ADDRESSING UNMET NEED IN NEPAL

Nepal is committed to improving the health status of its people through improvements in maternal, neonatal and child health. In Nepal, various health plans, policies and strategies have all emphasized the need of equitable access to women for all reproductive health services.

In the area of Family Planning (FP), the Government of Nepal aims to enable women and couples to attain the desired family size and have healthy spacing of childbirths by improving access to FP services and reducing unmet need for contraceptives. Unmet need refers to the percentage of women who do not want any more births or those who want to postpone the next birth but are not yet using any method of contraception. Although there have been large investments and extensive efforts by both public and private sectors in family planning, there has been no remarkable progress in the use of modern contraceptives and in reducing unmet need in the last few years.

Current situation of Family Planning and Unmet Need

The Nepal Demographic Health Survey (NDHS), 2011 suggests that the contraceptive prevalence rate (CPR) of Nepal is 49.7%. Survey results from past fifteen years show a notable increase in the use of modern contraceptives. However, NDHS report shows that a modern CPR that increased from 1996 to 2006 has stalled between 2006 (44.2%) and 2011 (43.2%). Although Multiple Indicator Cluster Survey (MICS) showed that the modern CPR has increased to 47% in 2014, FP services are not yet universal across the country with significant disparities across regions.

Further, a higher unmet need in Nepali women provides a scope for equitable expansion of FP services across the country. The unmet need for FP in Nepal was 25.2% in 2014(MICS) which is a steady decline from that of 2011 (27% as per NDHS). Various studies and survey data reflects that highest unmet needs are amongst the women in rural and hilly areas. Also unmet need is highest among women in the poorest wealth quintile. Greater demand for family planning is among 35-39 age group women. The unmet need is also significantly higher among mothers within 24 months postpartum.

National Programs and Policies on Family Planning

Family planning being one of the priority programs of Government of Nepal had been considered as a component of reproductive health package and essential health care services of Nepal Health Sector Program II. The New Health Policy (2014), the Second Long- Term Health Plan (1997–2017), and the National Reproductive Health Strategy (1998) have all emphasized on the need of equitable access to FP services.

Under current National Family Planning Program, short-acting FP methods such as male condoms, pills, and injectables are offered regularly through all peripheral government health facilities including PHC-ORCs and FHCVs (condom and resupply of pills). Long acting reversible contraceptives (LARCs) are limited to few Primary Health Care Centres and Health Posts. Sterilization services are either provided at static sites or through scheduled seasonal or mobile outreach services. District FP MNCH clinics also provide all types of temporary family planning methods on regular basis. Various I/NGOs and private sectors are also the major stakeholders in FP services and support national programs in various ways.

Major gaps and challenges

Both at the demand and supply side various gaps and challenges exists; which constraints FP access and uptake. At supply side major gaps lie in the shortage of trained FP service providers and lack/ stock outs of family planning commodities and supplies. While Ministry of Health aimed to provide at least five types of modern FP methods from Health posts by 2015, all five methods are offered by only 43% health facilities. According to the Facility Based Assessment of Reproductive Health Commodities and Services, 2014, although stock outs of condoms, pills and injectables were negligible, 20% of PHCCs and 28% of HP had stock out of IUCD and implants for various reasons. Further, lack of proper counseling on FP including during postpartum and post abortion visits may also be another reason for low uptake of modern contraceptives.

In the demand side, the family planning use are more constrained by several factors like time taken to reach health facility, lack of transport, costs of travel, myths, misconceptions and fear of side effects, family restrictions, etc.

Appropriate Strategies

Taking into considerations the current FP situation, existing programs, policies and the efforts to address prevailing challenges and gaps, following strategies are appropriate to reducing unmet needs.

1.    Increase demand generation.

• Develop and implement FP sensitization program targeting hard-to-reach people: Focus marginalized groups and rural communities with high unmet needs.
• Implement BCC interventions targeting specific groups with higher unmet needs: Conduct mapping to identify such communities.
• Address fear of side effects, myths and misconceptions about FP through widespread use of IEC materials and other communication channels and prioritize interactive IPC sessions through FCHVs and health workers.

2.    Build Capacity of Service Providers

• Conduct trainings including refreshers for enhancing quality service delivery, particularly on provision of LARCs and quality FP counseling. Prioritize providers in areas with higher unmet need.
• Promote onsite coaching to improve and sustain providers' skills on FP service delivery especially LARCs.

          

3.    Improve Service Delivery

• Expand LARC services (commodity, trained service provider, equipments and IP supplies) up to health post levels.
• Integrate postpartum family planning (including PPIUCD) services in Health Facilities with birthing centre to address postpartum FP need.
• Promote task-shifting to expand services especially in districts with high unmet need.

4.    Reposition Family Planning

• Promote "Well-Planned Family" concept to establish positive image of family planning.
• Make FP services adolescent friendly to address unmet need of adolescents and youth.
• Redesign FP programs so as to increase male involvement.
• Promote special FP campaigns integrated with social support programs to reach underprivileged groups.

5.     Improve logistics management

• Strengthen logistics management system to reduce stock outs and overstocks of FP commodities and supplies at health facilities.
• Strengthen supply chain management to support contraceptive security

6.    Encourage alternative strategies

• Deploy roving ANMs to share family planning methods with hard to reach and underserved groups.
• Expand social marketing of contraceptives to underserved areas.

7.    Integrate FP into other national programs

• Integrate FP with services like immunization, emergency obstetric care and abortion.

8.    Promote Public Private Partnership

• Engage private & NGO providers in FP and coordinate reporting on FP services by private sectors.   

From: Various Sources