We conducted needs assessment through the Remote Areas Maternal and Neonatal Health Pilot (RAMP) which identified improving the quality of obstetric care and access to medical abortions as local priorities.

In 2015, as a part of the Transition and Recovery Programme (TRP) in districts affected by the earthquakes, we implemented three days of quality improvements at all the birthing centres in two districts and in one strategic birthing centre in a third district. 

We also developed and piloted a hospital quality improvement process (HQIP) at two district hospitals to improve quality of care, particularly around child birth, from admission to discharge.  As a result, good basic skills, financial incentives for staff and institutions, and access to essential equipment led to higher levels of awareness, concern and engagement with quality of care, making it a priority for health workers. We also supported the development of clinical mentors at district hospitals to sustain quality improvement efforts in their own hospitals and at rural health facilities.

We supported five rounds of self-assessments by hospital teams on HQIP in two districts. The HQIP aims to support district hospitals to achieve the Hospital Minimum Service Standards and is designed to reinforce district level quality improvements.

Project achievements

  • We supported ten referral hospitals to extend and improve service provision through the recruitment of 10 doctors (including 3 anaesthetists), 20 nurses, 8 auxiliary nurse midwives  and 1 anaesthesia assistant, the installation of new maternity beds and equipment, repairs to rooms and improvements in electricity supply and waste disposal.
  • We put specific measures in place in these hospitals to improve quality of care, such as referral arrangements, human resources and infrastructure improvements, as well as sustainable funding for further improvements. We supported initiatives including building a biogas plant to provide cooking gas for a hospital, building a laundry area and an extra storey on an emergency unit.
  • The Hospital Quality Improvement Process has been tested in two hospitals. Using learning from this process and outcomes from the tools used, we developed indicators to monitor and evaluate the quality of services and link the hospitals to the centre thereby feeding into the Ministry’s broad Quality Assurance system.


In 2014-15, the AWPB allocated new funds for 3 hospitals to address overcrowding of MNH services

6 RAMP health facilities with birthing centres added BEmONC services after the quality improvement drive

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