The Geographic Inequities of Child Nutrition Service Readiness in Nepal’s Primary Care System: A Cross-Sectional Analysis

Problem

Despite progress, undernutrition remains responsible for 45% of deaths in children under five years, with substantial variation depending on geographical and socioeconomic factors. Universal coverage of quality growth monitoring and promotion (GMP) services for children under 24-months is essential to effectively and sustainably address this global health challenge. Nutrition interventions during this critical period contribute to preventing short- and long-term morbidity and mortality, reducing poverty, and stimulating national economic growth. However, evidence suggests that appropriate primary care infrastructure readiness - a prerequisite to the provision of quality nutrition services - is lacking. This research aims to assess potential geographical factors associated with primary care facilities' readiness to provide GMP services in Nepal to support the development of evidence-informed strategies to reduce inequalities in service provision.

Approach

Cross-sectional health facility assessment data, collected in 2017 by Suaahara II, a USAID-funded multisectoral program, across all primary care facilities in 41 of Nepal’s 77 districts was analyzed. Infrastructure readiness was assessed in terms of the availability of basic amenities, anthropometry equipment, and nutrition supplements required for the provision of GMP services to children under 24-months. Basic amenities score was the primary outcome variable. Multivariate logistic and linear regression analyses were used to identify geographic predictors for infrastructure availability, with random effects to control for clustering by district.

Findings

All 1,895 primary care facilities were included. Primary care facilities in Provinces 3 and 7 had increased equipment scores compared to Province 1 (β:0.80; 95% CI:0.29-1.31; p=0.002 and β:0.59; 95% CI:0.12-1.05; p=0.013, respectively), yet there was no evidence of an association between province and basic amenities score. Primary care facilities in the lowland plains, versus those in the hills, had an increased basic amenities score (β:0.52; 95% CI:0.29- 0.76; p<0.001) and equipment score (β:0.47; 95% CI:0.12-0.82; p=0.009). Urban primary care facilities also had a higher basic amenities score than rural centers (β:0.16; 95% CI:0.06-0.27; p=0.002). The availability of each micronutrient supplement was above 95%. Individual models of availability of power and of a consultation room had a significant interaction between ecological region and province (likelihood ratio test p-value<0.05).

Consequences

Overall, this study found primary care facilities had sub-optimal infrastructure readiness to provide GMP services to children under 24-months, with rural, mountain, and hill areas significantly less prepared than urban and lowland areas. Federal and local governments must acknowledge these discrepancies to effectively prioritize where to make future investments into primary care services. Such improvements will optimize the quality and minimize the inequities of services provided. Further research is needed to determine if these inequities apply to other countries.